Interventions and treatments for adolescent substance abuse: Publications guide

Annotated bibliography

Below are some citations and abstracts from publications about interventions and treatment for adolescent substance abuse.

Allen, M. L., Garcia-Huidobro, D., Porta, C., Curran, D., Patel, R., Miller, J., & Borowsky, I. (2016). Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review. Pediatrics, 138(2), e20154425.

Context: Parenting interventions may prevent adolescent substance use; however, questions remain regarding the effectiveness of interventions across substances and delivery qualities contributing to successful intervention outcomes.

Objective: To describe the effectiveness of parent-focused interventions in reducing or preventing adolescent tobacco, alcohol, and illicit substance use and to identify optimal intervention targeted participants, dosage, settings, and delivery methods.

Data sources: PubMed, PsycINFO, ERIC, and CINAHL.

Study selection: Randomized controlled trials reporting adolescent substance use outcomes, focusing on imparting parenting knowledge, skills, practices, or behaviors.

Data extraction Trained researchers extracted data from each article using a standardized, prepiloted form. Because of study heterogeneity, a qualitative technique known as harvest plots was used to summarize findings.

Results: A total of 42 studies represented by 66 articles met inclusion criteria. Results indicate that parenting interventions are effective at preventing and decreasing adolescent tobacco, alcohol, and illicit substance use over the short and long term. The majority of effective interventions required ≤12 contact hours and were implemented through in-person sessions including parents and youth. Evidence for computer-based delivery was strong only for alcohol use prevention. Few interventions were delivered outside of school or home settings.

Limitations: Overall risk of bias is high.

Conclusions: This review suggests that relatively low-intensity group parenting interventions are effective at reducing or preventing adolescent substance use and that protection may persist for multiple years. There is a need for additional evidence in clinical and other community settings using an expanded set of delivery methods.

Becker, S., Hernandez, L., Spirito, A., & Conrad, S. (2017). Technology-assisted intervention for parents of adolescents in residential substance use treatment: protocol of an open trial and pilot randomized trial. Addiction Science & Clinical Practice, 12(1), 1-13.

Adolescents in residential substance use disorder (SUD) treatment have poor outcomes post-discharge, with follow-up studies suggesting that most adolescents relapse within 90 days. Parenting practices directly influence adolescent SUD outcomes, but parents of adolescents with SUDs are difficult to engage in traditional behavioral treatments. The current study adapts and evaluates a technology-assisted intervention for parents of adolescents in residential SUD treatment. Based on pilot qualitative data with parents, adolescents, and residential staff, we augment an existing computerized intervention (Parenting Wisely; PW) with four in-person coaching sessions, personalized text messages, and an expert-moderated online parent message board. We hypothesize that parents will find enhanced PW (PW+) both feasible and acceptable, and that adolescents whose parents receive PW+ will have better post-discharge outcomes than adolescents who receive standard care (SC) only. A two phase approach is used to adapt and evaluate PW+. Phase 1 consists of an open trial with 10 parents of adolescents (age 12–17) in residential SUD treatment. Post-discharge qualitative and quantitative data from parents and adolescents will support PW+ refinement. Phase 2 is a randomized pilot trial with 60 parents testing the effectiveness of adding PW+ to SC. Adolescents and parents will complete assessments at baseline, 6-, 12-, and 24-weeks post-discharge. Primary outcomes will be measures of feasibility and acceptability. Secondary outcomes will include adolescent substance use, truancy, high-risk sexual behavior, and criminal involvement. Two parenting processes (monitoring and communication) are examined as potential mediators of change. This study will adapt and evaluate a technology-assisted parenting intervention as a means of improving adolescent outcomes following residential SUD treatment. Results have the potential to advance the field by: addressing a high-risk population, improving parental engagement; targeting parenting practices (putative mediators of change) that have been linked to adolescent outcomes; and developing a highly disseminable approach.

Black, J. J., & Chung, T. (2014). Mechanisms of change in adolescent substance use treatment: How does treatment work?. Substance Abuse, 35(4), 344-351.

Background: Adolescent substance use treatment outcome research generally shows small to moderate effects in reducing substance use, with no specific “brand” of treatment emerging as clearly superior to any other, and treatment gains that fade over time. The relatively weak and temporary effects of treatment call for improving the potency and durability of intervention effects. In response to this call, this critical narrative review summarizes research on mechanisms of change for both adults and adolescents in substance use treatment, with a particular focus on reviewing what is known regarding “how” adolescent substance use treatment works.

Methods: A comprehensive review of the adolescent (ages 11–18) substance use treatment literature was conducted to identify empirical studies that examined mediators of intervention effects. Relevant databases (e.g., PsychINFO, Medline) were searched using key words (e.g., “mediator”), and relevant articles from reference sections of identified studies and review papers were considered.

Results: Studies of mechanisms of psychotherapy change are rare in the adult, and particularly adolescent, substance use treatment outcome literature. The four adolescent studies that examined substance use treatment mechanisms found that positive social support, motivation to abstain, and positive parenting behaviors mediated treatment effects. To date, research has not supported therapy-specific mechanisms of change, finding instead that “common” processes of change largely account for improvements in outcome across distinct “brands” of treatment.

Conclusions: The lack of empirical support for treatment-specific mechanisms of change may be due to the need for greater precision in defining and measuring treatment-specific causal chains. Future directions include neuroscience approaches to examining changes in brain functioning that are associated with treatment response and recovery and examining mechanisms in adaptive treatment designs, which can accommodate individual differences in targets for intervention and response to treatment.

Das, J. K., Salam, R. A., Arshad, A., Finkelstein, Y., & Bhutta, Z. A. (2016). Interventions for adolescent substance abuse: An overview of systematic reviews. Journal of Adolescent Health, 59(4), S61-S75.

Many unhealthy behaviors often begin during adolescence and represent major public health challenges. Substance abuse has a major impact on individuals, families, and communities, as its effects are cumulative, contributing to costly social, physical, and mental health problems. We conducted an overview of systematic reviews to evaluate the effectiveness of interventions to prevent substance abuse among adolescents. We report findings from a total of 46 systematic reviews focusing on interventions for smoking/tobacco use, alcohol use, drug use, and combined substance abuse. Our overview findings suggest that among smoking/tobacco interventions, school-based prevention programs and family-based intensive interventions typically addressing family functioning are effective in reducing smoking. Mass media campaigns are also effective given that these were of reasonable intensity over extensive periods of time. Among interventions for alcohol use, school-based alcohol prevention interventions have been associated with reduced frequency of drinking, while family-based interventions have a small but persistent effect on alcohol misuse among adolescents. For drug abuse, school-based interventions based on a combination of social competence and social influence approaches have shown protective effects against drugs and cannabis use. Among the interventions targeting combined substance abuse, school-based primary prevention programs are effective. Evidence from Internet-based interventions, policy initiatives, and incentives appears to be mixed and needs further research. Future research should focus on evaluating the effectiveness of specific interventions components with standardized intervention and outcome measures. Various delivery platforms, including digital platforms and policy initiative, have the potential to improve substance abuse outcomes among adolescents; however, these require further research.

Goorden, M., Schawo, S., Bouwmans-Frijters, C., van der Schee, E., Hendriks, V., & Hakkaart-van Roijen, L. (2016). The cost-effectiveness of family/family-based therapy for treatment of externalizing disorders, substance use disorders and delinquency: a systematic review. BMC Psychiatry, 16(1), 1-22.

Family therapy and family-based treatment has been commonly applied in children and adolescents in mental health care and has been proven to be effective. There is an increased interest in economic evaluations of these, often expensive, interventions. The aim of this systematic review is to summarize and evaluate the evidence on cost-effectiveness of family/family-based therapy for externalizing disorders, substance use disorders and delinquency. A systematic literature search was performed in PubMed, Education Resource information Centre (ERIC), Psycinfo and Cochrane reviews including studies conducted after 1990 and before the first of August of 2013. Full economic evaluations investigating family/family-based interventions for adolescents between 10 and 20 years treated for substance use disorders, delinquency or externalizing disorders were included. Seven hundred thirty-one articles met the search criteria and 51 studies were initially selected. The final selection resulted in the inclusion of 11 studies. The quality of these studies was assessed. Within the identified studies, there was great variation in the specific type of family/family-based interventions and disorders. According to the outcomes of the checklists, the overall quality of the economic evaluations was low. Results varied by study. Due to the variations in setting, design and outcome it was not feasible to pool results using a meta-analysis. The quality of the identified economic evaluations of family/family-based therapy for treatment of externalizing disorders, adolescent substance use disorders and delinquency was insufficient to determine the cost-effectiveness. Although commonly applied, family/family-based therapy is costly and more research of higher quality is needed.

Liddle, H. A., Dakof, G. A., Rowe, C. L., Henderson, C., Greenbaum, P., Wang, W., & Alberga, L. (2018). Multidimensional Family Therapy as a community-based alternative to residential treatment for adolescents with substance use and co-occurring mental health disorders. Journal of Substance Abuse Treatment, 90(1), 47-56.

This randomized clinical trial (RCT) compared Multidimensional Family Therapy (MDFT) with residential treatment (RT) for adolescents with co-occurring substance use and mental health disorders on substance use, delinquency, and mental health symptoms. Using an intent-to-treat design, 113 adolescents who had been referred for residential treatment were randomly assigned to either RT or MDFT in the home/community. The sample was primarily male (75%) and Hispanic (68%) with an average age of 15.4 years. Seventy-one percent of youth had at least one previous residential treatment placement. Participants were assessed at baseline and at 2, 4, 12 and 18 months post-baseline. During the early phase of treatment (baseline to 2 months), youth in both treatments showed significant reductions in substance use [substance use problems (d = 1.10), frequency of use (d = 1.36)], delinquent behaviors (d = 0.18) and externalizing symptoms (d = 0.77), and youth receiving MDFT reported significantly greater reductions in internalizing symptoms than youth receiving RT (d = 0.42). In phase 2, from 2 to 18 months after baseline, youth in MDFT maintained their early treatment decreases in substance use problems (d = 0.51), frequency of use (d = 0.24), and delinquent behaviors (d = 0.42) more effectively than youth in RT. During this period, there were no significant treatment differences in maintenance of gains for externalizing and internalizing symptoms. Results suggest that Multidimensional Family Therapy is a promising alternative to residential treatment for youth with substance use and co-occurring disorders. The results, if supported through replication, are important because they challenge the prevailing assumption that adolescents who meet criteria for residential treatment cannot be adequately managed in a non-residential setting.

Stanger, C., Lansing, A. H., & Budney, A. J. (2016). Advances in research on contingency management for adolescent substance use. Child and Adolescent Psychiatric Clinics, 25(4), 645-659.

Multiple interventions for treating adolescents with substance use disorders have demonstrated efficacy, but the majority of teens do not show an enduring positive response to these treatments. Contingency-management (CM) based strategies provide a promising alternative, and clinical research focused on the development and testing of innovative CM models continues to grow. This article provides an updated review on the progress made in this area since we last commented on the published literature in 20101. Areas covered include: controlled trials of treatment for adolescents referred to substance use treatment, innovative applications of CM to tobacco cessation among youth, analyses of moderators and mechanisms of CM treatment outcomes, the emerging literature on dissemination and implementation, and other literature suggesting a growing acceptance of CM as viable and effective intervention. The literature in this area continues to progress at a moderate pace, with many indicators of budding interest in the application of CM, and in finding cost effective models to enhance dissemination and implementation. As with other types of substance use disorder treatments, we need to continue to search for more effective models, focus on post-treatment maintenance (reduce relapse), and strive for high levels of integrity and fidelity during dissemination efforts to optimize outcomes.

Stockings, E., Hall, W. D., Lynskey, M., Morley, K. I., Reavley, N., Strang, J., … & Degenhardt, L. (2016). Prevention, early intervention, harm reduction, and treatment of substance use in young people. The Lancet Psychiatry, 3(3), 280-296.

We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision—which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted eff orts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta-analysis. Journal of Substance Abuse Treatment, 44(2), 145-158.

Meta-analysis was used to synthesize research on the effects of outpatient treatment on substance use outcomes for adolescents with substance use disorders. An extensive literature search located 45 eligible experimental or quasi-experimental studies reporting 73 treatment–comparison group pairs, with many of the comparison groups also receiving some treatment. The first analysis examined 250 effect sizes for the substance use outcomes of adolescents receiving different types of treatment relative to the respective comparison groups. As a category, family therapy programs were found to be more effective than their comparison conditions, whereas no treatment programs were less effective. However, not all treatment types were compared with each other in the available research, making it difficult to assess the comparative effectiveness of the different treatments. To provide a more differentiated picture of the relative improvement in substance use outcomes for different treatments, a second analysis examined 311 pre–post effect sizes measuring changes in substance use for adolescents in the separate treatment and comparison arms of the studies. The adolescents in almost all types of treatment showed reductions in substance use. The greatest improvements were found for family therapy and mixed and group counseling. Longer treatment duration was associated with smaller improvements, but other treatment characteristics and participant characteristics had little relationship to the pre–post changes in substance use. Based on these findings family therapy is the treatment with the strongest evidence of comparative effectiveness, although most types of treatment appear to be beneficial in helping adolescents reduce their substance use.

Van Ryzin, M. J., Roseth, C. J., Fosco, G. M., Lee, Y. K., & Chen, I. C. (2016). A component-centered meta-analysis of family-based prevention programs for adolescent substance use. Clinical Psychology Review, 45, 72-80.

Although research has documented the positive effects of family-based prevention programs, the field lacks specific information regarding why these programs are effective. The current study summarized the effects of family-based programs on adolescent substance use using a component-based approach to meta-analysis in which we decomposed programs into a set of key topics or components that were specifically addressed by program curricula (e.g., parental monitoring/behavior management, problem solving, positive family relations, etc.). Components were coded according to the amount of time spent on program services that targeted youth, parents, and the whole family; we also coded effect sizes across studies for each substance-related outcome. Given the nested nature of the data, we used hierarchical linear modeling to link program components (Level 2) with effect sizes (Level 1). The overall effect size across programs was .31, which did not differ by type of substance. Youth-focused components designed to encourage more positive family relationships and a positive orientation toward the future emerged as key factors predicting larger than average effect sizes. Our results suggest that, within the universe of family-based prevention, where components such as parental monitoring/behavior management are almost universal, adding or expanding certain youth-focused components may be able to enhance program efficacy.

 

 

 

Annotated bibliography: Teenagers and substance use

Annotated bibliography

Annotated bibliography: Unemployment and mental health

Annotated bibliography

 Bidargaddi, N., Bastiampillai, T., Schrader, G., Adams, R., Piantadosi, C., Strobel, J., & … Allison, S. (2015). Changes in monthly unemployment rates may predict changes in the number of psychiatric presentations to emergency services in South Australia. BMC Emergency Medicine, 15(1), 1-6.  

The aim of this paper was to establish if monthly presentation rates to Mental Health Emergency Departments (MHED) in South Australia Public Hospitals (SAPH) was associated with Australian Bureau of Statistics (ABS) unemployment rates. The data was collected using times series modelling of relationships between monthly MHED SAPH presentations obtained from the Integrated South Australian Activity Collection (ISAAC) and the ABS South Australia unemployment figures between January 2004 and June 2011. The study found that over 32% of MHED presentations in males could be predicted by male unemployment rates from the two months prior. Over 63% of MHED presentations in females could be predicted by male and female unemployment in the previous months. They concluded that small shifts in unemployment rates can increase MHED presentations particularly in women and that ABS unemployment statistics can be a useful tool for predicting future MHED. A limitation of this study is that it establishes an association between MHED presentations and unemployment but not causality, so increased unemployment might not be the cause of the increase in MHED presentations.

 Buffel, V., van de Straat, V., & Bracke, P. (2015). Employment status and mental health care use in times of economic contraction: a repeated cross-sectional study in Europe, using a three-level model. International Journal for Equity in Health, 14(1), 1-19.

 This study aimed to compare the mental health care use of the unemployed with that of the employed and whether the relationship between unemployment status and mental health care use varied across different economic climates. They wanted to establish whether the economic context affected mental health care use due to its impact on mental health or irrespective of mental health. Data from three waves of the Eurobarometer (2002, 2005/6 and 2010) was utilised, which consists of a repeated cross-sectional and cross-national design. The data was analysed using linear and logistic multi-level regression in which mental health and contacting a medical practitioner for mental health issues were considered variables. They found that mean unemployment rate was negatively associated with mental health, although in women this only applied to those employed. There was no association found in women between changes in the macro-economic climate and mental health.  Men’s care use however is associated with changes in the unemployment rate and gross domestic product (GDP) irrespective of mental health. This is true of both employed and unemployed men. They conclude that it is important to consider macro-economic conditions when studying mental health care use, particularly in men. A limitation noted in the study is that the Eurobarometer records employment status at the time of the interview and mental health in the twelve months preceding the interview. Therefore it is not able to distinguish between causation and reverse causation for any association between mental health and employment. 

Crowe, L., Butterworth, P., & Leach, L. (2016). Financial hardship, mastery and social support: Explaining poor mental health amongst the inadequately employed using data from the HILDA survey. SSM – Population Health, 2(1), 407-415.

 Data from the Household Income and Labour Dynamics in Australia (HILDA) Survey were analysed to try and establish if there was a relationship between employment status and mental health, along with the effects of financial hardship, mastery and support. They also wanted to explore how duration of unemployment impacted on mental health. Three waves of data were analysed from the HILDA Survey which encompassed 4965 adult respondents. The relationship between employment status and mental health was assessed using longitudinal population-averaged logistic regression models to explain associations between employment groups (unemployed vs. employed; employed vs. underemployed). The effect on duration of unemployment on mental health was evaluated using regression analysis. Unemployed or underemployed respondents exhibited poorer mental health than their employed counterparts. Mastery, financial hardship and social support ameliorated this association particularly in the underemployed. Transition to unemployment was associated with a decline in mental health among a broad age range of respondents.  The relationship between mental health and unemployment duration was not linear but mental health showed a marked decline in the first nine weeks. The study concluded that mastery, financial hardship and social support are important factors to consider in the understanding of the relationship of poor mental health and un- or underemployment. It also suggests intervention should commence immediately after job loss with deterioration in mental health being most severe in the first weeks before plateauing.  A limitation in this study is the possibility of reverse causation or low mastery and lack of social support causing unemployment.

 Limm, H., Heinmüller, M., Gündel, H., Liel, K., Seeger, K., Salman, R., & Angerer, P. (2015). Effects of a Health Promotion Program Based on a Train-the-Trainer Approach on Quality of Life and Mental Health of Long-Term Unemployed Persons. Biomed Research International, 2015(1),

 The authors of this study state that long-term unemployment is associated with poorer mental health. They therefore conducted this study to evaluate the effectiveness of a health promotion program to improve the mental health and health related quality of life (HRQL) utilising the train-the-trainer approach. A parallel-group study was performed using 287 unemployed participants (179 were in the intervention group and 108 in the control group), who were reassessed after 3 months. The intervention comprised individual sessions based on motivational interviewing and participatory group sessions, with the control group receiving no health promotion. Within 3 months HRQL improved and symptoms of depression and anxiety decreased in the intervention group, but not in the control group. The trainers were all professionals (mainly social workers) who had received three days training to deliver the interventions.  A limitation of this study was that participants were not “blinded” and the positive results may be influenced by this. 

Olesen, S., Butterworth, P., Leach, L., Kelaher, M., & Pirkis, J. (2013). Mental health affects future employment as job loss affects mental health: findings from a longitudinal population study. BMC Psychiatry, 13(1), 144.

 Internationally, participation in the workforce is regarded as an important factor in mental health policies and social inclusion. This study aimed to examine simultaneously the effects on mental health on unemployment and how mental health effects employment prospects and participation. The data was derived from respondents who completed the nine waves of the HILDA Survey in Australia. They were all of working age (20-55 years) at commencement of the study (n=7176). Simultaneous relationships between employment and mental health were tested over time using cross-lagged path analysis, whilst adjusting for sociodemographic differences. They found that poor mental health was both a result of and a predisposing factor for unemployment. Poorer mental health in people who are unemployed can be both attributable to the unemployment and existing mental health issues. In women both these factors had equal rating, whereas in men the impact of unemployment on mental health was weaker than mental health on subsequent unemployment. The data available in the HILDA survey meant that the researchers were limited to using the respondents’ concept of their mental health rather than diagnosed mental illnesses.

 Strandh, M., Winefield, A., Nilsson, K., & Hammarström, A. (2014). Unemployment and mental health scarring during the life course. The European Journal of Public Health, 24(3), 440.

 The long-term relationship between unemployment and mental health over the life course has been little researched. This study examined the relationship between youth unemployment along with periods of adult unemployment and mental health at several life stages (16, 18, 21, 30 and 42 years) who all graduated from compulsory school in a town in Sweden.  Originally there were 1083 participants and of those still living at the 27 year follow-up, 94.3% were still involved. The researchers measured mental health in three ways: nervous symptoms, depressive symptoms and trouble sleeping. These were analysed using a repeated measures linear mixed models approach at ages 16, 21, 30 and 42 years. Unemployment was measured using a period of unemployment of at least six months over three time periods: 18–21, 21–30 and 30–42 years. They found that youth unemployment was significantly associated with poor mental health at ages 21, 30 and 42 years. Later single unemployment periods did not appear to have the same long-term effects, although two or more periods of unemployment did have a significant relationship with poor mental health. A limitation of the study is its small geographical sample base, with consequent limits on sociodemographic variants.

Annotated bibliography: Screen time and its impact on young people’s mental health.

Annotated bibliography

 

Babic, M. J., Morgan, P. J., Plotnikoff, R. C., Lonsdale, C., & Eather, N. (2015). Skinner, Geoff; Baker, Amanda L.; Pollock, Emma; Lubans, David R. “Rationale and study protocol for ‘Switch-off 4 Healthy Minds'(S4HM): a cluster randomized controlled trial to reduce recreational screen time in adolescents”. Originally published in Contemporary Clinical Trials Vol. 40, p. 150-158 (2015). Clinical Trials, 40, 150-158.

This paper describes a school-based strategy trialled in New South Wales to reduce screen time for adolescents in response to the known adverse effects high screen time can have on their mental and physical health. It uses self-determination theory and involves educating both the adolescent and their parents. Prompts were sent to the young via the social media platform of their choice and newsletters were sent to parents to raise awareness of screen time and its dangers. There wasn’t much detail in the paper about the interventions that would be employed in implementing the strategy.

Chassiakos, Y. L. R., Radesky, J., Christakis, D., Moreno, M. A., & Cross, C. (2016). Children and adolescents and digital media. Pediatrics, 138(5), e20162593.

This report provides a summary of the benefits and risks of childhood exposure to digital media. Social media can have beneficial effects to the mental health of LGBTIQ teenagers if they use it to engage with supportive communities. Similarly, individuals with mental illness may also benefit when using social media to share stories with others experiencing similar challenges. However, this can also leave them open to exposure, misinformation, negativity and hostility. Examples of digital media which may have adverse effects on the mental health of young people are pro-anorexia sites. Exposure to risky behaviour in media has been proven to increase teenage uptake of the behaviour and this exposure can be difficult to police on digital devices by parents. Social media has been shown to have both positive and negative effects on young people’s mental health. Used in moderation it can enhance their feelings of social connectedness. Passive use of social media or following attractive celebrities can increase depression and lower self-esteem, whereas engaging actively with family and friends has the opposite effect.

Gunnell, K. E., Flament, M. F., Buchholz, A., Henderson, K. A., Obeid, N., Schubert, N., & Goldfield, G. S. (2016). Examining the bidirectional relationship between physical activity, screen time, and symptoms of anxiety and depression over time during adolescence. Preventive Medicine, 88, 147-152.

This study was performed to establish relationships between low levels of physical activity, high screen time, depression and anxiety in adolescents. It took place over 11 years and took the form of four time specific questionnaires covering the ages from 10-21 years old (n= 1160, mean age = 13.54 years).  The results were controlled for variables such as gender, ethnicity, location and educational level of parents. A decrease in physical activity and increase in screen time, depression and anxiety over time was observed. Initial high anxiety was associated with higher screen time and lower physical activity independent of symptoms of depression. Higher initial levels of depression were also associated with higher screen time and predicted greater decreases in physical activity over time.  Limitations include the data collected was self-reported, type of screen time and type of physical activity was not identified and there was a high rate of attrition.

Hoare, E., Milton, K., Foster, C., & Allender, S. (2016). The associations between sedentary behaviour and mental health among adolescents: a systematic review. International Journal of Behavioral Nutrition and Physical Activity, 13(1), 108.

This systematic review examined 32 papers, all of which reported the use of screen time for leisure amongst adolescents and two thirds identified depressive symptoms. Adolescence is a significant risk period for the development of mental health disorders and it is also a period when lifestyle behaviours are developed which can impact on mental health into adulthood. Depressive symptoms and length of  screen time for leisure use were consistently linked in the evidence. There was moderate evidence for an association between length of screen time and low self-esteem. More than 2-3 hours of screen time per day in adolescents is linked to poorer mental health status. It identified that the link may be in part due to the sedentary nature of screen time, as physical activity has been found to have a positive effect on mental health. Adolescents with poor mental health may lack motivation to exercise and instead opt for screen based activities. Young people who lead sedentary lifestyles are more likely to suffer from obesity, which can lead to stigmatisation and bullying resulting in adverse effects on their mental health.

Maras, D., Flament, M. F., Murray, M., Buchholz, A., Henderson, K. A., Obeid, N., & Goldfield, G. S. (2015). Screen time is associated with depression and anxiety in Canadian youth. Preventive Medicine, 73, 133-138.

Increased screen time has been linked to low physical activity and obesity in youth, factors that have been linked to an increase in depression and anxiety. The study aimed to examine the relationship between length of screen time and anxiety and depression in young people using a large community sample of Canadian adolescents (n=2482). They found that depression was associated with any type of screen behaviour except watching the TV, whereas anxiety was only associated with gaming. This is consistent with other large-scale studies including studies from the USA and Australia. They offer several explanations for this including social isolation and cyberbullying.  A limitation of the study was that they couldn’t conclude whether it was increased screen time that caused the depression and anxiety or whether the opposite was true that people with depression and anxiety spent more time on their electronic devices.

Przybylski, A. K., & Weinstein, N. (2017). A large-scale test of the Goldilocks Hypothesis: Quantifying the relations between digital-screen use and the mental well-being of adolescents. Psychological Science, 28(2), 204-215.

This study tested the Goldilocks Hypothesis for screen time in adolescents to try and ascertain the optimum amount of screen time that would benefit development without adversely affecting mental health. They studied 120115 British adolescents. They found the relationship between screen time and mental health was non-linear and a moderate time spent on screens was not harmful and may even have positive effects on wellbeing. There were differences in effect depending on the screen type, the type of activity, the day or time used and the level of engagement in the activity. They recommend studying the functionality of screen time against other daily pursuits in order to get a fuller understanding. Overall they concluded that moderate technology use was not intrinsically harmful and may prove beneficial in an increasingly digital world.

Saquib, N., Saquib, J., Wahid, A., Ahmed, A. A., Dhuhayr, H. E., Zaghloul, M. S., … & Al-Mazrou, A. (2017). Video game addiction and psychological distress among expatriate adolescents in Saudi Arabia. Addictive Behaviors Reports, 6, 112-117.

This study was conducted using a self-reported survey distributed to 276 students in expatriate schools in Saudi Arabia. The researchers use DSM-V criteria to diagnosed video game addiction and it was compared with other variables including screen time and psychological distress. The mean age of the participants was 15.3 years and nearly 75% reported screen time greater than 2 hours and 20% reported sleeping less than 5 hours a night. Those addicted to video games encompassed 15.8% of the sample and they were more likely to be boys, have higher screen time and less sleep. Addiction to video games was strongly related to psychological distress, as was screen time greater than 2 hours a day.  Psychological distress was also related to gender, with girls being more likely to experience it and inversely to sleep patterns. This study didn’t find any link between physical activity or BMI and psychological distress. The study concludes that screen time has an independent association with psychological distress even when other variables are taken into consideration.

Straatmann, V. S., Oliveira, A. J., Rostila, M., & Lopes, C. S. (2016). Changes in physical activity and screen time related to psychological well-being in early adolescence: findings from longitudinal study ELANA. BMC Public Health, 16(1), 977.

In this study, data was analysed from 526 adolescents in Brazil, assessing physical activity, screen time and psychological distress using a questionnaire. Psychological distress was associated with exceeding the recommended screen time of 4 hours per day in girls, although they questioned whether there was a negative causality impacting on this that is the psychological distress caused them to withdraw and spend more time on screen based activities. For boys, psychological distress was associated with a reduction in physical activity in this study. The study was limited in that the data collected was self-reported.

Trinh, L., Wong, B., & Faulkner, G. E. (2015). The independent and interactive associations of screen time and physical activity on mental health, school connectedness and academic achievement among a population-based sample of youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 24(1), 17.

The study aimed to establish the effects high screen time and physical activity had independently and together on the mental health of young people. Data was collected from 2660 adolescents using a survey. It found that high screen time is consistently associated with poorer mental health independent of the amount of physical activity. However, there may be reverse causality where depressed youth seek social isolation or comfort in their digital devices. The study also found that high screen time was associated with low self-esteem, which did not improve with physical activity.  Higher screen time was associated with lower physical activity. It concluded that screen time and physical activity had both independent and interactive effects on the mental health of young people. A limitation in the study was that the data was self-reported.

Twenge, J. M., Joiner, T. E., Rogers, M. L., & Martin, G. N. (2017). Increases in depressive symptoms, suicide-related outcomes, and suicide rates among US adolescents after 2010 and links to increased new media screen time. Clinical Psychological Science, 2167702617723376.

There was an increase in teenage depression and suicide in the USA between 2010 and 2015, which corresponded with the increased use of smartphones and other digital devices. This study analysed the data from two national surveys of high school students in the USA to establish if there was a link between screen time and depression and suicide.  There were 388275 respondents to the surveys, who completed them retrospectively. The study found a positive correlation between screen time and depression and suicide especially amongst females. No significant variation occurred in other variables such as socioeconomic status. Exercise and face-to-face social interaction negatively correlated with depression and suicide, but increased screen time was often associated with low physical activity and social interaction. Lack of sleep has also been identified in other studies as being linked to increased screen time and as a risk factor for depression and suicide. The study was unable to establish if screen time was the sole cause of increased incidence of depression and suicide, the joint cause or if the cause was one of the other factors. Another limitation was the surveys were completed retrospectively rather than in real time, which may have affected the answers given.

Wu, X., Tao, S., Zhang, Y., Zhang, S., & Tao, F. (2015). Low physical activity and high screen time can increase the risks of mental health problems and poor sleep quality among Chinese college students. PLoS One, 10(3), e0119607.

High screen time and low physical activity have been shown to interact to cause psychological problems. The study has suggested that high screen time is associated with a higher incidence of depression, anxiety, psychopathological symptoms and poor sleep quality. It is also associated with reduced physical activity. Physical activity has been shown to reduce symptoms of depression, anxiety and other mental health problems. The results of this study suggest that high screen time and low physical activity both increase psychological stress independently and synergistically. A limitation of the study is that it assessed self-reported symptoms and not clinically diagnosed disorders.

Wu, X., Tao, S., Zhang, S., Zhang, Y., Chen, K., Yang, Y., … & Tao, F. (2016). Impact of screen time on mental health problems progression in youth: a 1-year follow-up study. BMJ Open, 6(11), e011533.

This study examined the association between screen time and mental health in a group of Chinese university students (n=2521, mean age=18.43 years). Nearly all of the participants reported screen time of more than 2 hours per day. They found consistent associations with screen time and anxiety, depression or other psychopathology. The associations also remained after adjustments for other variables. Due to the small effects size it is unclear to what degree screen time effects mental health outcomes. The limitations of the study include that the data collected was self-reported and it doesn’t differentiate between different screen uses.