26 ingredients to beat youth anxiety & depression: reviewing the evidence

In June 2020 we commissioned our first evidence reviews for active ingredients: the aspects of anxiety and depression interventions that really make a difference for young people (14-24) worldwide.

30 research teams from 12 countries reviewed the evidence for 26 active ingredients proposed as their “best bets”.

The table below shows the focus of the review for each of 26 active ingredients chosen.

This is by no means an exhaustive list of active ingredients. We recognised from the start that it is most likely that different people will need a range of active ingredients in different combinations, at different times and in different contexts. This is why we will be commissioning a second round of reviews in early 2021 - stay tuned!

But, we wanted to consider a selection of active ingredients as a starting point. Those reviewed ranged from the cellular to the societal, from using anti-depressants to unconditional cash transfers.

Last month I shared my overarching reflections and our next steps.

Below I share selected highlights from the completed reviews. With thanks to the commissioned research teams and to Inês Pote and Charlotte Payne for helping compile this summary.

1. Better able to shift perspective

Marc Bennett (UK) with Tim Dalgleish & Tamsin Ford

•  Being better able to shift perspective (sometimes called “decentring”) is an ability to disengage from the content of negative inner experiences by noticing them as products of the mind rather than genuine truths. This reduces the impact of negative inner experiences on emotions, decisions and sense of self.
• Some studies have found improvements in shifting perspective precede reductions in core symptoms of anxiety and depression.
• There is also evidence that boosting shifting perspective skills can help prevent anxiety and depression from returning in future. 

2. Better gut microbiome

Kathrin Cohen Kadosh (UK) with Jennifer Lau & Glenn Gibson

• Dietary interventions using so-called psychobiotics (live bacteria that, when ingested in appropriate amounts, might confer a mental health benefit) are an attractive alternative to other early interventions because they are natural and cheap, easy to access without the need for costly therapist time and could be empowering.
• Young people involved expressed much enthusiasm for research into dietary interventions, and many had used dietary changes to improve their anxiety.
• But; there is limited research and what evidence there is is mixed.
• To date, the strongest effects on anxiety symptom reduction were found in participants with high anxious traits.

3. Better sleep-wake cycle

Ian Hickie (Australia), Joanne Carpenter, Jacob Crouse 

• There is evidence of sleep-wake cycle (sometimes called 'circadian rhythms') disturbances in some cases of depression in young people. Therefore it may be beneficial to improve this cycle to prevent or treat depression.
• Strategies such as getting exposure to bright light in the morning and throughout the day, minimising light exposure in the evening, being physically active throughout the day, and keeping a regular and predictable sleep schedule are important to maintain a strong sleep-wake cycle.

4. Better stress response via relaxation

Syed Usman Hamdani (Pakistan) with Ahmed Waqas & Atif Rahman 

• Evidence indicates that relaxation techniques are highly effective in treating anxiety, moderately effective in reducing distress and have only a weak effect on improving depression in 14-24 year-olds.
• Relaxation techniques delivered face-to-face were more effective than online delivery in reducing anxiety.
• The qualitative accounts of young people who received relaxation training found that they found the techniques easy to understand, learn and use.
• Reported challenges were difficulty in finding time to practice, experience of heightened sensory sensitivity, and perceptual and physical changes while practicing relaxation techniques.

5. Better urban access to green spaces

Issy Bray (UK) with Danielle Sinnett & Faith Martin

• There is strong evidence that walking or being in a green space, like a forest or a park, can improve mood and reduce feelings of anxiety for young people aged 14-24.
• This may be due to the restorative properties of green spaces. Time away from noise, work, people and social media enables young people to notice and appreciate nature, which appears to encourage mindfulness and increase resilience to cope with stress.
• ·Although even short (15-minute) walks in a green space are beneficial, there is some evidence that spending time in larger parks is more helpful, and excursions to natural environments outside of urban areas also have psychological benefits.

6. Developing more helpful thinking patterns

Jennifer Lau (UK) with Victoria Pile & Colette Hirsch

• The following unhelpful ways of thinking are associated with more anxiety and depression in youth: being unable to shift attention away from negative information to focus on positive or even neutral information; not being able to generate a positive (or even neutral) perspective of an ambiguous situation, and instead jumping to negative inferences.
• Training young people in spotting positive information can make them better at attending to positive over negative information. But the effects on anxiety and depression symptoms have not been found to be strong or immediate.
• Helping young people control their own attention (choosing when and where to focus as part of relaxation, shifting perspectives or mindfulness techniques) has been found to reduce youth anxiety and depression.

7. Engagement with theatre or the arts

Kamala Easwaran (India) with Yog Japee & Tasneem Raja

• Arts-based interventions appear to have strong positive outcomes for young people with experiences of trauma.
• Group-based interventions, encouraging social participation and self-expression, can be particularly helpful for young people to make better sense of their experiences and articulate their mental health needs.
•  Apart from areas of active conflict, school-based arts interventions can promote significant improvements in mental health.
• However, there is limited evidence for the long-term effects of arts interventions, particularly amongst those with severe mental illness.

8. Helpful use of mental imagery

Victoria Pile (UK) with Jennifer Lau & Emily Holmes

•  Young people with anxiety and depression commonly experience negative and upsetting images of the past and future. Understandably, they often try to avoid these images but this can mean they keep popping up in upsetting ways when not wanted and positive images are switched off.
• Helping young people to explore a distressing event in their imagination in new ways ("imagery rescripting") appears to help those with anxiety but has not been tried extensively with those with depression
• Helping young people to generate positive future images can protect against low mood and increase engagement in life. 
• These interventions appear to work best when the young person is helped to imagine the end goal, the steps to get there and how to overcome difficulties along the way.  

9. Improved management of emotions

Alexander Daros (Canada) with Lena C. Quilty & Sasha Allen

•  Learning effective management of emotions (emotion regulation skills) was found to be more important for treatment success than reducing ineffective skills.
• Emotion regulation skills are more effective at reducing symptoms of anxiety and depression when delivered in group (vs. individual) formats.

Sarah Skeen (South Africa) with Mark Tomlinson & G.J Melendez-Torres

• A wide range of emotional regulation skills are provided across different interventions and the review did not identify one particular skill that seemed to be more effective than others.
• It may be really important that emotion regulation skills are taught in the context of supportive relationships and taking into account external stressors that might influence young people's capacity to learn and employ their new skills. 

Joanne Beames (Australia) with Aliza Werner-Seidler

• Monitoring mood in real-time using phone apps can increase awareness of feelings and decrease symptoms of depression.
• Increasing affective awareness of emotions using apps might be beneficial for some young people (e.g. those highly motivated to monitor) but not others (e.g. those with severe mental health problems).
• Of the young people and psychologists interviewed for this review, both groups seemed interested in using monitoring apps. However, these apps are not yet widely used in daily life or clinical practice. They are also not widely studied and therefore we need ways to assess the effectiveness and safety of mood monitoring apps for young people.

10. Improved problem solving

Karolin Krause (Canada) with Darren Courtney & Peter Szatmari

• Problem-solving involves four skills: (1) define the problem and its impact; (2) consider solutions; (3) appraise the pros and cons of each and select the most promising and (4) implement and review the outcomes, all the while adopting an optimistic solution-focused outlook.
• The evidence is mixed and there are few high quality trials. 
• One high quality trial found counsellor-led problem-solving training in India helped youth with mild mental health difficulties (including depression) resolve personal problems. However it was not more effective than self-help booklets at reducing symptoms of depression and anxiety. 
• Problem-solving training may be beneficial for youth with mild mental health difficulties who face stress from challenging events or daily hassles and struggle with problem solving.
• To meet young people's needs, problem-solving training should be youth-driven, strengths-based, comprehensive, and personalised.

Robyn Mildon (Australia) with Jane Lewis, Bryce D. McLeod & Kristina Metz

• Problem-solving interventions exist in different forms including: approaches that are standalone; as part of a wider therapeutic programme; for individuals or groups; delivered in-person or online; in community settings such as schools or prisons, or in health settings.  
• Examples of effective problem-solving interventions found by this review: a problem-solving programme of 5 sessions for school students in Brazil with depression; problem-solving programme of 12 sessions for women in Zimbabwe with post-natal depression; a 35 minute video on problem-solving for university students with suicidal thoughts in the US; problem-solving as part of a wider programme for young people with depression in the US moving to high school 
• Problem-solving interventions may be less effective where people have other serious mental health difficulties, or if the problems they face are not easily solved.

Daniel Michelson (UK) with Vikram Patel & Bruce Chorpita

• Problem solving on its own appears to be an effective intervention for youth depression but there was no evidence that it is effective for anxiety. 
• Multi-component interventions that included problem solving were effective for both depression and anxiety. 
• Problem solving may be most suitable in the early stages of depression and anxiety.  

11. Improved view of self

Faith Orchard (UK) with Laura Pass, Brioney Gee & Tim Clarke

• The way in which depressed young people view themselves can be improved, however, current treatments rarely target this directly.
• Expert advisors (e.g. young people with personal experience of depression, mental health professionals and researchers) think that treatments should place more emphasis on ‘view of self’.

12. improving social relationships

Paul Badcock (Australia) wih Kate Filia 

• In terms of prevention there was evidence of impact for training to help young people develop effective communication, support giving, coping skills, and social activity scheduling.
• Of these, the school-based program of Interpersonal Psychotherapy—Adolescent Skills Training (IPT-AST) shows promise for those with high levels of depressive symptoms but not yet meeting thresholds for referral to specialist services. 
• In terms of treatment, there was strong evidence for a 12 week course of Interpersonal Psychotherapy for Adolescents (IPT-A); a structured intervention which targets personal disputes (e.g. conflict with parents), transitions (e.g. changing schools, roles), grief (e.g. loss of a friend), and interpersonal deficits (e.g. poor communication skills).
• Involvement of parents and carers seemed to be beneficial.
• In discussing the results of the review with young people, there was a clear disconnect between the types of approaches they considered important versus the evidence-based approaches currently available.
• Young people consulted emphasised the importance of using informal ways to foster social connection and social support rather than formalised approaches that concentrate on improving social skills. 

13. Increased financial resources via cash transfers

Johannes Haushofer (USA & Kenya) with Jimena Romero & Kristina Esopo

• Economic transfers appear to be a promising approach to improving youth mental health. Although the magnitude of the treatment effect is small, it is consistent and robust.
• Unconditional cash transfers are the most effective poverty reducing programmes for reducing depression. Other relevant programmes include lotteries and “graduation programmes”.

14. Increased neighbourhood cohesion (connection)

Josefien Breedvelt (Netherlands) with Claudi Bockting & Claire Niedzwiedz

• Feeling safe, trusting others, having positive relationships and social support as well as having low levels of crime and violence are suggested as key building blocks of neighbourhood cohesion linked to lower symptoms of depression and anxiety.
• Potential avenues for future interventions include co-creating community centres, co-designing neighbourhood parks and spaces, building neighbourhood community groups, and increasing opportunities to meet online for further social connections offline.

15. Increased self-compassion

Sarah Egan (Australia) with Clare Rees & Amy Finlay-Jones

• The literature defines self-compassion as treating yourself in a kind and balanced way, the way you would treat a good friend, and realising that going through difficulties is part of the human experience. 
• Self-compassion is strongly related to anxiety and depression: the more self-compassion, the less likely young people are to feel anxious and depressed. 
• Self-compassion interventions are effective in reducing anxiety and depression in young people, but treatments need to be four or more sessions, as brief (two-session) mindfulness training does not work. 
• One way interventions work is by changing self-compassion. This appears to be more about reducing self-criticism than increasing self-kindness. 
• A barrier to treatment in young people can be the fear of not achieving if they stop being self-critical. 

 16. Increased sense of mattering

Dean Ho (Singapore) with Matt Oon & Theodore Kee

• Mattering is the extent to which we make a difference to the world we live in. It consists of attention (people are aware of our presence and our unique qualities), importance (the interest and concern others bestow on us) and reliance (others turn to us and make us feel needed).
• Mattering appears to be a protective factor that reduces psychological symptoms and promotes wellbeing
• A higher sense of mattering is associated with lower depressive and anxiety symptoms. 
• Mattering significantly predicts psychological wellness in females but not in males, with females perceiving a higher overall sense of mattering. 
• No interventions specifically targeted at mattering were identified.

17. Increased social connectedness (via digital interventions)

Lindsay Dewa (UK) with Emma Lawrance, Hutan Ashrafian & Lily Roberts

• Important attributes for a positive social connection in digital interventions include having good rapport, having some shared identity and commonality, developing a valued interpersonal dynamic, positive engagement, and feeling responded to and accepted.
• The quality of the digital social connection may help to improve outcomes, particularly for depression. 
• Some evidence suggests that the outcomes of digital interventions are better when a young person has first had a positive face-to-face interaction. 

 18. Increasing engagement with positive activities

Kanika Malik (India) with Bruce Chorpita & Vikram Patel

• Interventions that increase engagement with positive activities (sometimes called 'behavioural activation'), either as a core component or standalone intervention, show promising outcomes for depression.
• There are only a few high quality trials for standalone interventions.
• The evidence is less clear on whether behavioural activation also works for anxiety.
• Interventions with behavioural activation appear to work better in a group format and among non-clinical participants.
• Young people report using behavioural strategies in their own life to increase engagement with positive activities. These appear similar to clinical behavioural activation interventions to cope with depression effectively.

19. Learning to be more hopeful

Clio Berry (UK) with Jo Hodgekins & David Fowler

• Hopefulness involves the belief in the ability to reach goals and the ability to find different routes towards reaching goals. 
• The evidence focusing on hopefulness in interventions for young people with major or complex depression is limited.
• However studies suggest that some specific interventions (e.g. CBT and activity-based interventions like yoga and meditation, having a supportive relationship) might help to increase hopefulness and reduce depression.  
• It is unclear whether increasing hopefulness in this way is the key route to reducing depression or an effect of that reduction. 

20. More bodily movement

Alan Bailey (Australia) with Alexandra Parker & Rosemary Purcell

• For young people already experiencing depression, physical activity interventions do seem to reduce symptoms.
• For young people with anxiety, the evidence is less clear. 
• Current evidence does not support a particular minimum dose of activity required to improve symptoms in young people experiencing depression or anxiety.  
• Rather, any amount of activity will be helpful, even small amounts, but some is better than none, and more is better than less. 
• Most important is a young person’s preference for what they do, how much they do, and the contexts they do it in.  
• Engagement can be facilitated by ensuring prescribed exercise is achievable and enjoyable. 
• Inactive young people may stand to benefit most from activity-based interventions. More active young people may encounter ceiling effects in their activity levels, potentially reducing opportunity to experience mood/anxiety improvement. 

21. Reduced avoidance of feared things

Jennie Hudson (Australia) with Ron Rapee, Viv Wuthrich & Cathy Creswell 

• Facing your fears in a planned manner while stopping avoidance of feared things is what therapists call “exposure therapy”. The most common way of doing exposure is through ‘live’ confrontations or one’s imagination, while gradually increasing the difficulty. 
• Most research has found that exposure-based treatments are effective in treating anxiety conditions, which include specific phobias, social or performance-related anxiety, OCD and PTSD. In fact, there is some evidence to show that exposure works better than other treatments for young people aged 14-24 with anxiety.  
• Exposure works best when fears are faced in multiple contexts (e.g. school, home, clinic), it is made more challenging, it is conducted closer to sleep, individuals have more control in facing their fear, individuals believe in their ability to handle exposure, and individuals focus on the defining features of fearful memories while using breathing exercises.
• Individual exposure therapy may benefit from the involvement of parents, as they can help by doing exposures out of therapy, providing rewards, and being role-models in fearful situations. It is critical that parents know exactly what to do, and that the therapist clearly explains the what, how and why of exposure. 
• The evidence suggests that exposure may not work when it is not practiced outside of therapy, other mental or physical health problems complicate the treatment, there is a poor therapist-client relationship, or therapy is not personalised.

22. Reduced loneliness

Ellie Pearce (UK) with Roz Shafran & Gerhard Andersson

• Loneliness is a mismatch between the relationships you have and those you’d like to have. This can be about the number of friends you have, or whether you have people around you who you can really rely on and trust.  
• Although we can't be completely sure yet, reducing loneliness appears to be a promising way to reduce anxiety and depression in young people.  
• Some of the strategies that might help address loneliness include learning new ways of thinking (e.g. via mindfulness); time for self-reflection, exercise or music; strategies that enhance ongoing social support (e.g. peer-mentor programmes); or meaningful shared activities (e.g. music, sport) to increase opportunities for social contact. 
• Barriers to addressing loneliness include those that are psychological (e.g. lack of motivation), situational (e.g. caring responsibilities), practical (e.g. accessibility – cost/transport), and social (e.g. stigma). 

23. Reduced perfectionism

Tracey Wade (Australia) with Sarah Egan & Roz Shafran

• Perfectionism is when a person bases their self-worth on meeting really high standards, even when there are negative consequences like feeling down and stressed.  
• Perfectionism has a very strong link with anxiety and depression, mainly because of self-criticism. 
• The following might help to reduce perfectionism: broadening self-evaluation by judging self-worth on issues other than achievements, re-evaluating goals and the value of mistakes, and using self-compassion not criticism when facing adversity and setbacks.
• Perfectionism is perceived to have many benefits (e.g. feeling good about success, working hard, organisation), which is a barrier to identifying a need for prevention and/or intervention programs.

24. Reduced repetitive negative thinking

Imogen Bell (Australia) with Mario Alvarez-Jimenez & John Gleeson

• Repetitive negative thinking involves getting caught up in negative thoughts in a way that is excessive, unproductive and difficult to control. 
• Psychological treatments can reduce repetitive negative thinking in young people, and this seems to be associated with improvements in depression and anxiety.  
• Several treatments appear to work, but overall techniques focusing on addressing the process of getting caught up in negative thoughts rather than the content of those thoughts seemed to be more effective. 
• More complex or lengthy treatments were not more effective, with promise for group and online or mobile-based approaches. 
• The timing of when treatments are delivered seems to be important, with young people and clinicians both calling for resources to provide support in daily life or at key moments in the cycle of repetitive negative thinking.  
• Young people and clinicians consider a clear emphasis on variety, choice, timing and context important. 

25. Reducing levels of inflammation in the body

Lianne Schmaal (Australia) with Yara Toenders

• Overall, there appears to be some evidence for inflammation in youth depression, but the differences are subtle, and results are not always consistent. This may be because of differences between studies, or because only some young people with depression show inflammation.
• Some treatments (e.g. antidepressants and psychotherapy) seem to affect mood and inflammation, while others (e.g. anti-inflammatory medication, mindfulness and exercise) have not been studied sufficiently to draw conclusions yet.
• In future, it may be useful to screen for inflammation in young people with depression. If inflammation is detected, the cause of the inflammation should be identified and additional treatment for it could be introduced, such as anti-inflammatory medication or lifestyle changes in the form of diet and exercise.

26. Use of antidepressants

Cath Harmer (UK) with Susannah Murphy, Argyris Stringaris & Liliana Capitao

• Antidepressants (SSRIs) are an effective treatment for depression and anxiety and may be particularly beneficial when symptoms are severe or when psychological treatments alone are not effective. 
• Despite SSRIs being commonly used in young people, there is still a lot we don’t know. We need to better understand how antidepressants work in young people (this might be quite different to adults); the long-term effects; what happens when they end; and which symptoms are not well treated by SSRIs (and find other treatments that help these). 

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