Search Strategy
The population, intervention, comparison, outcome and study design (PICOS) strategy(42) was used to specify the research question and guided the forming of the search string for this systematic review (see Table 1 for full PICOS strategy). The review followed the Preferred reporting items for systematic review and meta-analysis (PRISMA;(43)) and this protocol was written following the PRISMA for protocols guidelines (PRISMA-P(44)) checklist. PubMed and PsycINFO electronic databases were used for a literature search until August 31, 2018. The protocol has been registered at The International Prospective Register of Systematic Reviews (PROSPERO) with a registration number is CRD42020166756.
Table 1
PICOS and Inclusion and Exclusion Criteria
PICOS strategy
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Include
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Exclude
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P - Population
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Adolescents (12–18 years) and young adults (18–30 years) with a mental disorder diagnosis: anxiety, obsessive-compulsive and trauma-related disorders, depressive and bipolar disorders, psychotic disorders, eating disorders, personality disorders, substance-related disorders, autism, attention deficit/ hyperactivity, conduct disorders.
Filters:
adolescent OR young adult
Keywords:
Anxiety Disorders: anxiety disorder; neurotic disorder; panic disorder; agoraphobia; social phobia; social anxiety; mutism; separation anxiety; phobic disorder; phobia; generalized anxiety; obsessive compulsive; ocd; hoarding; body dysmorphic disorder; body image disorder; trichotillomania; hair pulling disorder; excoriation disorder; dermatillomania; skin picking disorder; trauma and stressor related disorders; traumatic stress disorder; posttraumatic stress disorder; stress disorder, post-traumatic; ptsd; acute stress disorder; adjustment disorder; Depressive Disorders: mood disorder; depressive disorder; depression; affective disorder; dysthymic disorder; dysthymia; premenstrual dysphoric disorder; seasonal affective. Bipolar Disorders: bipolar and related disorders; bipolar disorder; mania; manic depression; bipolar depression; pediatric bipolar; cyclothymic disorder; cyclothymia. Psychotic disorders: schizophrenia spectrum and other psychotic disorders; psychotic disorder; psychosis; psychoses; schizophrenia; schizoaffective; schizophreniform; reactive psychosis; reactive psychoses. Eating disorders: feeding and eating disorder; feeding disorder; eating disorder; anorexia; bulimia; binge eating; pica; rumination disorder; avoidant restrictive food intake; arfid; avoidant eating; purging disorder; night eating syndrome; food addiction; orthorexia; ednos; ofsed. Personality disorders: personality disorder, schizotypal personality, schizoid personality; paranoid personality; narcissistic personality; borderline personality; histrionic personality; antisocial personality; obsessive compulsive personality; avoidant personality; dependent personality; character pathology; character neurosis; axis II disorder. Substance use disorders: substance related disorder; substance use disorder; substance abuse; substance misuse; substance dependence; addiction; drug use; drug abuse; drug addiction; alcohol related disorder; alcohol use disorder; alcohol abuse; alcohol dependence; alcoholism; amphetamine; cocaine; inhalant ; marijuana; cannabis; opioid; heroin; opium; morphine; hallucinogen; tobacco; nicotine; smoking; polydrug; stimulant; substance induced psychosis; substance induced psychotic disorder; drug psychosis; drug psychoses. Autism: autistic spectrum disorder; autism spectrum disorder; autistic disorder; autism; asperger syndrome; asperger; asperger’s; child development disorders, pervasive; pervasive child development disorder. ADHD: attention deficit disorder; adhd; hyperkinetic disorder; attention deficit hyperactivity disorder; conduct; conduct disorder; oppositional defiant; defiant disorder; externalizing behavior; externalizing behavior; antisocial behavior; antisocial behaviour
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Age range or mean age of participants under 12 or over 30 years
Participants not being diagnosed or having disorder specific symptoms bellow the agreed-upon cut-off point
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I -Intervention
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Psychotherapeutic interventions:
Keywords: Psychotherapy; Psychotherapeutic treatment; Psychotherapeutic intervention; Psychological therapy; Psychological treatment; Psychological intervention; Psychosocial therapy; Psychosocial treatment; Psychosocial intervention; Supportive therapy
Supportive treatment; Counselling; Counseling; Motivational interviewing; Psychoeducation; Psychoeducational; Cognitive therapy; Cognitive analytic therapy; Behavioral therapy; Behavioural therapy;
CBT; Psychoanalysis; Psychodynamic therapy; Psychoanalytic therapy;
Dynamic therapy; Transference focused (therapy); Mentalization based (therapy); Metacognitive therapy; Interpersonal therapy; Interpersonal and social rhythm therapy; Schema therapy; Schema-focused therapy;
Acceptance and Commitment Therapy; Acceptance based (therapy); Problem solving therapy; Problem solving treatment; Insight oriented therapy; Rational emotive; Solution focused therapy; Family therapy
Family systems therapy; Parenting intervention; Parent management training; Group therapy; Mind-Body Therapy; Art Therapy; Dance Therapy; Music Therapy; Play Therapy; Expressive therapy; Cognitive remediation; Cognitive training; Behavioral activation; Behavioural activation; Behavior activation; Behavioral weight control; Behavioural weight control; Applied behavior analysis; Applied behaviour analysis; Attention bias modification; Exposure and response prevention; Exposure therapy; Systematic Desensitization; Eye movement desensitization reprocessing; EMDR; Psychology biofeedback; Hypnosis; Mindfulness; Relaxation
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Prevention programs
Studies testing interventions using only medication arms
Studies with interventions targeting only parents
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C - Comparison
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No exclusion criteria
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O - Outcome
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Quantitative studies including pre- and post- measurement published in peer-review journals
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Qualitative studies
Dissertations
Book Chapters
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S – Study design
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Clinical outcome trials: RCT, controlled trials, empirical trials, naturalistic setting, case studies
Filters: Clinical Trial OR Comparative study
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Case studies where n < 10 or results not being reported in group level
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Searches were conducted combining search strings for: (a) psychotherapeutic interventions search terms; (b) mental disorder search terms; (c) age range search terms and (d) study type terms. Controlled descriptors (i.e., PubMed MeSH terms, PsycINFO thesaurus) and their synonyms (key words) were verified in each database. The search terms were combined using the Boolean operators ‘AND’ and ‘OR’.
Searches were conducted separately for each mental disorder. The following mental disorder categories were chosen for inclusion: (a) anxiety, obsessive-compulsive and trauma-related disorders; (b) depressive and bipolar disorders; (c) psychotic disorders; (d) eating disorders; (e) personality disorders; (f) substance-related disorders; (g) autism spectrum disorders; (h) attention deficit/hyperactivity disorder; and (i) conduct disorders.
To ensure successful identification of relevant studies for the specific age group targeted, we added age filters for ‘adolescents’ and ‘young adults.’ To identify clinical trials, we used the filter for study type, including ‘clinical study’ OR ‘comparative study’ in Pubmed and ‘clinical case study’ OR ‘clinical trial’ OR ‘empirical study’ OR ‘treatment outcome’ in PsycINFO. Preliminary manual searches that were carried out with relevant search terms (clinical trial treatment response, treatment outcome, random allocation, controlled trial, efficacy, effectiveness) yielded comparable results to the filters selected. This was used to determine that the chosen filters had adequate sensitivity.
Capitalizing on the culturally diverse background of our research team, we had no a priori restriction regarding the language of the published full text, in order to increase the yield of appropriate articles and, thus, generalizability of our findings. However, it was decided that the title and abstract must be available in English so as to be searchable by English keywords and all team members to be able to appraise the study design.
One researcher (VG) formed the final search strings in collaboration with information specialists and conducted the searches. Two researchers (EV and SP) performed the searches independently to cross-check the results. The open access bibliographic software Mendeley was used to store, organize and manage all the references and ensure a systematic and comprehensive search. Duplicate publications from the database search results were removed. An example of a search strategy for the PubMed database for anxiety disorders is presented in Table 2.
Table 2.
Search Strategy for Anxiety Disorders on PubMed.
Search terms for all disorders:
1. Treatments:
"psychotherapy"[MeSH Terms] OR "psychotherapy"[All Fields] OR "psychotherapeutic treatment"[All Fields] OR "psychotherapeutic treatments"[All Fields] OR "psycho-therapeutic treatment"[All Fields] OR "psychotherapeutic intervention"[All Fields] OR "psychotherapeutic interventions"[All Fields] OR "psychological therapy"[All Fields] OR "psychological therapies"[All Fields] OR "psychological treatment"[All Fields] OR "psychological treatments"[All Fields] OR "psychological intervention"[All Fields] OR "psychological interventions"[All Fields] OR "psychosocial therapy"[All Fields] OR "psychosocial therapies"[All Fields] OR "psychosocial treatment"[All Fields] OR "psychosocial treatments"[All Fields] OR "psychosocial intervention"[All Fields] OR "psychosocial interventions"[All Fields] OR "supportive therapy"[All Fields] AND "supportive therapies"[All Fields] OR "supportive treatment"[All Fields] OR "supportive treatments"[All Fields] OR "counseling"[MeSH Terms] OR "counselling"[All Fields] OR "counseling"[All Fields] OR "motivational interviewing"[All Fields] OR "psychoeducation"[All Fields] OR "psychoeducational"[All Fields] OR "psycho-education"[All Fields] OR "psycho-educational"[All Fields] OR "cognitive therapy"[All Fields] OR "cognitive therapies"[All Fields] OR "behavioural therapy"[All Fields] OR "behavioural therapies"[All Fields] OR "behavioral therapy"[All Fields] OR "behavioral therapies"[All Fields] OR "cbt"[All Fields] OR "psychoanalysis"[MeSH Terms] OR "psychoanalysis"[All Fields] OR "psychodynamic therapy"[All Fields] OR "psychodynamic therapies"[All Fields] OR "psychoanalytic therapy"[All Fields] OR "psychoanalytic therapies"[All Fields] OR "dynamic therapy"[All Fields] OR "dynamic therapies"[All Fields] OR "transference focused"[All Fields] OR "mentalization based"[All Fields] OR "metacognitive therapy"[All Fields] OR "metacognitive therapies"[All Fields] OR "interpersonal therapy"[All Fields] OR "interpersonal therapies"[All Fields] OR "interpersonal and social rhythm therapy"[All Fields] OR "schema therapy"[All Fields] OR "Schema-focused Therapy"[All Fields] OR "Schema-focused Therapy"[All Fields] OR "acceptance and commitment therapy"[All Fields] OR "acceptance based"[All Fields] OR "problem solving therapy"[All Fields] OR "problem solving therapies"[All Fields] OR "problem solving treatment"[All Fields] OR "problem solving treatments"[All Fields] OR "insight oriented therapy"[All Fields] OR "insight oriented therapies"[All Fields] OR "rational emotive"[All Fields] OR "solution focused therapy"[All Fields] OR "solution focused therapies"[All Fields] OR "family therapy"[All Fields] OR "family therapies"[All Fields] OR "family systems therapy"[All Fields] OR "parenting intervention"[All Fields] OR "parenting interventions"[All Fields] OR "parent management training"[All Fields] OR "group therapy"[All Fields] OR "group therapies"[All Fields] OR "mind-body therapies"[MeSH Terms] OR "mind body therapy"[All Fields] OR "mind body therapies"[All Fields] OR "art therapy"[All Fields] OR "art therapies"[All Fields] OR "dance therapy"[All Fields] OR "dance therapies"[All Fields] OR "music therapy"[All Fields] OR "music therapies"[All Fields] OR "play therapy"[All Fields] OR "play therapies"[All Fields] OR "expressive therapy"[All Fields] OR "expressive therapies"[All Fields] OR "cognitive remediation"[All Fields] OR "cognitive training"[All Fields] OR "behavioral activation"[All Fields] OR "behavior activation"[All Fields] OR "behavioural activation"[All Fields] OR "applied behavior analysis"[All Fields] OR "applied behaviour analysis"[All Fields] OR "behavioral weight control"[All Fields] OR "behavioural weight control"[All Fields] OR "attention bias modification"[All Fields] OR (("attention"[MeSH Terms] OR "attention"[All Fields]) AND bias-modification[All Fields]) OR "exposure and response prevention"[All Fields] OR (exposure[All Fields] AND "response prevention"[All Fields]) OR "exposure therapy"[All Fields] OR "systematic desensitization"[All Fields] OR "eye movement desensitization reprocessing"[All Fields] OR "emdr"[All Fields] OR "psychology biofeedback"[All Fields] OR "hypnosis"[All Fields] OR "mindfulness"[All Fields] OR "relaxation"[MeSH Terms]
2. Age:
("adolescent"[MeSH Terms] OR "adolescent"[All Fields] OR "adolescents"[All Fields]) OR ("young adult"[MeSH Terms] OR "young adult"[All Fields] OR "young adults"[All Fields])
3. Anxiety:
"anxiety disorders"[MeSH Terms] OR "anxiety disorders"[All Fields] OR "anxiety disorder"[All Fields] OR "neurotic disorders"[MeSH Terms] OR "neurotic disorders"[All Fields] OR "neurotic disorder"[All Fields] OR "panic disorder"[All Fields] OR "panic disorders"[All Fields] OR "agoraphobia"[All Fields] OR "social phobia"[All Fields] OR "social phobias"[All Fields] OR "social anxiety"[All Fields] OR "mutism"[All Fields] OR "separation anxiety"[All Fields] OR "phobic disorders"[All Fields] OR "phobic disorder"[All Fields] OR "phobia"[All Fields] OR "phobias"[All Fields] OR "generalized anxiety"[All Fields] OR ("obsessive-compulsive"[All Fields] AND "disorder"[All Fields]) OR "obsessive compulsive disorder"[All Fields] OR ocd[All Fields] OR "hoarding disorders"[All Fields] OR "hoarding disorder"[All Fields] OR "body dysmorphic disorders"[All Fields] OR "body dysmorphic disorder"[All Fields] OR "body image disorder"[All Fields] OR "trichotillomania"[All Fields] OR "hair pulling"[All Fields] OR excoriation[All Fields] OR dermatillomania[All Fields] OR "skin picking"[All Fields] OR "Trauma and Stressor Related Disorders"[MeSH Terms] OR "traumatic stress disorder"[All Fields] OR "traumatic stress disorders"[All Fields] OR "posttraumatic stress disorder"[All Fields] OR "posttraumatic stress disorders"[All Fields] OR "stress disorders, post-traumatic"[MeSH Terms] OR "post-traumatic stress disorders"[All Fields] OR "ptsd"[All Fields] OR "acute stress disorder"[All Fields] OR "acute stress disorders"[All Fields] OR "adjustment disorders"[All Fields] OR "adjustment disorder"[All Fields]
4. Filters (Article types):
Clinical Study[ptyp] OR Comparative Study[ptyp]
5. Date Filter
"0001/01/01"[PDAT] : "2018/08/31"[PDAT]
Combined Total Results: 1581
Study Selection Criteria
Eligibility of outcome studies were determined with the following criteria, specified by two researchers (BT, VG): (a) clinical outcome study (b) with at least one treatment condition involved being a psychotherapeutic intervention of any length or orientation for (c) adolescents or young adults aged 12–30 years (d) with specified mental disorders (e) as determined by DSM-5, ICD-10, or other diagnostic criteria or high level of symptoms on at least one relevant self-report measure (above the defined cut-off point for that measure), that (f) reports on the relationship between baseline variables and treatment outcome. Moreover, the clinical study should report at least two assessment points: pre-treatment (compulsory) and post-treatment (compulsory). Follow-up assessment was not compulsory for study inclusion; however, to be considered a follow-up at least one month between post-treatment and follow-up was necessary for the third assessment point. In addition, the study must be published in a peer-review journal, and at least title and abstract must be published in English.
In this study, psychotherapeutic interventions were defined as well-known psychotherapy approaches and other psychosocial interventions previously known to show promising evidence on treatment outcome for chosen disorders. A more detailed summary of the participants, interventions, comparators and outcomes considered, as well as the type of studies included according to PICOS strategy, is provided in Table 1.
Moderators of treatment outcome were defined as variables (a) measured at baseline that (b) interact with treatment to change outcome for each sub-group, and (c) the interaction is related to outcome in the linear model with or without a main effect. Predictors of treatment outcome were defined as (a) baseline variables that (b) affect outcome (significant main effect only) but do not interact with the allocated intervention. Both terms have been described in the literature under different terminology(36). To avoid making any assumptions on the definition of relevant predictors and moderators for treatment outcome in advance, we first conducted systematic search to identify eligible outcome studies, and from that pool of clinical studies, predictor and moderator studies will be searched manually.
Screening Procedure
Screening of studies was conducted using a three-stage screening process. Stage one included screening of all titles and abstracts, performed independently by two researchers for each diagnostic group. During stage two, the pair of researchers independently screened each full text article. Any discrepancies in screening of titles/abstracts and full text articles were resolved via discussion between the pair until consensus was reached, and when necessary, a third reviewer was called in adjudicate. In the event that a full-text article was not available in the databases the research team had access to, the researchers contacted the corresponding authors.
The final, third step, is in progress. The eligible outcome studies will be screened for predictors and moderators of treatment outcome. The pair of reviewers will independently screen eligible studies for candidate predictors and moderators and will reach a consensus on which relevant moderator studies should be included. All predictor variables will be included, as long as they are assessed pre-randomization and do not change as a response to treatment(45).
Data Extraction And Coding
This is an ongoing study. Screening of articles by independent reviewers is close to completion, but data extraction has not begun. We plan to extract data from the final list of included studies in the following categories (1) identification of the study (article title; journal title; authors; publication year; host institution of the study (hospital; university; research centre; single institution; multicentre study); (2) methodological characteristics (study design; sample characteristics, e.g., sample size, gender; age, race; diagnostic procedures and measures; intervention groups and controls; length of follow-up; statistical analysis); (3) predictor or moderators (4) relationship between predictor/moderator and outcome.
The coding of predictors and moderator variables was based on the structure found in Knopp et al.(46). Variables will be coded as: (a) non-specific predictors of outcome, if the main effect of a predictor on outcome was assessed for the sample as a whole; and (b) moderators, if the effect of the baseline variable on outcome was assessed through a direct test of the interaction between the baseline variable and the intervention(s).
Variables identified through the splitting of the data into groups will be coded as predictors of outcome. Several strategies for such subgroup analysis can be found in the literature (see(46)). One approach includes assessing the main effect of a predictor on outcome only for the treatment or control group. Another approach is to select patients from the treatment and control groups based on a baseline characteristic and compare intervention with control patients within that subgroup (for example, comparing efficacy of intervention vs. control among male participants). Another possibility is to split the overall sample into two groups and look at the effect of the predictor on outcome for both groups separately (e.g., splitting the sample into those with and without co-morbid mental disorders and assessing outcome for both groups separately).
For data extraction, a minimum of two independent reviewers will extract and summarize the data from each included study. If the outcome data in the original article is unclear, the corresponding author will be contacted via email for clarification.
Quality Assessment
As the study is ongoing, quality assessment of included studies has not yet started. First, in order to estimate the possible sources of bias in RCTs, we will use the four criteria of the Cochrane Collaboration Risk of Bias Tool (RoB1 tool;(47)), where overall ratings vary from low, to unclear and to high risk of bias. The criteria are (a) random sequence generation - the adequate generation of the allocation sequence, (b) allocation concealment – concerning the concealment of allocation to conditions, (c) blinding of outcome assessment – i.e., blinding of outcome assessors and considering how subjective or objective an outcome is, and d) incomplete outcome data – the manner in which incomplete data were addressed. The Risk of Bias assessment will be made by two independent raters and disagreements will be discussed and resolved by reaching consensus.
Second, in order to assess the possible sources of bias in non-randomized controlled studies or NRCTs, the ROBINS-I tool will be used(48). ROBINS-I uses seven domains at three moments in time: pre-intervention, intervention, and post-intervention. At pre-intervention, selection bias is assessed in the form of (1) bias due to the presence of confounding factors affecting outcome and (2) bias in selection of some participants into the study. During intervention, bias is assessed in terms of (3) biases in classification of interventions. At post-intervention wise, four other domains are assessed: (4) bias due to deviations from intended interventions, (5) bias due to missing data, (6) bias in measurement of outcomes, and (7) bias in selection of the reported results. The risk level of each domain is classified as low, moderate, serious, or critical. As in the case of the RoB1 tool, in the current research, two independent reviewers will perform the risk of bias assessment and disagreements will discussed and resolved by reaching consensus. A review-level narrative summary of the risk of bias will also be provided.
To assess the quality of predictor and moderators, we will employ the criteria developed by Pincus et al.(49) and Sun et al.(50), implemented in the study by Knopp et al.(46). These include: (a) predictor and moderator variables are assessed through validated assessment tool; (b) predictor and moderator variables are measured pre-randomization (non-applicable for non-modifiable variables, such as gender or age); (c) fewer than five predictors tested in the model; (d) predictor and moderator variables tested through a priori hypothesis of anticipated effects; (e) for moderator variables, analysis of direct test of interaction between moderator and treatment type is conducted.
Data Analysis
The final stage of the systematic review will be a data synthesis of the different predictors and moderators of outcomes of psychotherapeutic interventions. Given the anticipated heterogeneity of clinical studies, we will conduct a narrative synthesis of extracted data, a method that has been carried out in similar studies(46). Data will be organized by predictor/moderator variable and by targeted disorder.