Young people's mental wellbeing is a growing focus in both the UK and Woodland World. A number of studies have been conducted looking at the implementation of universal interventions for young people to try to protect his well-being and prevent disease. Unfortunately, the literature to date shows that universal interventions are not effective in promoting youth well-being (see Soffia's recent blog universal DBT interventions in schools).

An Ofcom report in 2023 noted this By the age of 11, 9 out of 10 children have a mobile phone and this 98% of 16-17 year olds have a smartphone. There are concerns that smartphone use may increase anxiety and depression in this age group (Haidt, 2024) – but could the smartphone be the answer?

To date, studies testing smartphone apps have been small-scale (e.g., fewer than 100 participants), which limits reliability. However, Watkins et al. (2024a; 2024b) recently used preventive (PREVENT ECoWeB) and encouraging (SCHEDULE ECoWeB CALENDAR) effects of a mobile phone program for at-risk youth and healthy youth, respectively.

The holy grail would be a smartphone app capable of both promoting well-being and preventing mental illness in young adults — but are we asking for too much?

Methods

This is an international, multicentre, parallel, open-label RCT at four trial sites in the UK, Germany, Spain and Belgium. This is a cohort multiple RCTmeans that one an emotional competence profile was completed at baseline, and those without risk were allocated to ECoWeB PROMOTE and those at identified risk to ECOWeB PREVENT. Risk was defined as individuals scoring in the worst quartile on measures of anxiety, worry, achievement appraisal, and rejection sensitivity.

Participants were excluded if they presented with major depressive disorder or had past episodes. Other exclusion criteria were:

• Active suicide
• A self-reported history of serious mental health problems such as bipolar disorder and psychosis
• Currently receiving psychological therapy, counseling, or psychiatric medications, including antidepressants
• High hypothesized vulnerability in the emotional competence profile based on baseline assessment of emotional competence skills

Within each RCT, participants were randomized to usual care or:

• Emotional competence program;
• Cognitive-behavioral therapy (CBT) program; or
• Self-monitoring program

All outcome assessors and statisticians were masked to treatment, and follow-up was conducted at 12 months with clinical rating scales completed at 3 and 12 months.

Results

Participant characteristics

Between October 15, 2020 and August 3, 2021, 21,277 people aged 16-22 were examined; 10,030 individuals were included in the baseline assessment and 3,794 were eligible for the ECoWeB cohorts.

Results: CALENDAR

3-month follow-up:

• Mental well-being did not differ between the emotional competence program and the CBT application (mean difference WEMWBS = -0.21 (95% CI –1.08 to 0.66)).
• Mental well-being did not differ between the emotional competence application and the self-control program (0.32 (-0.54 to 1.19)).
• Mental well-being did not differ between CBT practice and self-control practice (0.53 (−0.33 to 1.39)).

12-month follow-up:

• Mental well-being was lower in the emotional competence practice than in the CBT practice (mean difference WEMWBS = 1.17 (95% CI –2.11 to –0.24)), but this was not a clinically significant difference.
• No difference in mental well-being occurred between the emotional competence program compared to the self-control program (-0.76 (-1.69 to 0.18)).
• No difference in mental well-being occurred between CBT application compared to self-monitoring application (0.42 (-0.51 to 1.34)).

Results for all secondary outcomes were similar to the primary outcome There was no global difference between the three groups at 3 months or 12 months.

Implications: PREVENT

3-month follow-up:

• Depressive symptoms were significantly lower with CBT than with self-control (mean difference on PHQ-9 = –1.18 (95% CI –2.01 to –0.34); p = .006).
• There was no difference in depressive symptoms between emotional competence program and CBT application (0.63 (-0.22-1.49); p = .15).
• There was no difference in depressive symptoms between the emotional competence program and the self-control program (–0.54 (–1.39 to 0.31); p = .21).
• PHQ-9 scores were lower with CBT (59 of 191 (31%)) than with self-control (85 of 199 (43%); odds ratio (OR) = 0.50 (95% CI 0, 0.81 of 31) ).
• PHQ-9 scores were higher with emotional competence (69 of 178 (39%)) than with CBT (1.63 (1.01 – 2.64); number needed to treat (NNT) = 8.33) . PHQ-9 scores did not differ between emotional competence and self-control practice (0.82 (0.52–1.30)).
• With CBT, work or academic and social functioning and health-related quality of life were higher than in the self-monitoring program group.
• Work or academic and social functioning and health-related quality of life showed no benefit of emotional competence practice compared to self-control practice.

There were no significant differences between groups on anxiety (GAD-7) or well-being (WEMWBS) at 3-month or 12-month follow-up. There were no significant differences between any of the groups at 12 months.

Contrary to the authors' hypotheses, there was no additional benefit of emotional competence training in the PROMOTE or PREVENT trial compared with CBT or self-control training.

Results

The ECoWeB PROMOTE trial found that no Additional benefit of emotional competence training or CBT training over a self-control program in promoting mental well-being.

However, the ECoWeB PREVENT trial found that a A general CBT self-help program has beneficial protective effects compared with self-monitoring on depressive symptoms, functioning, and quality of life in depression-vulnerable youth..

The emotional competence program was not more helpful than either the CBT program or the self-control program.

While ECoWeB PROMOTE found no significant differences between the three programs, PREVENT found that general CBT practice had beneficial protective effects for youth at risk of developing a mental health condition.

Strengths and limitations

Arguably, strengths include studies using a RCT model. Recruitment from several European countries refreshing to see as it helps generalize. There was also a targeted age group (16-22 years) that could help put the findings into practice. In addition, all raters and statisticians were blinded to the intervention, which reduced the risk of interference.

There 'usual care' was not a control interventionwhich is often typical in RCTs; however, I think that the use of self-monitoring controls has somewhat reduced the variability and inconsistency that “usual care” can bring to trials like this. The authors felt this was a limitation, but I think it could be a strength.

First, there were large sample sizes; however, it is an obvious limitation lowering application compliance rates and subsequent rates being lost to follow-up. Application enrollment was approximately 80% in both studies, and the overall follow-up rate was 47.8% (95% CI 35.8–60.0). The authors state that this is not unusual in implementation studies and that they feel there are still enough participants for a “conservative estimate,” but I feel it also says something about the program. the acceptability of the intervention.

The generalizability of the results is limited The population was predominantly white, female, and university educated. However, the selection process used a number of recruitment strategies: online and website advertising, social media and press campaigns, newsletters and other circulars, and notice boards in schools, colleges, and universities. The paper did not say what the demographics of the final follow-up groups were – which might be interesting to note, especially if there were differences.

The research focused on self-help programs, and comments about improving uptake with human intervention are valid, although this would completely change the research, costs, and opportunities.

Some may view the lack of usual care control conditions as a limitation – but since such conditions typically introduce variability into trials, is this really a strength?

Implications for practice

These results add to the evidence base for efforts to reduce the global burden of poor mental health in young people. are more selective and more effective at preventing at-risk populations than universal efforts to promote mental well-being..

A byproduct of this study highlights the benefits of CBT practice. The app itself is said to be automated, scalable, non-consumable and cost-effective – could it become a public mental health intervention?

The ECoWeB trial provides further evidence that universal interventions are not effective in healthy populations, and we need to move beyond this study.

With advances in technology, we may overlook some of the more traditional methods of disease promotion or prevention (such as contact and communication); like the video that killed the radio star…

Statement of interest

I have no conflicting interests related to this paper.

Connections

Primary documents

Watkins, Edward R et al. (2024) An emotionally competent self-help mobile phone app and a cognitive behavioral self-help app and self-monitoring app (ECoWeB PROMOTE) to promote mental well-being in healthy young adults: an international, multicenter, parallel, open-label, randomized controlled trial. Lancet Digital Health, Online First October 4 2024 https://doi.org/10.1016/S2589-7500(24)00149-3

Watkins, Edward R et al. (2024) An emotional competence self-help program and cognitive behavioral self-help and self-monitoring program to prevent depression in high-risk young adults (ECoWeB PREVENT): an international, multicenter, parallel, open-label, randomized controlled trial Lancet Digital Health, Online First October 4 2024 https://doi.org/10.1016/S2589-7500(24)00148-1

Other references

OfCom Children and Parents: Media Use and Attitudes 2023 Posted on March 29, 2023

Haidt, J. (2024). A disturbed generation: How the great restructuring of childhood is causing an epidemic of mental illness. Penguin books.

Kornatska, S. (2024). Can a DBT-based school intervention improve adolescent well-being? Mental Elf.

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