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Childhood maltreatment is a key predictor of mental health problems across the life span. Yet, how maltreatment types independently and jointly influence the risk for psychiatric problems remains unclear. The aim of the study was two-fold: first, to replicate recent findings regarding the impact of maltreatment types on youth psychiatric symptoms, based on a Brazilian sample of high-risk adolescents (n = 347; age range = 11-17 yrs), and second, to extend existing findings by examining whether this relationship is mediated by bullying victimization and/or perpetration. Measures included self-report ratings of childhood maltreatment and peer victimization, as well as multi-informant reports of internalizing and externalizing symptoms. Consistent with prior research, we found that: (i) maltreatment types often co-occurred; (ii) there was a linear association between number of maltreatment types experienced and symptom severity (i.e. cumulative effect); and (iii) emotional abuse emerged as the most consistent independent predictor of poor mental health across domains, raters, and gender. Additionally, this study extends previous findings by showing that the influence of maltreatment on psychiatric outcomes is partially mediated by peer victimization, but not by bullying perpetration. In conclusion, these findings expand our understanding of the heterogeneity in individual responses to maltreatment as well as highlighting emotional abuse as an important predictor of poor mental health.

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IMPORTANCE: Depression can have devastating effects unless prevented or treated early and effectively. Schools offer an excellent opportunity to intervene with adolescents presenting emotional problems. There are very few universal school-based depression interventions conducted in low- and middle-income countries. OBJECTIVE: To assess the effectiveness of a school-based, universal psychological intervention to reduce depressive symptoms among adolescents from low-income families. DESIGN, SETTING, AND PARTICIPANTS: A 2-arm, parallel, cluster, randomized clinical trial was conducted in secondary schools in deprived socioeconomic areas of Santiago, Chile. Almost all students registered in the selected schools consented to take part in the study. A total of 2512 secondary school students from 22 schools and 66 classes participated. INTERVENTIONS: Students in the intervention arm attended 11 one-hour weekly and 2 booster classroom sessions of an intervention based on cognitive-behavioral models. The intervention was delivered by trained nonspecialists. Schools in the control arm received the standard school curriculum. MAIN OUTCOMES AND MEASURES: Scores on the self-administered Beck Depression Inventory-II at 3 months (primary) and 12 months (secondary) after completing the intervention. RESULTS: There were 1291 participants in the control arm and 1221 in the intervention arm. Primary outcome data were available for 82.1% of the participants. There was no evidence of any clinically important difference in mean depression scores between the groups (adjusted difference in mean, -0.19; 95% CI, -1.22 to 0.84) or for any of the other outcomes 3 months after completion of the intervention. No significant differences were found in any of the outcomes at 12 months. CONCLUSIONS AND RELEVANCE: A well-designed and implemented school-based intervention did not reduce depressive symptoms among socioeconomically deprived adolescents in Santiago, Chile. There is growing evidence that universal school interventions may not be sufficiently effective to reduce or prevent depressive symptoms. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN19466209.

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BACKGROUND: Depression is common and can have devastating effects on the life of adolescents. Psychological interventions are the first-line for treating or preventing depression among adolescents. This proposal aims to evaluate a school-based, universal psychological intervention to reduce depressive symptoms among student's aged 13-14 attending municipal state secondary schools in Santiago, Chile. STUDY DESIGN: This is a cluster randomised controlled trial with schools as the main clusters. We compared this intervention with a control group in a study involving 22 schools, 66 classes and approximately 2,600 students. Students in the active schools attended 11 weekly and 3 booster sessions of an intervention based on cognitive-behavioural models. The control schools received their usual but enhanced counselling sessions currently included in their curriculum. Mean depression scores and indicators of levels of functioning were assessed at 3 and 12 months after the completion of the intervention in order to assess the effectiveness of the intervention. Direct and indirect costs were measured in both groups to assess the cost-effectiveness of this intervention. DISCUSSION: As far as we are aware this is the first cluster randomised controlled trial of a school intervention for depression among adolescents outside the Western world. TRIAL REGISTRATION: ISRCTN19466209.

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