Identifying prevention strategies for adolescents to reduce their risk of depression: A Delphi consensus study

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Identifying prevention strategies for adolescents to reduce their risk of depression: A Delphi consensus study Kathryn E. Cairns, Marie B.H. Yap, Nicola J. Reavley, Anthony F. Jorm

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S0165-0327(15)00319-5 http://dx.doi.org/10.1016/j.jad.2015.05.019 JAD7455

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Journal of Affective Disorders

Received date: 23 February 2015 Revised date: 8 May 2015 Accepted date: 8 May 2015 Cite this article as: Kathryn E. Cairns, Marie B.H. Yap, Nicola J. Reavley, Anthony F. Jorm, Identifying prevention strategies for adolescents to reduce their risk of depression: A Delphi consensus study, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2015.05.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Identifying prevention strategies for adolescents to reduce their risk of depression: a Delphi consensus study Kathryn E Cairns1, Marie B H Yap1,2, Nicola J Reavley1, Anthony F Jorm1

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Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Victoria, 3010, Australia. 2

School of Psychological Sciences, Monash University, Bld 17, 18 Innovation Walk, Clayton, Victoria, 3800, Australia

Corresponding author: Marie Yap Address: School of Psychological Sciences, Monash University, Bld 17, 18 Innovation Walk, Clayton, Victoria, 3800, Australia Telephone: +613 9905 0723

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Abstract Background: Adolescence is a peak time for the onset of depression, but little is known about what adolescents can do to reduce their own level of risk.

Method: This study employed the Delphi methodology to establish expert consensus on self-help prevention strategies for adolescent depression. A literature search identified 194 recommendations for adolescents. These were presented over three questionnaire rounds to panels of 32 international research and practice experts and 49 consumer advocates, who rated the preventive importance of each recommendation and the feasibility of their implementation by adolescents.

Results: 145 strategies were endorsed as likely to be helpful in reducing adolescents' risk of developing depression by ≥80% of both panels. Endorsed strategies included messages on mental fitness, personal identity, life skills, healthy relationships, healthy lifestyles, and recreation and leisure. 127 strategies were endorsed as likely to be helpful in reducing risks for depression for both junior and senior adolescents. One strategy was rated as likely to be helpful during the period of junior adolescence only, and 17 strategies were endorsed for the senior adolescent period only. Ratings of the ease of implementing the strategies during the adolescent period accorded by panellists were typically moderate.

Limitations: This study used experts from developed, English-speaking countries, hence the strategies identified may not be for relevant or minority cultures within these

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countries or for other countries.

Conclusions: This study produced a set of self-help preventive strategies for depression that are supported by research evidence and/or international experts, which can now be promoted in developed English-speaking communities to help adolescents reduce their risk of depression.

Keywords: adolescents; Delphi; depression; universal prevention; self-help

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Introduction Adolescence is a peak period for the incidence of depressive disorders, which are associated with considerable functional impairment and can have deleterious consequences that extend across the life course (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Hankin, 2006; Hankin et al., 1998). A significant proportion of young people who experience depression are not diagnosed, or do not receive appropriate care (Slade et al., 2009). Further, even if detection and treatment rates were to improve, there is evidence that only a proportion of the burden of depression can be reduced by effective treatment alone (Andrews, Issakidis, Sanderson, Corry, & Lapsley, 2004). Efforts to prevent the occurrence of depressive disorders in adolescence before they emerge, in addition to early intervention and treatment, are thus increasingly recognised as an important strategy to reduce the burden of depression at a population level. Several reviews now support the contention that depression can be prevented, or its onset delayed, during the adolescent period (e.g., Christensen, Pallister, Smale, Hickie, & Calear, 2010; Horowitz & Garber, 2006; Merry et al., 2011; Stice, Shaw, Bohon, Marti, & Rohde, 2009; van Zoonen et al., 2014). However, a major limitation of prevention programs is the resources required to provide them in an on-going way. While there are some universal prevention programs that can be delivered relatively cheaply via the internet or mobile phone applications, many programs developed to date have been resource-intensive, relying on a professional (e.g., a clinician or a teacher) to facilitate the intervention over a brief period of time. These interventions

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have often focused on those who are deemed to be at elevated risk for depression. This involves a screening element which can be inherently stigmatising and exclude a significant proportion of the adolescent population who could potentially benefit from the intervention (Pössel, 2005). Consequently, some researchers have argued that an approach to depression prevention is needed that is scalable, cost effective, and easily disseminated, given the limited resources currently available to support prevention (Cairns, Yap, Pilkington, & Jorm, 2014; Jacka et al., 2013; McLaughlin, 2011; Munoz, Beardslee, & Leykin, 2012). The promotion of universal prevention messages within the community represents one such approach. During adolescence, young people shoulder increasing responsibility for decisions that can potentially influence their mental health status, highlighting the importance of educating them about prevention strategies at this time. The potential for behavioural patterns established during this period to persist over the life course and influence long-term mental health trajectories further underscores the importance of bolstering adolescent mental health prevention literacy (Gladstone, Beardslee, & O’Connor, 2011). However, public mental health campaigns have tended to be situated at the early intervention end of the prevention spectrum, focusing on encouraging early help seeking and reducing stigma (e.g., beyondblue: the national depression initiative, 2011; Mental Health Council of Australia, 2013). There has been relatively little emphasis on equipping individuals with the knowledge and skills they need to make informed choices about factors contributing to risk of depression and other mental health problems. As noted by Jorm and Griffiths (2006), health promotion

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campaigns targeting other major contributors to disease burden, such as heart disease and cancer, routinely provide members of the public with information on actions that can be taken to minimise their personal risk profile. They called for this approach to be extended to campaigns targeting risk for depression (Jorm & Griffiths, 2006). A recent systematic review and meta-analysis identified various modifiable risk and protective factors associated with adolescent depression that have a sound evidence base (Cairns et al., 2014). Risk factors identified include substance use (alcohol, tobacco, cannabis, other illicit drugs, and polydrug use); dieting; negative coping strategies (e.g., avoidant or withdrawal coping); and weight. Protective factors identified were healthy diet and sleep. Although these findings provide guidance as to the risk and protective factors that are influential in the development of depression during adolescence, they do not adequately describe specific, actionable strategies that can be readily implemented by adolescents. To facilitate the application of this research evidence into practice, these broader risk and protective factors need to be translated into specific, practical suggestions that adolescents can act on in their daily lives (Jorm, 2012). Given the relatively rudimentary stage of the universal prevention evidence base, evaluations of interventions containing this level of implementation detail across the spectrum of preventive action are scarce. Therefore, other approaches to evaluating evidence are needed. One approach is to use researcher, practitioner and consumer advocate expertise to establish consensus on which preventive strategies are most likely to be helpful. The expert consensus approach is increasingly used in the development of

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practice guidelines for clinicians, and more recently in the development of mental health promotion guidelines for the public (e.g., Morgan & Jorm, 2009; Yap, Pilkington, Ryan, Kelly, & Jorm, 2014). In this paper, we report a Delphi consensus study on preventive strategies for adolescent depression. The aim was to identify strategies that are likely to be both effective and feasible for adolescents to implement without professional intervention. The delineation of these strategies could also provide a sound basis for the development of universal prevention interventions targeting adolescents (e.g., websites, mobile applications, school-based programs), much like a ‘behavioural vaccine’ for depression (Van Voorhees et al., 2011).

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Method Delphi method The Delphi method (Jones & Hunter, 1995) was used to establish expert consensus on strategies that adolescents at two developmental stages could apply to reduce their risk of depression. This involved two panels of experts independently rating the extent to which they believed a series of preventive strategies would be effective and feasible for an adolescent to implement without professional intervention. Researchers or practitioners with depression prevention expertise (hereafter ‘professionals’) formed one panel, while consumers who had lived experience of depression during adolescence and were currently in an advocacy role (hereafter ‘consumers’) formed a second panel. Having the former represented as a panel increases the likelihood that the preventive messages developed will conform to experts’ current understandings of the evidence base. The inclusion of the latter panel was designed to enhance the relevance and authenticity of the resultant messages. Each panel was asked to reflect on the helpfulness and the feasibility of the strategies for junior adolescents (aged 12-15 years) and senior adolescents (aged 16-18 years), in recognition of the varying salience of risk and protective factors and the different developmental contexts associated with these two phases of adolescence. Following each questionnaire round, panel members were provided with summaries of the findings from the previous round, and asked to consider whether they would like to change or maintain their original rating.

Panel formation All panellists were required to be aged 18 years or older and reside in an English-speaking, Western country. The professional panel comprised experts with a minimum of five years’ experience in researching depression prevention, or who were involved in depression prevention

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in practice or clinical work. To identify these panellists, key publications and reviews in the fields were identified and their authors invited to participate. Further, members of key prevention research consortia (e.g., The Alliance for the Prevention of Mental Disorders; The Global Consortium for Depression Prevention) were invited to participate. Individuals known to the authors as having relevant research experience were also invited to participate. The consumer panel comprised individuals who had personal experience with depression as an adolescent, were currently well, and were active as an advocate for mental health (e.g., via peer support, public awareness raising), to ensure they had sufficient understanding of the diversity of mental illness experience. These panellists were recruited with the support of several mental health consumer organisations. As the aim of a Delphi study is to achieve consensus rather than investigate group differences, conventional notions of statistical power are not relevant. Rather, the target sample size was based on the experience of earlier studies using this methodology. One study found that reliable results could be achieved in a Delphi consensus study using 23 panellists (Akins, Tolson, & Cole, 2005). In this study, we aimed to recruit a minimum of 30 participants per panel (i.e., 30 consumer advocates and 30 research experts) to allow for some attrition across questionnaire rounds. It is noteworthy that Delphi panels do not aim for representativeness in membership. Rather, panel members are intentionally selected to be “information rich”; thus professional panellists investigating a wide range of research foci within the broader field of youth depression prevention, and consumer panellists with lived experience and a diversity of advocacy experiences were approached to participate. Experts were recruited via an email invitation designed to solicit interest from potential panel members. Interested individuals were instructed to email the first author with expressions of interest. Upon receipt of expressions of interest, the first author emailed potential panellists with a plain language description of the study that outlined the eligibility criteria, the contribution 9

required by panel members, and the voluntary nature of participation. They were also emailed a link to the online questionnaire; informed consent was implied if they choose to complete the first round of the questionnaire. The project was approved by the Human Research Ethics Committee at the University of Melbourne.

Literature search for possible preventive strategies A literature search was conducted with the aim of developing a questionnaire covering the full range of possible strategies that adolescents could adopt to reduce their risk of depression. This search involved a systematic search of websites identified by entering the search terms ‘depression AND (prevent OR prevention) AND (adolescent OR teenager OR youth)’ into five search engines (Google; Google Australia; Google Canada; Google New Zealand; Google UK). The top 50 websites identified through these searches were screened for all recommendations for adolescents to prevent or reduce their risk of depression. In addition, targeted searches were conducted across the five search engines using the above search string with the addition of a keyword or words that corresponded to each of the themes that emerged in a systematic literature review of modifiable risk and protective factors for depression during adolescence (Cairns et al., 2014; see Online Supplement 1 for a full list of search terms). The top ten websites generated by these searches were screened for recommendations for adolescents to prevent or reduce risk of depression. Relevant links in the screened websites were also examined for applicable preventive strategies. A search for books containing relevant information was conducted by entering the search terms "Prevent adolescent depression" into Amazon (http://www.amazon.com); however this search did not identify any relevant sources. The quality or veracity of the websites from which strategies were extracted was not assessed, as it was our intention to sample the totality of guidance available to adolescents on the internet with regards to depression prevention. However, in having the two expert panels rate the statements for

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helpfulness and feasibility, we expected to eliminate any strategies that were potentially unhelpful or impractical for the target audience.

Questionnaire development The literature search identified 773 prevention strategies from 114 website sources (279 webpages). A large number of items were repetitive in content (although worded differently), and many items combined multiple recommendations in a single statement, or contained implementation detail which was considered out of scope for the focus of the present study. A content analysis was conducted by one author (KC) to group similar items, resulting in 35 themes. These thematically grouped items were then presented to a working group (KC, MY, NR, and AJ). The working group was responsible for ensuring that all ideas within the statements identified in the literature search were represented and that items were clear, not repetitive, and actionable by adolescents. Through this process of content analysis, 194 unique prevention strategies were identified and organised into six higher-order themes by the working group: Mental fitness, Personal identity, Life skills, Healthy relationships, Healthy lifestyles and Recreation and leisure. Definitions for these themes are provided in Online Supplement 2. The questionnaire included definitions of key terms. Depression was defined as depressive disorders such as Major depressive disorder, Minor depressive disorder, Dysthymia and unspecified depressive symptomatology, following the DSM-V diagnostic criteria for these various depressive disorders (American Psychiatric Association, 2013). Adolescents were defined as individuals between the age of 12 and 18 years, with a junior adolescent aged between 12 and 15 years and a senior adolescent aged between 16 and 18 years.

Questionnaire administration The questionnaire was administered over three rounds using web-based survey software (http://www.surveymonkey.com). The panels were given 12 weeks to complete Round 1, six 11

weeks to complete Round 2, and three weeks to complete Round 3. Non-responders were sent up to three email reminders for each round. The Round 1 questionnaire consisted of items identified from the literature search containing potential prevention strategies, following review by the working group. Panel members were asked to rate the helpfulness of items for preventing the development of depression among a) junior adolescents (12-15 years); and b) senior adolescents (16-18 years) as 1 = Very likely helpful, 2 = Likely helpful, 3 = Not likely helpful or 4 = Uncertain. Panel members were instructed that ratings could be based on whatever sources of knowledge were available to them, including research evidence, theoretical understanding of depression, practice experience in preventing or treating depression and personal experience of depression. Panel members were provided with evidence summaries from a systematic review of modifiable risk and protective factors for depression (Cairns et al., 2014) as one source of evidence to consider in their ratings1. Panellists were also given the opportunity to suggest additional statements not included in the Round 1 questionnaire, to be rated in Round 2. Suggestions judged by the working group to be new ideas were drafted into items and included in the Round 2 questionnaire. In Round 2, a summary of the results was provided to panel members, indicating which strategies in the Round 1 questionnaire reached consensus and were endorsed, which strategies were rejected, and which strategies did not establish clear consensus and required re-rating. Rerating allows panel members to reconsider their opinions in the light of other panellists’ ratings, as well as consider any new preventive strategies proposed by panellists in Round 1. An additional step was undertaken in the Round 2 questionnaire to assess the feasibility of both the strategies endorsed for adolescent prevention depression in Round 1, and those to be re-

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Evidence summaries were available for the following sub-themes within the questionnaire: coping strategies; emotion regulation; family and peer relationships; spirituality; employment; leaving home; romantic relationships; substance use; sleep; healthy diet; being active; weight; media use; sport; and extracurricular activities. 12

rated in Round 2. For each strategy, panellists were asked to indicate whether it could be easily implemented by junior adolescents, senior adolescents, both junior and senior adolescents, or neither junior nor senior adolescents. Panel members were instructed that these ratings should be based on the effort, resources, and expertise/knowledge required to enact the strategy. Knowledge-based items (i.e. those commencing with the stem “The young person should know that…”) were not presented to panellists for rating the ease of implementation. New items in Round 2 that did not establish clear consensus were re-rated in the third and final round. Items from Round 1 that were re-rated in Round 2 and did not achieve sufficient consensus a second time were excluded. Members of the panel were not given the opportunity to suggest additional statements in Round 2. Therefore, Round 3 consisted solely of items from Round 2 that required re-rating due to an inadequate level of consensus.

Statistical analysis After each questionnaire round, participants’ responses for each item and for each developmental level were collated and analysed to determine which items reached consensus. Following the conventions of similar Delphi consensus studies (Reavley, Ross, Killackey, & Jorm, 2012) the following cut-off points were used to define consensus with respect to the helpfulness of the strategies: 1. Endorsed. If between 80 and 100% of participants rated a statement as either ‘Very likely helpful’ or ‘Likely helpful’, it was endorsed as a prevention strategy. 2. Re-rate. Strategies which were rated as ‘Very likely helpful’ or ‘Likely helpful’ by 80% (or more) of one panel only were included in the subsequent questionnaire round for re-rating. Those items that did not reach the desired level of consensus, but fell between 70% and 79.9% for both panels were also included for re-rating. Items were re-rated once only.

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3. Rejected. If none of the above conditions were met, a strategy was excluded from subsequent rating rounds. For defining consensus for the feasibility ratings, a cut-off point of 60% was used (i.e., if >60% of both panels rated a strategy as easy to implement by both junior and senior adolescents). The cut-off score for feasibility was lower, because while the aim of the helpfulness ratings was to identify a list of strategies about which there is high consensus on their likely helpfulness in prevention, the aim of the feasibility ratings was to facilitate a rank ordering of the strategies. Thus, the more feasible strategies were selected out for promotion from the set that are likely to be helpful.

Results Panel members Thirty-two professionals and 49 consumers participated in Round 1. Overall, 52 (64.2%) were female (47% of professionals and 75.5% of consumers) and 29 (35.8%) were male (53% of professionals, 24.5% of consumers). The professional panel members were aged 31-83 years (M = 51.94, SD = 12.19), while the consumer panel members were aged 19-69 years (M = 31.90, SD = 14.58). Professionals’ self-identified areas of expertise included: ‘research investigating both prevention and treatment of mental disorders in childhood/adolescence’ (n=17, 53%); ‘research in risk and protective factors associated with depression during childhood/adolescence’ (n=12, 38%); ‘practical or clinical experience in both the prevention and treatment of mental disorders in childhood/adolescence’ (n=8, 25%); ‘research investigating the prevention of mental disorders in childhood/adolescence’ (n=7, 22%); ‘practical or clinical experience in the prevention of mental disorders in childhood/adolescence’ (n=2, 6%); and policy expertise (n=1, 3%). Thirteen participants nominated more than one area of expertise. Of the professionals, 18 were from Australia, eight were from the United States of America, five were from the United Kingdom, and 14

one was from New Zealand. Of the consumer advocates, 47 were from Australia and two from Canada. Some panel attrition occurred over the three questionnaire rounds. The Round 2 questionnaire was completed by 22 professionals out of 32 (69% of Round 1) and 26 consumers out of 49 (53%), while the Round 3 questionnaire was completed by 20 (63% of Round 1) professionals and 20 (48%) consumers.

Helpfulness of strategies There were 1452 strategies endorsed by both panels: 94 in Round 1, 66 in Round 2 and 0 in Round 3 (see Table 1). Consumers endorsed more strategies than professionals (291 vs 182 in the first round). There were some large differences in endorsement of helpfulness between the two expert panels (see Table 2), particularly for the following strategies: ‘If the young person is feeling sad or overwhelmed, or experiencing a difficult time, they should employ positive coping strategies, such as: going to a quiet spot with no one around and expressing their feelings (e.g., cry or scream)’; and ‘The young person should use music to provide a backdrop for self-reflection, for understanding sadness or grief, and to help them explore their emotions’. Ratings of helpfulness between panels were significantly correlated (Round 1 r= 0.71, p < 0.01). The items which were rejected over the course of the three questionnaire rounds are provided in Online Supplement 3.

Ease of implementation of endorsed strategies The endorsed strategies accorded the highest ease of implementation ratings (i.e., rated as easily implemented by both junior and senior adolescents by >60% of both panels) are indicated with an asterisk in Table 1. The ease of implementation ratings for each of the endorsed prevention strategies are provided in Online Supplement 4. Feasibility ratings were on average

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Some strategies were endorsed for one developmental period in Round 1, and the other developmental period in Round 2. The total number of strategies endorsed is thus less than the total number endorsed in the respective rounds. 15

moderate (between 40% and 70%), with strategies typically being rated as easier for senior adolescents to implement, relative to junior adolescents. Consumer panellists tended to be more conservative in making their feasibility ratings than professional panellists.

Discussion This study sought to address the issue of what adolescents can do to reduce their risk of developing depression. We aimed to establish expert consensus on key prevention messages to inform the development of resources that can provide practical, evidence-based advice to adolescents at various stages of development. In total, 127 strategies from a comprehensive range were endorsed by the panellists as likely to be helpful in reducing risks for depression for both junior and senior adolescents. In addition, one strategy was rated as likely to be helpful during the period of junior adolescence only, while 17 other strategies were endorsed for the senior adolescent period only. In general, there was a high level of consensus within and across the professional and consumer panels about what is likely to be both helpful and easily implemented by adolescents. Statements that emphasised developing Mental fitness or resilience and Life skills, fostering Healthy relationships, and adopting Healthy lifestyles were highly endorsed by a consensus of the panellists. Items endorsed by 100% of both panels (n=4) related to getting enough sleep each day, both in everyday life and when feeling sad or overwhelmed, seeking professional help for a problem if it becomes too difficult to manage on their own, and taking time to learn about what makes them feel good and remembering to include some of those things in their day. However differences between the panels were evident for a small number of strategies. In particular, the topics of Personal identity and Recreation and leisure were endorsed more strongly by consumer advocates than by professional panellists. These differences likely represent the different

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perspectives and experiences these different experts drew on in rating the helpfulness of prevention strategies. Many of the strategies endorsed by the experts as helpful have a strong empirical base, as outlined in our systematic review of modifiable risk and protective factors for adolescent depression (Cairns et al., 2014). However some themes with a strong evidence base were not endorsed as helpful by panellists, such as abstaining from alcohol, tobacco and illicit drug use. Comments provided by some panellists suggested that the framing and messaging of these strategies was seen as critical to their uptake by adolescents, which may account for the rejection of these items as presented to the panellists. This is supported by the observation that a number of related items on substance use which were more nuanced were endorsed by the panellists (e.g., avoiding the use of alcohol or drugs to cope with their emotions). A number of themes without supporting evidence were also endorsed by a high proportion of both panels (e.g., getting involved in structured extracurricular activities, Cairns et al., 2014). Of the 145 endorsed strategies, 31 were rated as easy for both junior and senior adolescents to implement by >60% of both panels. The strategies rated as hardest to implement tended to be those with elements of cognitive-behavioural therapy or positive psychology, strategies requiring more advanced interpersonal skills, and those that would require the adolescent to deviate from what might be considered normative adolescent behaviours (e.g., substance use, sexual activity, and staying up late using electronic devices). Those rated as easiest to implement tended to be simple or lifestyle-related practices, which could be more readily integrated into adolescents’ daily lives without considerable effort on the part of the adolescent, such as making time for enjoyable activities, looking after their physical health, and staying socially connected. Feedback provided by the professional expert panel indicated that making judgments about the ease of implementation of the strategies was complex, given the differences in the 17

personal circumstances, resources and capabilities of adolescents across this period of development. For example Professional Panellist 1 acknowledged the complexities inherent in making these judgments: “The feasibility questions were difficult to answer as so much depends on context: are the family intact; is the school functioning etc.” Another panellist noted: “Something might be easy to implement practically (independent of support), but social factors such as peer-pressure could make it difficult.” (Professional Panellist 25). Another panellist alluded to the gap between knowledge and behaviour: “I think in most cases the young people have the capacity to learn new information in a self-directed fashion but whether that translates to action is another matter and far more difficult to achieve.” (Professional Panellist 8). It appeared that many respondents were factoring ease of implementation into their judgments about the helpfulness of strategies without being explicitly prompted to do so, which likely contributed to a number of statements being endorsed for one developmental level and rerated for another in the first questionnaire round (e.g., using online courses or other resources to learn cognitive-behavioural coping strategies).

Strengths and limitations The study utilized a well-established method that is widely used to develop mental health promotion guidelines (e.g., Morgan & Jorm, 2009; Ross, Hart, Jorm, Kelly, & Kitchener, 2012; Yap et al., 2014). Although there is a growing body of web-based resources on what adolescents can do to protect their mental health, to our knowledge this is the first to be formulated using a systematic, evidence-based approach. These key messages were developed based on the expertise of both consumers and professionals, from a variety of English-speaking countries. This strengthens their external and face validity, by integrating scientific evidence, practitioner experience, and personal experience of depression during this developmental period.

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This study did suffer from a relatively high rate of attrition over the three questionnaire rounds, more so for the consumer panel than the professional panel, which may have served to introduce bias into consensus levels in later questionnaire rounds. This is a commonly noted limitation associated with this methodology, often attributed to the requirement of active participation of panellists over an extended period of time, with particularly lengthy responses required in the early rounds of the process (Dawson & Brucker, 2001; Hsu & Sandford, 2007; Ivankova, Creswell, & Stick, 2006). Considerable effort was made in the design and conduct of the study to reduce the burden of participation for panellists. However, the large scope of the project meant that the commitment required of participants was considerable, which is likely to have influenced the observed attrition rates. A number of respondents raised concerns that the study did not sufficiently acknowledge the diversity of adolescents’ individual circumstances (e.g., quality of social networks), and some respondents felt that the use of the phrasing “The young person should” was too prescriptive. Following other studies of a similar nature (e.g., Morgan & Jorm, 2009), rather than identifying a smaller number of strategies that are likely to benefit all adolescents, we chose to present a larger menu of strategies that adolescents can select from according to their personal circumstances and preferences. Reavley et al. (2012) previously identified one of the challenges of developing guidelines as balancing specificity (i.e., precise enough to be useful to the individual) with generality (i.e., so as to be applicable to most people). As these strategies were pitched at a universal prevention level (Institute of Medicine, 1994), they are designed to be generalisable to most adolescents. However, as all panellists were recruited from developed English-speaking countries, it is not expected that the messages endorsed will necessarily be generalisable to other countries or to minority cultures within developed English-speaking countries. Finally, the cut-off point for defining consensus for the ease of implementation ratings was determined somewhat arbitrarily by the working group, as there was no precedent available 19

within similar Delphi consensus studies in the literature. The feasibility of adolescents enacting the endorsed strategies should be established in future research, given the conservative ease of implementation ratings they were accorded by the panellists in this study.

Conclusion The identified strategies can now be disseminated to the public as evidence-based, developmentally appropriate mental health promotion and education messages within youth and family settings. They could also serve as a foundation for the development of future self-help preventive interventions for youth, which could be delivered via web-based or mobile phone technologies. Most universal prevention programs have focused their programs more narrowly, to concentrate on, for example, cognitive-behavioural (e.g., MoodGYM; Calear, Christensen, Mackinnon, Griffiths, & O’Kearney, 2009) and/or interpersonal strategies (e.g., CATCH-IT; Van Voorhees et al., 2009). The set of strategies identified in this study is broader and more inclusive in scope, and thus covers content domains not typically seen in universal programs that have been delivered to date (e.g., healthy lifestyles). This provides adolescents with a larger menu of prevention strategies from which they may select those that are most appealing to them. Further, the emphasis within this study was on self-help prevention strategies that adolescents could feasibly implement and integrate into their lifestyle without professional assistance, or engagement with a program over an extended period of time. However, these strategies need to be subject to further research and evaluation before their feasibility and subsequent impact on reducing risks for the development of depressive disorders during adolescence can be determined.

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Role of Funding Source Author Cairns was funded by an Australian Postgraduate Award Scholarship. Additional funding for the study was provided by National Health and Medical Research Council Australia Fellowships to Author Yap (1061744) and Author Jorm (566652). The funding source had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Acknowledgments The authors would like to thank the expert panellists who generously contributed their time and expertise by participating in this study. We would also like to acknowledge the Alliance for the Prevention of Mental Disorders as well as the numerous mental health consumer organisations that supported recruitment of expert panellists by promoting the study within their networks. The authors also acknowledge the NHMRC from whom Jorm, Yap and Reavley all received salary support.

Conflict of Interest The authors declare that they have no conflict of interest.

Contributors Authors Cairns, Jorm and Yap developed the review protocol. Author Cairns conducted the literature review. All authors participated on the working group. Author Cairns wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

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Jacka, F. N., Reavley, N. J., Jorm, A. F., Toumbourou, J. W., Lewis, A. J., & Berk, M. (2013). Prevention of common mental disorders: what can we learn from those who have gone before and where do we go next? Australian & New Zealand Journal of Psychiatry, 47(10), 920-929. doi: 10.1177/0004867413493523 Jones, J., & Hunter, D. (1995). Qualitative research: consensus methods for medical and health services research. British Medical Journal 311(7001), 376-380. doi: 10.1136/bmj.311.7001.376 Jorm, A. F. (2012). Mental health literacy: empowering the community to take action for better mental health. American Psychologist, 67(3). doi: 10.1037/a0025957 Jorm, A. F., & Griffiths, K. M. (2006). Population promotion of informal self-help strategies for early intervention against depression and anxiety. Psychological Medicine, 36(01), 3-6. doi: 10.1017/s0033291705005659 McLaughlin, K. A. (2011). The public health impact of major depression: a call for interdisciplinary prevention efforts. Prevention Science, 12(4), 361-371. doi: 10.1007/s11121-011-0231-8 Mental Health Council of Australia. (2013). World Mental Health Day 2013 Campaign Report. . Retrieved July 9, 2014, from https://mhca.org.au/sites/default/files/docs/mhca_world_mental_health_day_campaign_re port_2013.pdf Merry, S. N., Hetrick, S. E., Cox, G. R., Brudevold-Iversen, T., Bir, J. J., & McDowell, H. (2011). Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews(12). doi: 10.1002/ebch.1867 Morgan, A. J., & Jorm, A. F. (2009). Self-help strategies that are helpful for sub-threshold depression: A Delphi consensus study. Journal of Affective Disorders, 115(1), 196-200. doi: 10.1016/j.jad.2008.08.004 Munoz, R. F., Beardslee, W. R., & Leykin, Y. (2012). Major Depression Can Be Prevented. American Psychologist, 67(4), 285-295. doi: 10.1037/a0027666 Pössel, P. (2005). Strategies for universal prevention of depression in adolescents. Journal of Indian Association for Child and Adolescent Mental Health, 1(1), 5. Reavley, N. J., Ross, A. M., Killackey, E. J., & Jorm, A. F. (2012). Development of guidelines to assist organisations to support employees returning to work after an episode of anxiety, depression or a related disorder: a Delphi consensus study with Australian professionals and consumers. BMC psychiatry, 12(1), 135. doi: 10.1186/1471-244x-12-135 Ross, A. M., Hart, L. M., Jorm, A. F., Kelly, C. M., & Kitchener, B. A. (2012). Development of key messages for adolescents on providing basic mental health first aid to peers: a Delphi consensus study. Early Intervention in Psychiatry. doi: 10.1111/j.1751-7893.2011.00331.x Slade, T., Johnston, A., Teesson, M., Whiteford, H., Burgess, P., Pirkis, J., & Saw, S. (2009). The Mental Health of Australians 2. Report on the 2007 National Survey of Mental Health and Wellbeing. Canberra. Stice, E., Shaw, H., Bohon, C., Marti, C. N., & Rohde, P. (2009). A meta-analytic review of depression prevention programs for children and adolescents: factors that predict magnitude of intervention effects. Journal of Consulting and Clinical Psychology, 77(3), 486. doi: 10.1037/a0015168 The Alliance for the Prevention of Mental Disorders. from http://apmd.org.au/ The Global Consortium for Depression Prevention. from http://www.preventionofdepression.org/ Van Voorhees, B. W., Fogel, J., Reinecke, M. A., Gladstone, T., Stuart, S., Gollan, J., . . . Ross, R. (2009). Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes. Journal of Developmental & Behavioral Pediatrics, 30(1), 23-37. Van Voorhees, B. W., Mahoney, N., Mazo, R., Barrera, A. Z., Siemer, C. P., Gladstone, T. R. G., & Muñoz, R. F. (2011). Internet-based depression prevention over the life course: a call for

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Tables Table 1 Strategies endorsed by at least 80% of both panels

Prevention strategy

Mental fitness The young person should develop positive strategies to help them cope with everyday life, such as… avoiding the use of alcohol or drugs to cope with their emotions.1 *trying something new that they can gain new skills from or that they may find entertaining, fun, or challenging.1 *spending time with their family.2 eating healthily.1 doing regular exercise.1 getting enough sleep each day.1 *taking time to relax and doing things they enjoy.1 using online courses or other resources to learn cognitive-behavioural coping strategies.1 using relaxation methods (e.g. progressive muscle relaxation, autogenic training, breathing exercises, self-hypnosis).2 learning to understand and work through feelings of anger, sadness or rejection and get beyond them.1 learning about and practising self-compassion strategies and exercises (e.g., being kind and warm in the face of failure or setbacks rather than harshly judgmental and self-critical).2 not taking risks such as fast driving or unsafe sex. 2,1 If the young person is feeling sad or overwhelmed, or experiencing a difficult time, they should employ positive coping strategies, such as… *seeking help from a trusted and empathic adult.1 confiding in people they trust so that others know what they are going through.1 avoiding using alcohol or drugs to cope with their emotions.1 *sticking to their usual routine, and maintaining interests or hobbies.1

Develop mental perioda endorsed for

Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Senior Senior Junior, senior Junior, senior Junior, senior

Junior, senior Junior, senior Junior, senior Junior, senior

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*trying something new that they can gain new skills from or that they may find entertaining, fun, or challenging.1 using online courses or other resources to learn cognitive-behavioural coping strategies.2 using relaxation methods (e.g. progressive muscle relaxation, autogenic training, breathing exercises, self-hypnosis).2 working out the cause or triggers of their negative feelings and developing strategies to manage these feelings.1 working out the cause or triggers of their negative feelings and developing strategies to solve the underlying problem.1 learning to understand and work through feelings of anger, sadness or rejection and get beyond them.2 eating healthily.1 *doing regular exercise.1 getting enough sleep each day.1 taking a problem-solving approach.1 *getting help from others to work out practical solutions to problems.1 trying not to stay all alone in their room, especially during the day.1 trying to be around people who are caring and positive.1 *taking time to relax and doing things they enjoy.1 not expecting to bounce back immediately, and accepting that they will have good days and bad.1 *taking a break and doing something to cheer themselves up.2 reminding themselves of their good qualities and what they like about themselves.2,1 not taking risks such as fast driving or unsafe sex. 2,1 not withdrawing from others.1 not engaging in self-harm. 1 visualising or writing a list of situations they have handled well and thinking about these when going into stressful situations.2 The young person should… try to identify and use the best coping strategies for them (e.g., by thinking about coping strategies that have worked for them in the past, exploring new strategies and assessing whether they work).1 seek out peers or adults who practice positive coping strategies, so that they can learn from them and elicit support to use these strategies in their own life.2 seek professional help (e.g., Lifeline or Kids Helpline, visiting a doctor, or online counselling) if a problem becomes too difficult for them to manage on their own. 1 know about resources to help them challenge unhelpful ways of thinking.1

Junior, senior Senior Senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior,

26

*use exercise, if feeling angry or anxious, to help them cope with these feelings.2 learn to identify unhelpful ways of thinking and practise some strategies that will allow them to challenge these.1 engage in problem-solving: gather information about the problem, think of possible solutions, weigh the pros and cons of each option.1 learn to identify and name their emotions.1 learn how to rate the intensity of their feelings at different times and on different days so that they can see changes and patterns.2 make a list of their fears and grade them in order of difficulty. Starting with one of the more manageable ones, they should challenge themselves to have a go at dealing with it constructively instead of avoiding it.2 learn about the physical signs that indicate that they are feeling strong emotions.1 *regularly do kind things for other people, such as helping a friend or relative with their chores, or volunteering for a charity.1,2 *perform acts of kindness that help other people, without expecting anything in return.2 *express their appreciation to people who are important to them.2 *set aside time at the end of each day to remember and reflect on positive events that occurred that day.2 learn techniques to help them savour pleasant experiences.2 *do something distracting to break a negative train of thought (e.g., play a game, look at what's going on outside their window for a few minutes, change their body posture).2 when faced with a negative thought or moment, try to look at the situation from a different angle to see if there is anything positive that can come out of it.2,1 practise everyday mindfulness: bring attention to current experience and nonjudgementally observe thoughts, feelings and sensations.2,1 learn to identify their personal strengths, and find ways to use them more.1

senior Junior, senior Junior, senior Junior, senior Junior, senior Senior Senior

Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior

learn about what to do and who to speak to if they are questioning whether their emotions are normal, or thinking that they may possibly have depression.2

Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior

Personal identity The young person should… try to cultivate a positive self-view (e.g., by thinking of things they are good at, focusing on what they have already achieved).1 know about strategies to improve their own body image.2 reflect on what is really important to them in their life, and act on this.2 talk to an adult they trust and respect if they have questions or concerns about their sexuality.2

Junior, senior Senior Senior Junior, senior

develop their personal strengths, and try to acquire new strengths.2 learn ways, other than eating, to manage their mood.2

27

Life skills The young person should learn to use effective communication strategies, including … communicating assertively, rather than passively or aggressively.1 seeing things from another person's point of view, negotiation, and conflict resolution.1 identifying and responding appropriately to non-verbal behaviour.2 *speaking to others respectfully.2 *listening to others and asking questions if they don't know what the person means.1 using strategies that can help them avoid arguments when discussing sensitive topics (e.g., using I-messages like "I feel...", using a calm voice, offering a solution).1 *not putting other people down.2,1 telling people respectfully if they are offended by what has been said.1 knowing how to plan for a difficult or sensitive conversation with people in their social network (e.g., family members, peers, an employer or colleague, coach).1 If the young person is being bullied, they should… *seek help from a friend.1 seek help from a parent.1 talk to a teacher or counsellor to see if they can help.1 approach the person who is bullying them and tell them that their behaviour is unwanted and that they won't put up with it, if they feel safe and confident to do so.2 If the young person is being bullied in the workplace, they should talk to a manager or supervisor about the problem, and if this doesn't work they should check any relevant workplace policies or contact organisations that may be able to assist (e.g., local workers compensation authority or a trade union).2 The young person should… learn how to form friendships and maintain healthy relationships.1 take time every week to plan their time, note deadlines, and prioritise their commitments.1,2 learn to recognise signs that they might be stressed or anxious or need a break (e.g. feeling irritable, not sleeping well, having difficulty concentrating).1 practise regular goal-setting: set specific goals that are achievable, work from smaller to larger goals, and monitor progress.1 find a balance between their work and home life that feels right for them.1 seek assistance and support from family and friends, or available services if they are leaving home.1 take time to consider the emotional impact that leaving home may have, and to prepare themselves for this, if they are considering leaving home for the first time.2 Healthy relationships The young person should… use strategies to build or maintain a positive relationship with their parent/s (e.g.,

Junior, senior Junior, senior Senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior Junior, senior Senior Senior

Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Senior

Junior,

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keeping the lines of communication open, respecting rules as much as possible, disagreeing without being disrespectful).1 *stay connected with supportive friends and family.1 learn about other avenues of support that are available to them if they have an unhealthy or dysfunctional relationship with their parents.2 *spend time with peers who have positive goals and are involved in positive activities.1 avoid isolating themselves.1 avoid or minimise contact with people who tend to make them stressed or feel bad about themselves.1 *be involved in their community (e.g., join a sporting club, faith/spiritual community or youth group).1 If the young person is in a romantic relationship, they should… communicate openly with their partner without shouting or yelling. They should listen to each another, respect each other's opinions, and be willing to compromise.1 respect their partner's culture, beliefs, opinions and boundaries.1 make consensual sexual decisions.2,1 be honest with their partner, although they may still choose to keep certain things private.2 respect their partner's need for personal space.2 If the young person decides to become sexually active, they should practice safe sex.2

The young person should… *know that healthy relationships can reduce their risk of depression, while unhealthy relationships can increase their risk.2 learn to recognise an unhealthy relationship.1 take steps to end an unhealthy relationship.1 know about resources that can help them with their relationships.1 take time to evaluate the quality of their interpersonal relationships, and end those that are unhealthy or unsupportive.2 Healthy lifestyles The young person should know that… using alcohol affects the chemistry of the brain, increasing the risk of depression.2,1 while alcohol use can cause short-term improvements in mood, it usually has the opposite effect in the long term, and can lead to feelings of depression.1 because areas of the brain are generally still developing into their twenties, they are more likely to experience the negative effects of alcohol at this time. Heavy alcohol

senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Senior Junior, senior Both junior and senior adolesce nts Junior, senior Junior, senior Junior, senior Junior, senior Senior

Junior, senior Junior, senior Junior, senior

29

use can cause brain damage resulting in learning difficulties, memory problems, and anxiety and depression.2 those who use alcohol regularly are more likely to experience alcohol dependence, depression, other mental health problems, and more general problems in life (e.g., conflict at home or school / work, financial problems).2 The young person should... know about strategies to avoid or limit drinking alcohol in situations where there is peer pressure to drink.1 If the young person decides to drink alcohol, they should… think about how much, when and why they drink.1 know about strategies to keep themselves safe while drinking.2,1 know about strategies to cut back on drinking (e.g., alcohol-free days) if they are concerned that they might be drinking too much. 2,1 know about resources that can help them manage their alcohol use.2 seek professional help if they are worried about, or want help to manage, their drinking.1 The young person should know that… adolescents are particularly at risk for drug-related harms since their brains are undergoing rapid, extensive development.2 although the immediate effect of drug use may be pleasant and cause feelings of relaxation or euphoria, it usually has the opposite effect in the long term, and can lead to feelings of depression.2,1 those who use drugs regularly are more likely to experience dependence on the drug, depression, other mental health problems, and more general problems in life (e.g., conflict at home or school / work, financial problems and memory problems).1 the risks for depression associated with drug use may be greatest for those who use both drugs and alcohol.2 using illicit drugs affects the chemistry of the brain, increasing risk of depression.2,1 those who start using drugs earlier (early adolescence) are more likely to experience depression, other mental health problems and general life problems (e.g., conflict at home or school / work, financial problems and memory problems).1 The young person should… seek professional help if they are worried about, or want help to manage, their drug use.1 learn about strategies to keep themselves safe, if they decide to use illicit drugs.2 talk to a trusted friend or family member if they are worried about, or want help to manage their drug use.1 know about strategies to cut back on using (e.g., drug-free days), if they are concerned that they might be using too much.2 use resources to help them quit smoking (e.g., Quitline, nicotine patches).2 seek professional help if they have difficulty quitting smoking.1 The young person should… practise good sleep hygiene (habits that promote healthy sleep such as maintaining a regular sleep pattern, improving their sleeping environment, relaxing their mind, and avoiding drugs).1 maintain a regular sleep schedule: get enough sleep at night and have a bedtime and

Junior, senior

Junior, senior Junior, senior Junior, senior Junior, senior Senior Junior, senior Senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior

Junior, senior Junior, senior Junior, senior Junior, senior Senior Junior, senior Junior, senior Junior,

30

rising time that varies little from day to day.1 aim to get 8-10 hours of sleep a night.1 take a break from using electronic devices (texts, emails, calls) during their scheduled sleep time.1 *regularly engage in exercise or physical activity (e.g. sport, walking, swimming).1 follow national physical activity guidelines.2 limit their intake of junk and processed foods (e.g., chips, fried foods, chocolate, and ice cream).2 eat regular meals and not skip breakfast.2 be aware of resources that can help them to get active.2 *have some exposure to natural sunlight every day.1 try to achieve or maintain a healthy body weight.1 avoid dieting, over-exercising or other unhealthy methods of losing weight.2

Recreation and leisure The young person should… *take time to laugh, have fun and be around people who make them feel good.1 *take time to learn about what makes them feel good and remember to include some of those things in their day.1 *participate in sport as part of a healthy lifestyle.2 limit the amount of time they spend online, playing video games and watching television.2,1 learn about and use strategies to keep themselves safe online (e.g., by adjusting their privacy settings, not sharing personal information with people that they don't know, etc.).2 get involved in structured extracurricular activities.2

senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior

Junior, senior Junior, senior Junior, senior Junior, senior Junior, senior

Junior, senior avoid over-scheduling of extracurricular activities.2 Junior, senior *try a variety of activities and interests to help them find out what they are Junior, interested in and what they are good at.2,1 senior Note. Asterisks indicate strategies most likely to be helpful and easy to implement by both junior and senior adolescents. 1 Statement endorsed in Round 1; 2Statement endorsed in Round 2. Where two superscripts are given, the strategy was endorsed for different developmental periods in different rounds. The first number refers to the junior adolescent period, while the second refers to the senior adolescent period. a ’Junior’ refers to adolescents aged 12-15 years; ‘Senior’ refers to adolescents aged 16-18 years.

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Table 2 Strategies with largea differences in endorsement between panels Prevention strategy

Developmental b period

If the young person is feeling sad or overwhelmed, or experiencing a difficult time, they should employ positive coping strategies, such as: going to a quiet spot with no one around and expressing their feelings (e.g., cry or scream). The young person should use music to provide a backdrop for selfreflection, for understanding sadness or grief, and to help them explore their emotions. The young person should know that: not drinking at all is the safest option for young people under 18 years of age. If the young person is feeling sad or overwhelmed, or experiencing a difficult time, they should employ positive coping strategies, such as: reducing their load of activities. If the young person finds it difficult to get enough sun exposure (e.g., during the winter), they should take a vitamin D supplement. The young person should find creative outlets through which to express their negative emotions (e.g., writing poetry or song lyrics, drawing). The young person should reflect on the difference between their real needs (food, shelter, clothing, transportation) and their "wants" (bigger TV, gadgets, expensive clothes). The young person should increase their dietary intake of B vitamins. The young person should talk to

Senior

Professional Very likely + Likely helpful (%) 9.0

Difference

Junior

Consumer Very likely + Likely helpful (%) 72.5

Senior

76.5

9.0

67.5

75.0

30.0

45.0

Junior

95.0 68.0

35.0 28.0

60.0 40.0

Junior

68.6

31.0

37.6

Senior

74.5

31.0

43.5

Junior

66.7

28.0

38.7

Senior

68.6

28.0

40.6

Junior

76.0

40.9

35.1

Senior

80.0

40.9

39.1

Junior

70.0

34.0

36.0

Senior

74.0

38.0

36.0

66.7

31.0

35.7

66.7 95.0

31.0 60.0

35.7 35.0

63.5

Junior Senior

Junior Senior

32

trusted peers about concerns they might have regarding body image pressures. 85.0 50.0 35.0 The young person should take time Junior to consider the emotional impact that leaving home may have, and to prepare themselves for this, if they are considering leaving home for the first time. 100.0 63.6 36.4 If the young person is feeling sad or Junior overwhelmed, or experiencing a Senior 96.0 63.6 32.4 difficult time, they should employ positive coping strategies, such as: not putting too much pressure on themselves to carry on as normal. 72.5 38.0 34.5 The young person should set Junior themselves a mission to photograph little things in their everyday life that make them smile. 74.5 41.0 33.5 The young person should learn to use Junior effective communication strategies, Senior 74.5 41.0 33.5 including: not expressing feelings of impatience towards others. 92.0 59.1 32.9 The young person should use music Junior Senior to improve their mood. 92.0 59.1 32.9 74.5 44.0 30.5 If the young person is in a romantic Junior relationship, they should: make Senior decisions together. 96.0 59.1 36.9 Junior 74.5 44.0 30.5 The young person should regularly think about the best possible future for themselves, using techniques like visualisation, writing or art. a Strategies with at least a 30% difference in endorsement between panels (Rosenthal, 1996). b ‘Junior’ refers to adolescents aged 12-15 years. ‘Senior’ refers to adolescents aged 16-18 years.

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Figure 1 Number of items included, re-rated, re rated, and excluded at each round of the questionnaire*

*Note that these figures represent the total items to be re-rated, rated, included and excluded. Some strategies were endorsed for one developmental period in Round 1, and the other developmental period in Round 2. The total number of strategies endorsed is thus less than the total number endorsed in the respective rounds.

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Highlights

•

The Delphi method was used to identify strategies to prevent adolescent depression.

•

International research and practice experts and consumer advocates rated the strategies.

•

Numerous self-help strategies were endorsed as helpful in preventing depression.

•

Fewer strategies were endorsed as feasibly implemented during the adolescent period.

•

The study identified evidence-based mental health promotion messages for adolescents.

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