Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial

Background Systematic reviews suggest school-based mindfulness training (SBMT) shows promise in promoting student mental health. Objective The My Resilience in Adolescence (MYRIAD) Trial evaluated the effectiveness and cost-effectiveness of SBMT compared with teaching-as-usual (TAU). Methods MYRIAD was a parallel group, cluster-randomised controlled trial. Eighty-five eligible schools consented and were randomised 1:1 to TAU (43 schools, 4232 students) or SBMT (42 schools, 4144 students), stratified by school size, quality, type, deprivation and region. Schools and students (mean (SD); age range=12.2 (0.6); 11–14 years) were broadly UK population-representative. Forty-three schools (n=3678 pupils; 86.9%) delivering SBMT, and 41 schools (n=3572; 86.2%) delivering TAU, provided primary end-point data. SBMT comprised 10 lessons of psychoeducation and mindfulness practices. TAU comprised standard social-emotional teaching. Participant-level risk for depression, social-emotional-behavioural functioning and well-being at 1 year follow-up were the co-primary outcomes. Secondary and economic outcomes were included. Findings Analysis of 84 schools (n=8376 participants) found no evidence that SBMT was superior to TAU at 1 year. Standardised mean differences (intervention minus control) were: 0.005 (95% CI −0.05 to 0.06) for risk for depression; 0.02 (−0.02 to 0.07) for social-emotional-behavioural functioning; and 0.02 (−0.03 to 0.07) for well-being. SBMT had a high probability of cost-effectiveness (83%) at a willingness-to-pay threshold of £20 000 per quality-adjusted life year. No intervention-related adverse events were observed. Conclusions Findings do not support the superiority of SBMT over TAU in promoting mental health in adolescence. Clinical implications There is need to ask what works, for whom and how, as well as considering key contextual and implementation factors. Trial registration Current controlled trials ISRCTN86619085. This research was funded by the Wellcome Trust (WT104908/Z/14/Z and WT107496/Z/15/Z).

[1]  J. García-Campayo,et al.  Teachers “Finding Peace in a Frantic World”: An Experimental Study of Self-Taught and Instructor-Led Mindfulness Program Formats on Acceptability, Effectiveness, and Mechanisms , 2021, Journal of educational psychology.

[2]  S. Blakemore,et al.  Universal Mindfulness Training in Schools for Adolescents: a Scoping Review and Conceptual Model of Moderators, Mediators, and Implementation Factors , 2021, Prevention Science.

[3]  Blanca Piera Pi-Sunyer,et al.  Update to the effectiveness and cost-effectiveness of a mindfulness training programme in schools compared with normal school provision (MYRIAD): study protocol for a randomised controlled trial , 2021, Trials.

[4]  S. Blakemore,et al.  The Role of Schools in Early Adolescents’ Mental Health: Findings From the MYRIAD Study , 2021, Journal of the American Academy of Child and Adolescent Psychiatry.

[5]  J. Pell,et al.  Antipsychotic and antidepressant prescribing for 704 297 children and young people with and without intellectual disabilities: record linkage study , 2020, The British Journal of Psychiatry.

[6]  L. Koerbel,et al.  Assessing Mindfulness-Based Teaching Competence: Good Practice Guidance , 2020, Global advances in health and medicine.

[7]  Catherine Crane, PhD,et al.  Training School Teachers to Deliver a Mindfulness Program: Exploring Scalability, Acceptability, Effectiveness, and Cost-effectiveness , 2020, Global advances in health and medicine.

[8]  Willem Kuyken,et al.  Research Review: The effects of mindfulness‐based interventions on cognition and mental health in children and adolescents – a meta‐analysis of randomized controlled trials , 2018, Journal of child psychology and psychiatry, and allied disciplines.

[9]  T. Dalgleish,et al.  The effectiveness and cost-effectiveness of a mindfulness training programme in schools compared with normal school provision (MYRIAD): study protocol for a randomised controlled trial , 2017, Trials.

[10]  M. Greenberg,et al.  Universal Interventions: Fully Exploring Their Impacts and Potential to Produce Population-Level Impacts , 2017 .

[11]  Alexander Robitzsch,et al.  Multiple Imputation of Multilevel Missing Data , 2016, 1611.03112.

[12]  Elisabeth Schramm,et al.  Mindfulness-based cognitive therapy for depression , 2016, The Lancet.

[13]  K. Allen,et al.  Validation of the Child and Adolescent Mindfulness Measure (CAMM) with Non-Clinical Adolescents , 2015 .

[14]  Gareth Furber,et al.  The validity of the Child Health Utility instrument (CHU9D) as a routine outcome measure for use in child and adolescent mental health services , 2015, Health and Quality of Life Outcomes.

[15]  N. Humphrey,et al.  How do schools promote emotional well-being among their pupils? Findings from a national scoping survey of mental health provision in English schools. , 2013, Child and adolescent mental health.

[16]  F. Huppert,et al.  Effectiveness of the Mindfulness in Schools Programme: non-randomised controlled feasibility study , 2013, British Journal of Psychiatry.

[17]  M. Janosz,et al.  School Environment and Adolescent Depressive Symptoms: A Multilevel Longitudinal Study , 2013, Pediatrics.

[18]  B. Zijlstra,et al.  The Meaning of Mindfulness in Children and Adolescents: Further Validation of the Child and Adolescent Mindfulness Measure (CAMM) in Two Independent Samples from The Netherlands , 2013 .

[19]  Katherine Stevens,et al.  Valuation of the Child Health Utility 9D Index , 2012, PharmacoEconomics.

[20]  S. Logan,et al.  Supporting teachers and children in schools: the effectiveness and cost-effectiveness of the incredible years teacher classroom management programme in primary school children: a cluster randomised controlled trial, with parallel economic and process evaluations , 2012, BMC Public Health.

[21]  Gregory T. Smith,et al.  Assessing mindfulness in children and adolescents: development and validation of the Child and Adolescent Mindfulness Measure (CAMM). , 2011, Psychological assessment.

[22]  T. Friede,et al.  Warwick-Edinburgh Mental Well-being Scale (WEMWBS): Validated for teenage school students in England and Scotland. A mixed methods assessment , 2011, BMC Public Health.

[23]  Katherine Stevens,et al.  Assessing the performance of a new generic measure of health-related quality of life for children and refining it for use in health state valuation , 2011, Applied health economics and health policy.

[24]  Daniel M. Johnson,et al.  A controlled trial of mindfulness training in schools: The importance of practice for an impact on well-being , 2010 .

[25]  Michael Herdman,et al.  Development of the EQ-5D-Y: a child-friendly version of the EQ-5D , 2010, Quality of Life Research.

[26]  David J Torgerson,et al.  Bias in identifying and recruiting participants in cluster randomised trials: what can be done? , 2009, BMJ : British Medical Journal.

[27]  T. Paus,et al.  Why do many psychiatric disorders emerge during adolescence? , 2008, Nature Reviews Neuroscience.

[28]  S. Fekete,et al.  Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. , 2008, Journal of child psychology and psychiatry, and allied disciplines.

[29]  J. Durlak,et al.  Implementation Matters: A Review of Research on the Influence of Implementation on Program Outcomes and the Factors Affecting Implementation , 2008, American journal of community psychology.

[30]  I. Goodyer,et al.  Cost-effectiveness of selective serotonin reuptake inhibitors and routine specialist care with and without cognitive–behavioural therapy in adolescents with major depression , 2007, British Journal of Psychiatry.

[31]  L. Hiller,et al.  The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation , 2007, Health and quality of life outcomes.

[32]  Vikram Patel,et al.  Mental health of young people: a global public-health challenge , 2007, The Lancet.

[33]  Julie Ratcliffe,et al.  Measuring and valuing health benefits for economic evaluation in adolescence: an assessment of the practicality and validity of the child health utility 9D in the Australian adolescent population. , 2012, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.

[34]  Elisabeth Fenwick,et al.  A guide to cost-effectiveness acceptability curves. , 2005, The British journal of psychiatry : the journal of mental science.

[35]  Lawrence H Moulton,et al.  Covariate-based constrained randomization of group-randomized trials , 2004, Clinical trials.

[36]  D. Altman,et al.  CONSORT statement: extension to cluster randomised trials , 2004, BMJ : British Medical Journal.

[37]  B J O'Brien,et al.  Analysis of uncertainty in health care cost-effectiveness studies: an introduction to statistical issues and methods , 2002, Statistical methods in medical research.

[38]  J. Rushton,et al.  Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. , 2002, Journal of the American Academy of Child and Adolescent Psychiatry.

[39]  R. Goodman,et al.  Psychometric properties of the strengths and difficulties questionnaire. , 2001, Journal of the American Academy of Child and Adolescent Psychiatry.

[40]  R. Goodman,et al.  Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka , 2000, European Child & Adolescent Psychiatry.

[41]  S. Thompson,et al.  How should cost data in pragmatic randomised trials be analysed? , 2000, BMJ : British Medical Journal.

[42]  John Mullahy,et al.  Net Health Benefits: A New Framework for the Analysis of Uncertainty in Cost-Effectiveness Analysis , 1998 .

[43]  L. Radloff.  The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults , 1991, Journal of youth and adolescence.

[44]  Ronald Mac Keith,et al.  JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY AND ALLIED DISCIPLINES , 1968 .

[45]  C. Dolea,et al.  World Health Organization , 1949, International Organization.

[46]  K. Stevens.  The development of a preference based paediatric health related quality of life measure for use in economic evaluation , 2009 .

[47]  D. Quinton,et al.  Unit Costs of Health and Social Care 2004 , 2004 .

[48]  P. J. Bayliss,et al.  University of Sheffield , 1949, Nature.