Always look on the bright side of life Increasing emotional resilience in adolescents by training cognitive processes to prevent anxiety and depression

Anxiety and depression are prevalent psychiatric disorders in adolescence. These internalizing problems have a high burden of disease; they are in the top 5 of diseases resulting in the greatest reduction in quality of life. Both are associated with negative consequences such as lower self-esteem, lower levels of social functioning, and lower grades at school, and could have far-reaching consequences such as less developed skills, reduced career choices, and unmarried status. The detrimental influence of anxiety and depression on individuals’ current and future functioning is further strengthened by the fact that only a small minority of adolescents reaches professional care. Longitudinal studies have shown that such untreated anxiety and depression in adolescence is strongly linked to adult psychopathology and substance misuse. Adolescent anxiety and depression have large societal costs in both short term (e.g. costs of treatment, drop out of school) and long term (sick leave, unemployment). Clearly, successful prevention of anxiety and depression is of great importance for reducing substantial individual suffering and saving substantial costs for society. Anxiety and depression are highly co-morbid and share much genetic variation. They have common risk and protective factors; the interaction between stress (risk factor) and emotional resilience (protective factor) plays an important role in the development of adolescent anxiety and depression. Emotional resilience has been defined as the capacity to cope successfully with stressful events. In the current project we focus on three interrelated cognitive mechanisms underlying the protective influence of resilience at the individual level. The tendency to direct attention towards positive information (positive attentional bias) and to interpret ambiguous information in a positive way (positive interpretive bias) have been shown to improve coping with stress. Self-regulatory capacities to control behaviour and emotions are also associated with better coping. These three factors (attention, interpretation, and cognitive control) of emotional resilience are based on sound empirical evidence indicating that (i) automatic cognitive processes (attention and interpretation) play a causal role in the etiology and maintenance of anxiety and depression, and (ii) the cognitive control system is still maturing during adolescence. Importantly, recent studies have shown that training these identified resilience processes by means of computerized cognitive tasks can be successfully applied to reduce symptoms of anxiety and depression. The aim of this project is to develop and test an on-line prevention program designed to reduce anxiety and depressive symptoms and prevent clinical diagnosis of anxiety and depression in adolescents by increasing emotional resilience. The research project consists of two RCT’s. Study 1 is a controlled, double blind trial to examine the efficacy of separate training modules in non-selected adolescents (primary, universal prevention). Adolescents will be randomized across four conditions: attentional training module, interpretation training module, cognitive control training module, or placebo-control condition. In order to test short and long term efficacy, five assessments are scheduled: pre, post, and at 3-, 6-, and 12- months follow-up. This efficacy study is the foundation of knowledge and in Study 2 we transport the modules with demonstrated efficacy into the prevention program “Always look at the bright side of life”. If results from Study 1 show that each training module is effective, then the prevention program will be a combination of all three training modules. Study 2 is more a pragmatic trial to examine the effectiveness, implementation and cost-effectiveness of the program “Always look at the bright side of life”. The program will be compared to a ‘doing nothing’ condition (monitoring) as that is the current situation in the Netherlands and effects up to 6 months follow-up will be examined. The goal of the prevention program is to teach adolescents resilience skills that help them to effectively manage stress. In both studies, the primary outcome measure is internalizing symptoms and number of clinical disorders (anxiety and depression). Secondary measures are emotional resilience, externalizing symptoms, substance misuse, and school functioning. Attention, interpretation, and cognitive control will be assessed as manipulation checks and proposed mechanisms of change. The role of potential moderators (ethnicity, SES, age, gender, and initial level of anxiety and depression) will be examined and in Study 2 cost-effectiveness and implementation possibilities.