Building Evidence-Based Supports for Teens Via Technology

Psychiatric disorders are the leading cause of disability worldwide, and 40.5% of this burden
is attributable to major depression (MD). Rates of MD increase markedly in adolescence, with
nearly 20% of youth experiencing MD between ages 12 and 18. Adolescent-onset MD accounts for
66% of lifetime MD cases and predicts interpersonal problems, substance abuse, and a 20-fold
increased risk for attempting suicide. Despite this early onset and protracted course, up to
70% of US adolescents with MD do not receive services. Even among those who do access
treatment, 30-65% fail to respond. These findings highlight the urgent need for more potent
and accessible MD interventions for adolescents.

Emerging work suggests that single-session interventions (SSIs) may increase accessibility of
youth MD interventions. SSIs include core elements of comprehensive, evidence based
treatments, but their brevity makes them easier to disseminate to diverse settings. Indeed,
SSIs can successfully treat youth psychiatric problems: In a meta-analysis of 50 RCTs, it has
been found that SSIs reduced youth mental health difficulties of multiple types (mean
g=0.32), including self-administered SSIs (e.g., web-based SSIs; mean g=0.32). One SSI, in
particular, has been shown to reduce adolescent MD symptoms: the growth mindset (GM) SSI, a
web-based program teaching the belief that personal traits are malleable, which has prevented
and reduced adolescent MD in recent RCTs. For example, in a recent RCT conducted by the
principal investigator on the proposed study, the GM SSI led to post-intervention increases
in adolescents' perceived control over behavior (d=.34, p<.001) and emotions (d=.19, p=.03)
relative to a comparison (supportive therapy, or ST) SSI. The GM SSI also predicted steeper
9-month declines in youth depression symptoms per parent (B=-.99, p=.047) and adolescent
reports (B=-1.37, p=.03), based on mixed-effects linear models.

However, it is notable that the GM SSI does not reduce depression in all adolescents. For
instance, the intervention reduced depression in adolescents who reported post-intervention
increases in perceived control over behaviors and emotions, but it did not lead to
significant depression reductions in adolescents who reported small or no increases in
perceived control. Thus, the potency of GM SSIs for adolescent depression has yet to be
optimized. Such potency may be advanced by developing new iterations of the growth mindset
intervention, which are designed to more systematically target predictors and mediators of
clinical outcomes, such as perceived control. Such efforts may increase the promise of growth
mindset interventions to produce greater symptom reductions for a larger proportion of youth
experiencing distress.

Accordingly, the goal of the present study is to test the acceptability and effectiveness of
a novel, single-session virtual reality-based growth mindset intervention—the VR Personality
Project—for depressive symptoms in adolescents. The VR Personality Project was designed to
systematically target and increase adolescents' sense of agency and perceived control by
offering a more immersive, active, and user-directed intervention experience than the
previously-tested web-based SSI can provide. By targeting an identified predictor and
mechanism of intervention response, the VR Personality Project may produce larger reductions
in depression than the existing web-based mindset SSI. Thus, this intervention may represent
a mechanism-targeted, efficient strategy for reducing for adolescent depression--one that is
both relatively affordable (less than $100 for any commercially-available VR headset, a
fraction of the cost of long-term psychotherapy) and engaging to adolescents experiencing
mood-related distress.

There are four specific study aims for this research:

AIM 1: Replication of past research. Our first aim is to replicate past research suggesting
that single-session growth mindset interventions can significantly reduce depressive symptoms
in at-risk adolescents. We hypothesize that adolescents who participate in a growth mindset
intervention (web-based OR virtual reality-based) will show larger reductions in depression
symptoms from baseline (pre-intervention) through the 9-month follow-up assessment, compared
to adolescents who receive an active, web-based control program.

AIM 2: Evaluation of new virtual reality intervention, including a comparative efficacy
study. Our second aim is to evaluate whether the new virtual reality-based growth mindset
intervention (the VR Personality Project) can reduce depressive symptoms in adolescents, both
relative to an active control program and relative to the previously tested web-based growth
mindset intervention. We hypothesize that adolescents who participate in the virtual
reality-based growth mindset intervention will show larger reductions in depressive symptoms
from baseline (pre-intervention) through the 9-month follow-up assessment, compared to
adolescents who receive the web-based growth mindset intervention AND adolescents who receive
the active web-based control program.

AIM 3: Testing mediation through perceived control. The VR Personality Project was explicitly
designed to target and increase adolescents' perceived control by offering a more immersive,
active, and user-directed intervention experience than the the web-based growth mindset SSI
can provide. Thus, the third goal of this study is to examine whether the VR Personality
Project does, in fact, reduce adolescent depressive symptoms by eliciting proximal increases
in perceived control. We hypothesize that the VR Personality Project will lead to larger
increases in perceived control than either web-based intervention from pre- to
post-intervention, and that these increases will mediate subsequent reductions in adolescent
depression across the follow-up period.

AIM 4: Gauge the relative acceptability and feasibility of the VR intervention. Adolescents'
perceptions of any intervention can impact completion rates, program engagement, and
ultimately intervention effectiveness. Thus, an additional aim of this research is to examine
whether adolescents view the VR Personality Project as more engaging, helpful, and
interesting than the web-based growth mindset intervention or the web-based control
intervention.

Inclusion Criteria:

- Youth is between the ages of 12-16 years (inclusive) at the time of study enrollment

- Youth has one parent or legal guardian willing to participate in the study (i.e., to
be present for the lab visit and to complete questionnaires throughout the study
period)

- Youth speaks English well enough to complete online or virtual reality-based
intervention activities, which are available in English only

- Indication of elevated risk for youth depression. This criterion may be met in one of
two ways (or both ways): (a) The adolescent exhibits elevations in depressive symptoms
(subclinical or greater symptom elevations, corresponding to 80th percentile or
higher, based on parent-report CDI 2 conducted an initial phone screen); (b) The
adolescent received treatment for depression within the previous 2 years (depression
tends to recur, so past treatment receipt indicates elevated risk). Past treatment
receipt will be assessed via parent report at the time of the phone screen.

Exclusion Criteria:

- Intellectual disability, as this may undermine comprehension of intervention materials

- Adolescent is non-English speaking, as the virtual reality and online interventions
are available in English only;

- Adolescent was hospitalized or received residential/inpatient treatment for suicide
attempt or self-harming behaviors within the past 2 months, as the interventions being
tested in this study are not designed for adolescents with acute medical and/or
psychiatric treatment needs