A 12-Month Follow-Up of PROCARE+, a Transdiagnostic, Selective, Preventive Intervention for Adolescents At-Risk for Emotional Disorders

Approximately 50% of mental health problems have their onset before the age of 14, and 75% before the age of 18 [1, 2]. These alarming rates indicate with clarity that the timing of good mental health preventive interventions is as early as possible, but especially better before the age of 18 years [2‐4].

More specifically, emotional disorders, which encompass a range of conditions primarily characterized by disturbances in mood, emotional regulation, and response to fear, are most prevalent among adolescents. Defined particularly by conditions like anxiety and depression, they often manifest as prolonged feelings of distress, sadness, or heightened anxiety. It is during adolescence that the initial symptoms or full-blown episodes of these disorders frequently emerge [2, 5, 6]. The challenges posed by the Covid-19 pandemic have further exacerbated this, leading to a notable rise in prevalence and an increased risk of adolescents suffering from these emotional disturbances [7‐11].

The presence of clinical and subclinical disorders can potentially be a public health problem since they are negatively related to social and family malfunctioning, psychological distress, poor academic performance and increased suicidality [12‐17]. The World Health Organization has stressed the need to prevent the consequences and the risk of chronicity of this problem, being necessary preventive interventions, prioritizing non-pharmacological approaches, with the aim of reinforcing the capacity of adolescents to regulate emotions, particularly among the most vulnerable [18, 19]. It is for this reason that selective prevention treatments are beneficial [20]. Selective prevention targets groups or individuals who exhibit specific risk factors, increasing their likelihood of developing symptoms compared to the broader population. This approach aims to address and mitigate these disorders before they escalate or become chronic. It is suggested that the positive effects of prevention programs diminish over time [21], so booster sessions are essential to maintain gains, as evidenced by studies that analyze their effect, making interventions that include them more effective and with larger effect sizes [22, 23]. Additionally, recent research supports the idea that group therapies often outperform individual sessions, allowing participants to gain insight from others’ experiences, promote mutual support, and foster a sense of community [24, 25]. The shift to online therapy formats has also shown promising results. Not only do they offer convenience and accessibility, but studies indicate that online interventions retain effectiveness, with some even suggesting that the digital format enhances patient engagement and reduces drop-out rates [26, 27].

PROCARE+ is a brief, personalized protocol for the selective prevention of emotional problems, adapted from the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A; [28] which includes additional modules tailored to the specific needs of each adolescent. This approach has been shown to be effective for the treatment of clinical disorders related to anxiety and depression in young population, as well as for universal and indicated prevention purposes [23, 28‐35]. Vivas-Fernandez et al. [36], was the first approach in the transdiagnostic selective prevention of emotional disorders in the adolescent population, proving that PROCARE+ can reduce the risk of developing emotional disorders and anxious and depressive symptomatology, as well as it can increase resilience and emotion regulation after intervention and 6-month follow-up. In addition, recent systematic reviews concluded that there is a lack of selective prevention treatments focused on anxiety and depression in adolescents [37].

Bearing all of this in mind, this paper aims to examine the long-term effect of PROCARE+, PROCARE and an active control condition based on emotional psychoeducation (ACC), 12 months after the interventions. To further understand the long-term impact and sustainability of well-founded and evidence-based selective prevention programs with a transdiagnostic focus for adolescents at risk of emotional disorders, this 12-month follow-up study aims to: assess the sustained acceptability, fidelity, and adherence to the three interventions; measure the enduring effects of each of the three treatments in terms of emotional risk, defined as the likelihood of developing emotional disturbances due to stressors or adverse events, resilience, and quality of life related to physical, mental, and social health as primary outcomes; and track the continued development or maintenance of emotional regulation skills, cognitive flexibility, and anxiety and depression symptomatology as secondary outcomes over a 12-month period. More specifically, this follow-up evaluates the lasting efficacy of a CBT transdiagnostic selective prevention intervention, adapted from UP-A to 8 sessions and conducted in a telepsychology group format. This intervention included add-on modules to target adolescents’ specific needs and risk factors, termed PROCARE+, in comparison to the core intervention without add-on modules (PROCARE) and the aforementioned ACC. The booster session, administered 6 months post-intervention, is also examined for its potential to maintain benefits over the extended period.

This study was aimed at examining the long-term efficacy of three interventions for adolescents at-risk for emotional problems. Between-group comparisons at 12-month follow-up showed significant differences across conditions both in the risk of emotional symptoms and obsessive–compulsive symptomatology, with small effect sizes. Meta-analytic reviews suggest that prevention programs for depression and anxiety have small to medium effect sizes [56, 57]. The effect sizes found in this study are in line with what is expected for this population.

Between-group post-hoc analyses at 12-month follow-up revealed that PROCARE was significantly superior to the ACC condition but limited to obsessive–compulsive symptomatology, with medium effect sizes. This special effect of transdiagnostic interventions in decreasing obsessive–compulsive symptomatology has been evidenced in other studies [58, 59]. Furthermore, PROCARE+ was superior to ACC in the emotional risk identified by both adolescents and parents and, as secondary outcome, on obsessive–compulsive symptomatology, with medium effect sizes. These findings are in line with other studies which have analyzed the long-term effect of transdiagnostic treatments focused on clinical disorders [28, 56, 57], including indicated transdiagnostic prevention treatments [23, 33, 35]. Finally, PROCARE+ was superior to PROCARE, with significant differences in the risk of emotional problems identified by both the adolescents and parents, ranging from small to medium effect sizes. The effect of PROCARE+ over PROCARE, limited to the inclusion of personalized add-on modules, suggests the importance of modules tailored to the adolescents’ needs in order to further reduce the level of emotional risk. These results are consistent with other studies pointing out the importance of personalized medicine in psychological interventions [9, 10, 60] and aligned with promising research on personalized medicine in which modest effect sizes have been found in cognitive-behavioral treatments controlling the effect of treatment moderators [61].

In particular, within-group comparisons between the pre-treatment and the 12-month follow-up for ACC revealed no significant changes in most of the primary or secondary variables. These findings are in the same line as studies reporting that short-term gains from preventive interventions for anxiety and/or depression tend to decrease over time [21]. Significant differences in primary outcomes for ACC were limited to the reduction in parent-reported emotional risk, as measured by the SDQ, and the improvement of quality of life as measured by the KIDSCREEN-10. As for secondary measures, differences were only found in global anxiety-depressive symptoms and obsessive–compulsive symptomatology measured by RCADS. Significant differences between the post-booster and the 12-month follow-up were limited to separation anxiety. There were no differences between the 6- and 12-month follow-up. However, significant differences described above suggest a small treatment benefit effect, consistent with the previous open trial study conducted by LaGreca et al. [47].

As far as within-group comparisons for the PROCARE condition are concerned, significant differences were found in most variables between the pre-treatment and the 12-month follow-up, with similar results to those found after the completion of the main treatment [36] and providing evidence in line with promising previous studies of the transdiagnostic approach for young people with clinical, indicated and universal samples [23, 29‐32, 34, 35, 62]. The sustained outcomes seen in PROCARE differ from research that shows a diminishing effect of preventive interventions as time goes on [21]. Within-group comparisons between the 6- and the 12-month follow-up showed PROCARE exhibited significant differences in the reduction of emotional symptomatology reported by parents, with medium effect size. The booster sessions held after 6 months of treatment seem to have a role in supporting emotional gains. Follow-up findings suggest a possible link between these sessions and sustained intervention effects, as well as a reduced likelihood of symptom relapse [57, 63]. Furthermore, in line with the recommendations by Gearing et al. [22], selective intervention programs for at-risk adolescents can produce small to medium beneficial effects when follow-up assessments and booster sessions are included, as observed in the PROCARE+ condition.

Finally, the PROCARE+ condition evidenced significant improvements in every primary and secondary outcome in comparisons between the pre-treatment and the 12-month follow-up. This means that there has been a decrease in the risk of developing an emotional problem, an improvement in resilience, quality of life, emotional regulation, cognitive flexibility and anxiety and depressive symptoms, maintaining the same gains found in previous phases of the study [36] and in contrast with research which concluded that the effect of preventive interventions tend to decrease over time [64, 65]. Furthermore, comparisons between the 6- and 12-month follow-up showed that PROCARE+ exhibited significant differences in the reduction of emotional symptomatology, as measured by the RCADS and its subscales, with medium to large effect sizes. Differences were also observed between the post-booster and the 12-month follow-up assessments but limited to social phobia symptomatology. The booster session conducted 6 months after the completion of the intervention may have a role in the maintenance of effects or reduction of the likelihood of symptoms relapse over time, just as was observed in the PROCARE condition [21, 66].

Overall, the three conditions evidenced positive impact on adolescents’ wellbeing. However, it must be noted that PROCARE+ showed a larger number of improvements in treatment outcome measures, with higher effect sizes at the 12-month follow-up, in line with the positive findings found by Vivas-Fernandez et al. [36]. These results highlight the importance of the personalized medicine which characterizes PROCARE+, where additional modules are added to address the specific risk factors for each adolescent, as recommended in previous studies [9, 10, 60, 67, 68]. The booster session’s effect is more pronounced in the PROCARE+ condition than in PROCARE, potentially because it includes extended material from additional modules unique to this intervention. This might explain the more substantial gains observed post-treatment in PROCARE+. Consequently, while improvements are seen in both groups after the booster session conducted 6 months later, they are especially marked in the PROCARE+ condition due to its personalized pretreatment having a heightened preventive effect [36]. Similar to Vivas-Fernandez et al., [36] study, it appears that the SDQ emotional subscale (self-reported and/or parent-reported measure) is an instrument particularly sensitive for selective prevention purposes. Studies have similarly highlighted the effectiveness of the SDQ both in clinical settings and as a tool to identify symptomatology geared towards prevention [69‐71].

Some limitations should be noted. First, while an intention-to-treat analysis was conducted to ensure data validity, the study would have benefited from a larger sample. This was mainly due to a reduction in participants for the 12-month follow-up, as some opted not to continue with the assessment process. Second, as the trial was conducted during the Covid-19 pandemic, and it is possible that improvements observed may have been influenced by the passage of time or by the normalization of the social situation in relation to Covid-19. To provide a clearer understanding, future studies might consider using a wait-list control group to discern these effects more distinctly. Notably, research indicates that adolescents remain among the most emotionally affected groups post-pandemic. Third, the booster sessions, while potentially pivotal, were not randomized, and hence, no direct causality can be established. It remains uncertain whether differences in outcomes for PROCARE+ participants were mainly due to the number or specificity of additional modules they received. This underscores the question of whether the success of PROCARE+ can be attributed mainly to an increase in treatment dosage or is more closely tied to the specificity of the modules based on the personal risk profile. Exploring this aspect will be central in future research. Lastly, forthcoming studies should also delve into the cost-effectiveness of prevention programs, as well as potential mediators and moderators of treatment.

This is the first time that a selective preventive transdiagnostic intervention was tested in a 12-month follow-up. The research emphasizes the long-term efficacy of targeted interventions for adolescents at risk for emotional disturbances, with a special focus on the success of the PROCARE+ approach. Benefits observed at the 12-month follow-up indicate that personalized, module-based treatments potentially outpace standard prevention programs in producing more significant and enduring improvements.

Notably, the PROCARE and PROCARE+ conditions exhibited significant differences 12 months post-treatment, pointing to a positive long-term impact on emotional health. The findings particularly spotlight the superiority of PROCARE+ over both PROCARE and ACC, underscoring its effectiveness in reducing the risk of emotional symptoms in at-risk adolescents over extended periods.

The booster sessions, introduced 6 months after the primary treatment, appear to enhance the interventions’ positive impact, emphasizing the importance of consistent, tailored support in consolidating treatment gains. Furthermore, add-on modules have emerged as particularly influential in the PROCARE+ condition, suggesting they play a pivotal role in diminishing emotional risk.

Additionally, the study reaffirms the SDQ emotional subscale’s consistent performance, underscoring its utility as a trusted instrument for evaluating emotional risks and the outcomes of preventive interventions.

This study aimed to explore the long-term effects of PROCARE+, an intervention for adolescents at risk of developing emotional problems, by comparing it with two interventions: PROCARE and an active control condition (ACC) based on emotional psychoeducation. Focusing on a 12-month follow-up period, the study assessed the sustainability of these interventions in reducing emotional risk, increasing resilience and improving quality of life and emotional regulation. The PROCARE+ and PROCARE interventions were adapted from the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A), with PROCARE+ providing additional modules tailored to individual needs.

The prevalence of emotional disorders in adolescents, particularly anxiety and depression, has been exacerbated in the context after the Covid-19 pandemic. These disorders are associated with a range of negative consequences, including social and family dysfunction, psychological distress, poor academic performance and increased suicidality. The importance of investing in non-pharmacological preventive interventions in this context, focusing on emotional regulation and resilience promotion, especially among vulnerable groups, has been highlighted.

The study findings indicated that while all three conditions resulted in positive outcomes in terms of adolescent well-being, PROCARE+ was the most effective. This intervention produced significant improvements in emotional risk, resilience, quality of life, emotional regulation, cognitive flexibility, and symptoms of anxiety and depression. The addition of personalised modules in PROCARE+ was particularly effective, underscoring the importance of personalised approaches in psychological interventions.

In comparison, PROCARE showed significant benefits, but these were more limited than PROCARE+. ACC showed the least improvement, indicating the value of designing more structured and comprehensive interventions such as PROCARE and PROCARE+. Booster sessions, conducted 6 months after the intervention, could play an important role in maintaining the benefits of the interventions over time.

In conclusion, this study supports the efficacy of CBT-based preventive interventions from the transdiagnostic approach for adolescents at risk of emotional disorders, tailored to their specific needs.