Two-Phase School-Based Prevention for Adolescent Depression In China: A Randomized Controlled Trial

Background and Purpose: Depressive symptoms affect 20% of Chinese adolescents, yet fewer than 4% seek professional help. Cognitive behavioral intervention is well-established for adolescent depression prevention, but randomized controlled trials in Chinese schools remain scarce. School-based prevention faces two constraints: low help-seeking rates prevent at-risk students from entering services, and specialist mental health personnel shortages limit delivery of evidence-based interventions. This study evaluated a two-phase intervention. Phase 1 tested a universal video-based help-seeking education intervention to improve help-seeking attitudes and facilitate service entry. Phase 2 tested a selective cognitive behavioral group intervention for adolescents with depressive symptoms, delivered by non-specialist teachers under a task-sharing model.

Methods: Phase 1 was a cluster randomized controlled trial across four county-level schools in Jiangxi Province, China. 193 classes (N = 8426, Grades 4-8 and 10-11) were randomized 1:1 to an 8-minute animated help-seeking video or treatment-as-usual. The primary outcome was help-seeking attitudes (ATSPPHS) two weeks post-intervention. Secondary outcomes included help-seeking willingness, stigma (self and public), confidence in helping peers seek support, self-reported help-seeking behavior, and an objective behavioral indicator (sign-up rate for a mental health group activity recruited via in-school posters). Phase 2 was an individually randomized controlled trial. 296 adolescents with depressive symptoms from Phase 1 sign-ups were randomized 1:1 to seven weekly 50-60-minute cognitive behavioral group sessions or treatment-as-usual. Of the 26 teachers, 84.6% were subject teachers without a mental health background. Primary outcome: depressive symptoms (CESD-R) at post-intervention and 3-month follow-up. Secondary outcome: generalized anxiety (GAD-7). Adherence, satisfaction, and qualitative feedback assessed feasibility. Intention-to-treat analyses were used.

Results: In Results: In Phase 1, compared with controls, the intervention group scored significantly higher on professional help-seeking attitudes (AMD = 2.19, p < .001) and willingness (AMD = 1.40, p < .001), and significantly lower on self-stigma and public stigma (ps < .001). Confidence in helping peers seek support was also significantly higher in the intervention group (p = .007). Self-reported help-seeking behavior did not differ significantly between groups (p = .769); however, sign-up rates for mental health activities were significantly higher in the intervention group (aOR = 2.32, p = .002). In Phase 2, compared with controls, the intervention group scored significantly lower on depressive symptoms at both post-intervention (AMD = -14.67, p < .001) and 3-month follow-up (AMD = -12.28, p < .001), as well as on generalized anxiety at post-intervention (AMD = -3.83, p < .001). Attendance was 92.4%, attrition 8.8%, satisfaction 25.67/32, with favorable acceptability from teachers and students.

Conclusions and Implications: An 8-minute universal video intervention improved help-seeking attitudes and promoted behavioral engagement with mental health services. A 7-session cognitive behavioral group intervention delivered by trained and supervised non-specialist teachers reduced depressive symptoms among Chinese adolescents with a spillover effect on generalized anxiety, with effects maintained at 3-month follow-up and reasonable feasibility. These findings demonstrate that a student-driven pathway from universal help-seeking promotion to selective depression prevention is feasible and scalable, offering empirical support for tiered school mental health services through task-sharing where specialist personnel are limited.