Mental health interventions targeting children and young people: A mapping review of interventions, follow-up, and evidence gaps

Astrid Dahlgren; Ingrid Borren; Brynhildur Axelsdottir; Mari Elvsåshagen; Karianne Hammerstrøm Nilsen

doi:10.12688/f1000research.123561.2

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Research Article

Revised

Mental health interventions targeting children and young people: A mapping review of interventions, follow-up, and evidence gaps

[version 2; peer review: 1 approved, 1 approved with reservations]

Astrid Dahlgren¹, Ingrid Borren², Brynhildur Axelsdottir², Mari Elvsåshagen², Karianne Hammerstrøm Nilsen²

Astrid Dahlgren¹, Ingrid Borren², [...] Brynhildur Axelsdottir², Mari Elvsåshagen², Karianne Hammerstrøm Nilsen²

PUBLISHED 08 May 2025

Author details Author details

¹ OsloMet, Faculty of Health Sciences, Oslo Metropolitan University, P.O. Box 4, St. Olavs plass, NO-0130 Oslo, Norway
² RBUP East and South, P.O. Box 4623 Nydalen, 0405 Oslo, Norway

Astrid Dahlgren
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Ingrid Borren
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

Brynhildur Axelsdottir
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

Mari Elvsåshagen
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

Karianne Hammerstrøm Nilsen
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Global Public Health gateway.

Abstract

Background

Young people with mental disorders should be offered evidence-based treatments. In 2018, we developed a national evidence portal in Norway providing access to living evidence summaries. This work has been an important contribution to mental health care in Norway but is also a rich data source for exploring the existing research. At the time of this study, eight overviews of overviews (OoO) were published addressing the effects of treatments for attention deficit / hyperactivity disorder (ADHD), anxiety, depression, bipolar disorder, psychosis, obsessive compulsive disorder, self-harm and trauma / post-traumatic stress disorder. The objective of this study was to do a secondary analysis of this evidence to describe the state-of-the art in this field, and to map:

treatments evaluated for each diagnostic group and the longest time of follow-up
treatment comparisons evaluated for more than one diagnostic group

Methods

We performed a mapping review. Data extraction was performed independently by two authors. All data was entered into Excel. Unique treatment comparisons were visualised in Sunburst diagrams. The longest time of follow-up and treatments evaluated across diagnostic groups were reported in descriptive tables.

Results

We identified 200 treatment comparisons including a wide variety of interventions. Some diagnoses are treated mostly with pharmaceutical therapies (such as bipolar disorder) or psychological therapy alone or in combination (such as anxiety and psychosis). Others are treated with a broader spectrum of therapeutic approaches (such as depression and ADHD). The evidence supporting most treatments is of low to very low certainty. Ten percent of the comparisons included follow-up assessments beyond 12 months. Cognitive behavioural therapy, dialectic behavioural therapy, physical activity and mindfulness interventions were effective across populations.

Conclusions

The evidence supporting treatment of mental disorders in young people has important limitations. Future research efforts should address these evidence gaps.

Keywords

mental health, children, youth, interventions, mapping review, evidence gaps

Corresponding author: Astrid Dahlgren

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 Dahlgren A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Dahlgren A, Borren I, Axelsdottir B et al. Mental health interventions targeting children and young people: A mapping review of interventions, follow-up, and evidence gaps [version 2; peer review: 1 approved, 1 approved with reservations]. F1000Research 2025, 12:2 (https://doi.org/10.12688/f1000research.123561.2) First published: 03 Jan 2023, 12:2 (https://doi.org/10.12688/f1000research.123561.1) Latest published: 08 May 2025, 12:2 (https://doi.org/10.12688/f1000research.123561.2)

Revised Amendments from Version 1

We appreciate this opportunity to improve and revise our manuscript. Our comments and suggested edits are described below.

We have accommodating most, if not all, of the peer reviewers comments. We have found these very useful and believe it has improved the clarity of our manuscript. The most important differences are; 1. improved description of the methods separating the initial overviews of systematic reviews (OoO) and the present study. 2. Improved the use of terminology as pointed out by reviewer 2. 3. Improved clarity of the description of reporting of the findings.

See the authors' detailed response to the review by Hiran Thabrew
See the authors' detailed response to the review by Heather Eileen Menzies Munthe-Kaas

Introduction

Acting early by providing children and youth with evidence-based treatments for mental health problems may prevent chronic illness and deterioration of other health outcomes and quality of life.¹ Attention-deficit / hyperactivity disorder (ADHD), behavioural disorders and internalising disorders such as anxiety and depression are common disorders diagnosed in childhood and adolescence.² While the etiology of these disorders may differ, they share commonalities, such as causing distress or impairment in key areas of functioning. In general, as many as one in four are reported to experience a mental disorder, and according to the WHO mental health disorders are among the leading causes of disability worldwide.¹^,²

Interventions targeting mental disorders encompass a range of treatments including (but not restricted to) psychological therapies, pharmacological therapies, peer-supported interventions, educational interventions, physical activity, nutritional interventions and alternative therapies such as acupuncture and yoga. Traditionally, treatments for mental health problems have taken a diagnostic approach, however a new school of thought argue for a transdiagnostic approach that cuts across traditional diagnostic boundaries.³

Children and young people should be offered evidence-based treatments. Summarised evidence is a necessity for good quality health care and should inform decision-making about treatment choices.⁴^,⁵ However, there is an abundance of systematic reviews published every year and many of these are not of satisfactory quality.⁶ Evidence summaries such as overviews of overviews are therefore important decision-making tools for users, professionals and policy makers.⁷

In 2018 we developed a national evidence portal (see here) in Norway hosting living evidence summaries of systematic reviews evaluating the effects of interventions for children and young people with mental disorders.⁸^,⁹ Living evidence summaries are systematic reviews being continuously updated and revised, using a systematic approach to literature search, screening of new publications for possible inclusion, data extraction and GRADE-assessments.

The evidence portal relies on best practice review methodology and was inspired by other international evidence portals targeting mainly adults and somatic illness.¹⁰ At the time the present study was conducted, eight overviews of overviews (here termed ‘OoOs’) had undergone peer-review and were published in the evidence portal. In an OoO, all available systematic reviews meeting explicit inclusion and exclusion criteria are summarised and quality assessed. Sometimes OoOs are also called umbrella reviews. Each of the OoOs addressed a specific diagnostic group and summarised the effects of treatments for children and young people with ADHD, anxiety, depression, bipolar disorder, psychosis (including schizophrenia), obsessive-compulsive disorder (OCD) self-harm and trauma (including post-traumatic stress disorder, PTSD) respectively.¹¹^–¹⁸

This immense work has been an important contribution to mental health care in Norway and has been integrated in the Norwegian national guidelines but also provides an opportunity for exploring the characteristics and evidence gaps of the existing research. This led us to conduct the study reported on in this paper, were we wanted to explore the diversity of treatments evaluated and to map their effects across diagnostic groups.

This is valuable knowledge for researchers planning new treatment evaluations for children and young people, but also for providing input to the debate on transdiagnostic approaches, and the potential value of some treatments to be effective for several mental disorders.³

Objectives

The purpose of this study was to do a secondary analysis of the eight evidence summaries included in the evidence portal and to describe the state of the art of the existing research in this field. Specifically, we aimed to:

(1) map all treatments evaluated for each diagnostic group and the longest time of follow-up included in these assessments
(2) map treatment comparisons evaluated across groups and to create an overview of the effects of these including the certainty of the evidence (using the Grading of Recommendations Assessment, Development and Evaluation framework – GRADE - on the primary outcome for each diagnostic group

To our knowledge, no mapping review exploring these aims have previously been conducted.

Methods

Design

This study is a mapping review and a secondary analysis of eight overviews of overviews (OoO). There is no gold standard for conducting mapping reviews, however a common set of guiding rules have been suggested.¹⁹^,²⁰ In general, mapping reviews provide an overview of the literature by describing and organising the research literature according to characteristics such as interventions, intervention components or population. Mapping reviews are also used for identifying evidence gaps, and to inspire and guide new research initiatives.¹⁹^,²⁰ The protocol for this mapping review has been published.²¹

Description of the included overviews of systematic reviews

There is an abundance of systematic reviews summarising the effects of interventions for child and young people’s mental health. We have in the above-mentioned previous work completed eight OoOs including systematic reviews evaluating all interventions targeting children and adolescents (0-18 years) with; ADHD, anxiety, depression, bipolar disorder, psychosis (including schizophrenia), OCD, self-harm and trauma (including PTSD).¹¹^–¹⁸

The analysis reported on in this paper is in its entirety based on these eight OoOs and represents a secondary analysis of what we considered at the time of the publication of this manuscript to be complete summaries of the effectiveness of interventions reported on in high quality systematic reviews.

The protocols for the included overviews have been published in PROSPERO (ADHD, CRD42020159885; Anxiety, CRD42020159884; Bipolar, CRD42020176356; Depression, CRD42020159883; Psychosis, CRD42020212244; Self-harm, CRD42019117942; Trauma CRD42019120078; OCD, CRD42020221081), however we briefly summarise the methods used here.

All OoOs were conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and according to “best practice”-principles of review methods.¹⁰ The search strategies for the OoOs were largely based on the database for systematic reviews IN SUM (indexing publications from all major databases. The search strategy applied by the IN SUM database can be accessed here). All systematic reviews indexed in IN SUM were considered for inclusion. We also hand searched national databases of evidence-based guidelines in Sweden, Denmark and the UK (NICE). The flow chart describing each step of the inclusion and exclusion of publications can be seen in Figure 1.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

PICO, population intervention comparison outcome; OCD, obsessive compulsive disorder; ADHD, attention deficit / hyperactivity disorder; OoO, overviews of overviews.

To be included in one of the OoOs, a review had to meet a set of minimum criteria (4 out of 5) for being considered “systematic”, set by DARE.²²

1. Clear inclusion and exclusion criteria
2. A comprehensive search strategy
3. A compilation of results from included studies, or
4. Quality assessment of included studies.
5. Sufficiently reported details about the individual included studies

Furthermore, all interventions intended to improve an aspect of mental health for children and adolescents under the age of 18 were included.

Data extraction and evidence included in the analysis of the mapping review

We mapped all unique interventions evaluated in the OoOs and sorted them by the following categories: medication therapies, combination therapies, training interventions (such as skills, training and psychoeducation), dietary interventions, psychosocial therapies, systemic interventions, physical interventions and other interventions. In the results section, we present these intervention categories in descriptive charts (Sunburst-diagrams) for each diagnostic group respectively. We also mapped the number of treatment comparisons evaluated and the longest time of follow-up included in these assessments (for any outcome).

To create a mega-map of intervention effects across diagnostic groups we also extracted data on the primary outcome for each intervention, and the judgement of certainty for this outcome.²³^,²⁴ All data were entered into Excel. The primary outcome was conceptualised as overall symptomatology associated with the relevant condition, such as anxiety symptoms for those with anxiety and depression symptoms for those with depression. In cases where the same outcome was assessed using different outcome measures, we extracted the outcome with the longest follow up and highest certainty.²³ If a review did not report findings on overall symptoms, we reported other symptoms as proxy, for example inattention in treatment of ADHD when total symptoms were not available.

Since this is a mapping review, we based our analysis on the effect-sizes and judgements of certainty as they were reported in the OoO. Judgements about certainty included in the OoO were made using the GRADE-criteria.²³^,²⁴ GRADE (Grading of Recommendations, Assessment, Development and Evaluations) is a transparent and widely adapted tool for developing and presenting summaries of evidence.²³ Using this framework, the evidence is judged to have high, moderate, low or very low certainty by considering the following criteria: risk of bias, imprecision, inconsistency, indirectness, publication bias, magnitude of effect, dose-response gradient and residual confounding.

We extracted the effect sizes and categorized these “small”, “moderate” or “large” based on statistical rule-of-thumb judgements (see Table 1).¹⁰^,²⁴ For outcomes judged to be of very low certainty, effect sizes were reported as “?” adhering to the GRADE- recommendations.²³

Table 1. Rule of thumb thresholds used for effect sizes.

Effect estimate	Small effect	Moderate effect	Large effect
Relative risk (RR)			RR >2
Odds ratio (OR)	1.68	3.47	6.71
Standardised mean difference (SMD), Cohen’s d and Hedge’s g	<0.2	0.5	>0.8
Number needed to treat (NNT)	>10	2-10	1
Remission	20%	50%	100%

What is considered “a meaningful effect” depends on the individual person and context. Thus, we made no attempt to consider the clinical importance of these results as this is best judged by those delivering and receiving treatments. In some cases, it was difficult to judge the size of the effect as the results were not reported using standardised or relative effect estimates. In these circumstances we used the systematic review authors’ own judgements and have annotated these in the results table. If no judgements were made by the review authors, we marked this as “effective” without making judgements about the size of effect. Trivial or small not statistically significant differences in effect was coded as “little or no difference” according to the GRADE-recommendations.²⁵

All data extraction was done by one author and double checked by another co-author. Any difference in opinion between these were discussed with a third co-author.

The OoOs are “living reviews”, and so for the sake of this secondary analysis we based our data collection on the latest updated version of each overview respectively, with the most recent of these updates including evidence published in April 2021 or later. The data collection for this mapping review took place between September 2021 and December 2022. On average, the OoO were updated on a yearly basis at the time of this publication.

Evidence not included in the mapping review

Some of the OoOs included both preventive and treatment interventions. For this mapping review, we only considered interventions targeting children and adolescents with a clinical diagnosis of mental disorder or otherwise judged by the systematic review authors to have moderate to serious symptomatology. The reason for this was that not all the OoOs included preventive studies and thus would render this secondary analysis incomplete.

The OoOs did not include full data extraction and GRADE-assessments of studies where pharmacological interventions were not compared to active interventions, thus this secondary analysis does not include such comparisons. Furthermore, studies evaluating mental health interventions targeting people where the primary health concern was somatic (e.g., people with asthma and co-occurring anxiety) were excluded in the OoOs and consequently not included in the secondary analysis.

Results

Treatment comparisons and follow-up

We reviewed 116 systematic reviews included in the eight OoOs (see Figure 1). As the OoOs are living documents and regularly updated, we have included a list of the systematic reviews included in the summaries at the time data was extracted for this study – see Underlying data.³⁰

The evidence underlying treatment options of mental disorders in children and young people includes 200 treatment comparisons evaluating the primary outcome for each specific diagnostic group. See Underlying data²⁹ for more information.

Overall, 49.5% of the treatment comparisons were non-pharmacological interventions, 36% included pharmacological or nutrition/supplemental interventions, and 14.5% were combination treatments including both pharmacological and non-pharmacological treatments.

The number of treatment comparisons varied greatly across the diagnostic groups; from 69 comparisons for ADHD to 7 for OCD (see Table 2).

Table 2. Number of treatment comparisons by diagnostic group.

ADHD, attention deficit / hyperactivity disorder; OCD, obsessive compulsive disorder; PTSD, post-traumatic stress disorder.

Diagnostic group	Treatment comparisons
ADHD	69
Anxiety	14
Bipolar	18
Depression	20
OCD	7
Psychosis	29
PTSD	16
Self-harm	14
Trauma	13
Total	200

Interventions evaluated by diagnostic group

Interventions by treatment categories are displayed in Sunburst-diagrams by diagnostic groups (see Figures 2–10). The evidence informing ADHD-treatment includes a range of psychological, psychosocial, dietary, systemic, physical activity, skills training and pharmaceutical interventions. About half of the ADHD-interventions are pharmacological or combination therapies including medication.

Figure 2. Unique intervention categories evaluated for attention deficit / hyperactivity disorder (ADHD).

CBT, cognitive behavioural therapy; DBT, dialectic behavioural therapy; NRI, norepinephrine reuptake inhibitors.

Figure 3. Unique intervention categories evaluated for anxiety.

CBT, cognitive behavioural therapy; MBSR, mindfulness-based stress reduction.

Figure 4. Unique intervention categories evaluated for bipolar disorder.

CBT, cognitive behavioural therapy; DBT, dialectic behavioural therapy.

Most treatment evaluations for depression are non-pharmacological and include different types of psychological therapies, physical activity, art therapy and medical treatments such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS). The evidence also includes pharmacological interventions including use of serotonin-norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors (SNRIs/SSRIs) in combination with cognitive behavioural therapy (CBT) or SSRI used alone.

The evidence for treating OCD represents less diversity, and most interventions are CBT-based, either used alone or in combination with medications.

Treatment evaluations for bipolar disorder and psychosis include mainly pharmacological treatments, either as direct comparisons or in combination with psychological treatments or other medications (bipolar disorder). Psychological treatments used for psychosis include psychoeducation, computer-based cognitive training, CBT and group- and family therapy. For bipolar disorder, evaluations also include psychoeducation, CBT, interpersonal therapy, Dialectic behavioural therapy (DBT) and family therapy.

Self-harm and trauma/PTSD-interventions are all psychological, psychosocial, or other therapeutic interventions such as psychoeducation. Several organisational or systemic treatments used for preventing suicide or reoccurrence of self-harm have also been evaluated, including interventions such as the use of “emergency green card” (self-admittance to specialist health care).

Time of follow-up

The longest follow-up for any outcome could be found for anxiety (6 years), followed by ADHD and depression (3 years), bipolar, self-harm and PTSD (2 years), trauma (1 year) and OCD (6 months).

Overall, approximately 40% of the treatment comparisons included only short-term follow-up (< 3 months). A total of 10% of the treatment comparisons included follow-up beyond 12 months (see Table 3).

Table 3. The longest follow-up times (by any outcome).

Time of follow up	%
End of treatment to 3 months	39.50%
3 to 6 months	16.00%
7 to 12 months	15.50%
13 to 18 months	3.50%
19 to 24 months	4.00%
25 months and more	2.50%
Unclear	19.00%
Grand total	100.00%

Figure 5. Unique intervention categories evaluated for depression.

CBT, cognitive behavioural therapy; DBT, dialectic behavioural therapy; ECT, electroconvulsive therapy; rTMS, repetitive transcranial magnetic stimulation; MBSR, mindfulness-based stress reduction.

Follow-up times by diagnosis and category can be seen in Table 4. Overall, it can be observed that for most diagnostic groups, treatment comparisons of pharmacological treatment included very short follow-up.

Table 4. Follow-up times by diagnostic group and outcome category.

ADHD, attention deficit / hyperactivity disorder; OCD, obsessive compulsive disorder; PTSD, post-traumatic stress disorder.

Follow up by diagnosis	%
ADHD
Non-pharm (29% of comparisons)
End of treatment to 3 months	10%
3 to 6 months	15%
7 to 12 months	30%
13 to 18 months	5%
19 to 24 months	10%
25 months and more	5%
Unclear	25%
Non-pharm/pharm (22% of comparisons)
End of treatment to 3 months	33%
3 to 6 months	20%
7 to 12 months	20%
13 to 18 months	13%
Unclear	13%
Pharm/suppl (49% of comparisons)
End of treatment to 3 months	59%
3 to 6 months	24%
7 to 12 months	3%
13 to 18 months	6%
Unclear	9%
Anxiety
Non-pharm (57% of comparisons)
End of treatment to 3 months	38%
3 to 6 months	13%
7 to 12 months	13%
Unclear	38%
Non-pharm/pharm (36% of comparisons)
25 months and more	20%
Unclear	80%
Pharm/suppl (7% of comparisons)
Unclear	100%
Bipolar
Non-pharm (6% of comparisons)
19 to 24 months	100%
Non-pharm/pharm (22% of comparisons)
End of treatment to 3 months	75%
7 to 12 months	25%
Pharm/suppl (72% of comparisons)
End of treatment to 3 months	62%
Unclear	38%
Depression
Non-pharm (80% of comparisons)
End of treatment to 3 months	38%
3 to 6 months	19%
7 to 12 months	6%
25 months and more	6%
Unclear	31%
Non-pharm/pharm (5% of comparisons)
Unclear	100%
Pharm/suppl (15% of comparisons)
3 to 6 months	33%
7 to 12 months	67%
OCD
Non-pharm (71% of comparisons)
End of treatment to 3 months	80%
3 to 6 months	20%
Non-pharm/pharm (29% of comparisons)
End of treatment to 3 months	50%
Unclear	50%
Psychosis
Non-pharm (24% of comparisons)
3 to 6 months	14%
7 to 12 months	43%
19 to 24 months	14%
25 months and more	14%
Unclear	14%
Non-pharm/pharm (7% of comparisons)
7 to 12 months	50%
Unclear	50%
Pharm/suppl (69% of comparisons)
End of treatment to 3 months	75%
7 to 12 months	10%
19 to 24 months	5%
25 months and more	5%
Unclear	5%
PTSD
Non-pharm (94% of comparisons)
End of treatment to 3 months	33%
3 to 6 months	7%
7 to 12 months	40%
13 to 18 months	7%
19 to 24 months	13%
Pharm/suppl (6% of comparisons)
End of treatment to 3 months	100%
Self-harm
Non-pharm (100% of comparisons)
End of treatment to 3 months	14%
3 to 6 months	21%
7 to 12 months	14%
13 to 18 months	7%
19 to 24 months	7%
Unclear	36%
Trauma
Non-pharm (100% of comparisons)
End of treatment to 3 months	31%
3 to 6 months	54%
7 to 12 months	15%

Figure 6. Unique intervention categories evaluated for obsessive compulsive disorder (OCD).

CBT, cognitive behavioural therapy; iCBT, internet-based cognitive behavioural therapy; ERP, exposure and response prevention; SSRI, selective serotonin reuptake inhibitors.

Treatment uncertainty and comparative effectiveness

There was a large diversity of treatment comparisons evaluated. We identified 24 unique groups of treatment comparisons evaluated for more than one diagnostic group. These can be seen in Table 5. GRADE-judgements are colour-coded accordingly: green for moderate to high certainty, yellow is used for low certainty and red for very low certainty.

Table 5. Overview of shared treatment comparisons, intervention effects and certainty of the evidence.

ADHD, attention deficit / hyperactivity disorder; OCD, obsessive compulsive disorder; PTSD, post-traumatic stress disorder; CBT, cognitive behavioural therapy; DBT, dialectic behavioural therapy; TAU, treatment as usual; TF-CBT, trauma focused cognitive behavioural therapy; EMDR, eye movement desensitisation and reprocessing.

	ADHD	Anxiety	Bipolar	Depression	OCD	PTSD	Trauma	Self-harm	Psychosis
Psychoeducation vs TAU	?/very low certainty		Effective/low certainty **	?/very low certainty			?/very low certainty
Psychological vs TAU						Small effect/low certainty	Little or no difference/low certainty	Small effect/moderate certainty
CBT vs TAU *	Moderate effect/moderate certainty	Large effect/moderate certainty		Moderate effect/moderate certainty	Large effect/low certainty	?/very low certainty
CBT vs other		Small effect/moderate certainty			Effective/low certainty **		?/very low certainty	Little or no difference/low certainty	?/very low certainty
TF-CBT vs TAU *						Moderate effect/moderate certainty	Large effect/low certainty
TF-CBT vs other *						Moderate effect/moderate certainty	Little or no difference/low certainty
TF-CBT vs EMDR						?/very low certainty	?/very low certainty
DBT vs TAU				Small effect/low certainty				Moderate effect/low certainty
Family therapy vs TAU *				?/very low certainty		?/very low certainty	?/very low certainty	Little or no effect/moderate certainty
Family therapy vs individual/other therapy		Little or no effect/moderate certainty		?/very low certainty	?/very low certainty				?/very low certainty
Psychodynamic vs other				?/very low certainty		?/very low certainty
EMDR VS TAU						?/very low certainty	?/very low certainty
Parent training vs TAU	Moderate effect/low certainty					?/very low certainty	?/very low certainty
Group therapy vs other								Little or no difference/moderate certainty	?/very low certainty
Interpersonal vs TAU				Moderate effect/low certainty				?/very low certainty
Other treatments
Physical activity vs TAU	Moderate effect/low certainty			Moderate effect/low certainty
Massage therapy vs TAU	?/very low certainty						?/very low certainty
Mindfulness vs TAU		Small effect/moderate certainty		Small effect/low certainty
Nutrition and supplements
Polyunsaturated fatty acids vs placebo	Little or no difference/moderate certainty			?/very low certainty
Pharmacological treatments
Aripiprazol 10 mg sammenliknet med aripiprazol 30 mg			?/very low certainty						?/very low certainty
Risperidone vs olanzapine			?/very low certainty						?/very low certainty
Psychological vs pharmacological		Small effect (in favour of psychological)/low certainty		Little or no difference/low certainty	Little or no difference/low certainty
Combination therapies
CBT and pharmacological treatment vs CBT ***	Little or no difference/low certainty	Moderate effect/low certainty		?/very low certainty
CBT and pharmacological treatment vs pharmacological treatment ****	Large effect/low certainty	?/very low certainty	?/very low certainty						?/very low certainty

* Several outcomes available, outcomes with larger effect and certainty included here.

** Difficult to assess size of effect, review authors report the intervention as “effective”.

*** Several outcomes available, outcomes with larger effect and certainty included here. Pharmacological treatment included stimulants (ADHD), SSRI (depression) and TCA (anxiety).

**** Several outcomes available, outcomes with larger effect and certainty included here. Pharmacological treatment included antipsychotics (psychosis) and SSRI (anxiety). Pharmacological treatment for bipolar and ADHD not specified.

Figure 7. Unique intervention categories evaluated for psychosis.

CBT, cognitive behavioural therapy.

Figure 8. Unique intervention categories evaluated for self-harm.

CAT, cognitive analytic therapy; CBT, cognitive behavioural therapy; DBT, dialectic behavioural therapy; MBT, mentalization-based therapy.

Figure 9. Unique intervention categories evaluated for post-traumatic stress disorder (PTSD).

CBT, cognitive behavioural therapy; EFT, emotion-focused therapy; EMDR, eye movement desensitisation and reprocessing; TF-CBT, trauma focused cognitive behavioural therapy.

Figure 10. Unique intervention categories evaluated for trauma.

EMDR, eye movement desensitisation and reprocessing; CBT, cognitive behavioural therapy; TF-CBT, trauma focused cognitive behavioural therapy.

Most treatment evaluations were associated with low or very low certainty. The certainty was higher for treatment evaluations including CBT, which also demonstrated moderate to large effects compared to treatment as usual across different diagnostic groups. DBT compared to treatment as usual has been evaluated for depression and self-harm with low to moderate effect sizes on primary symptoms (low certainty). Physical activity is found to have a moderate effect on primary symptoms of ADHD and depression (low certainty). Mindfulness interventions also result in small but beneficial effects compared to treatment as usual (TAU) for anxiety and depression (moderate to low certainty).

Little or no important difference in effect was found when comparing psychological treatments with pharmacological treatments for depression and OCD, however a small but beneficial effect in favour of psychological treatment was found for anxiety (all low certainty). Combination therapy of CBT and pharmaceutical treatments was found to have a moderate effect on anxiety, but there was little or no difference for ADHD when compared to psychological treatment alone. The certainty of the evidence for combination therapy compared to pharmacological therapy alone, was very low for three out of four diagnostic groups evaluating this treatment comparison (anxiety, bipolar and psychosis). For ADHD, combination treatment was found to produce large effects on the primary outcome, although with low certainty.

Treatment comparisons including psychoeducation (vs TAU), family therapy (vs TAU), psychodynamic (vs TAU), Eye Movement Desensitization and Reprocessing (EMDR) (vs TAU), massage therapy (vs TAU) is very uncertain across all diagnostic groups evaluated.

Discussion

Limitations and strengths

Our analysis is based on eight recent overviews of overviews summarising the evidence reported in 116 systematic reviews.¹¹^–¹⁸ This analysis includes only direct comparisons of treatments evaluated in high quality systematic reviews. To our knowledge this is the first review of its kind mapping treatments for child and youth mental health, and our findings is of great relevance to clinicians, funders of new research initiatives and researchers providing a blueprint for planning future research activities. Furthermore, acknowledging research uncertainties is an important step-stone in good patient care.

One limitation to our work is that research is accumulating rapidly in this field, and that while this report is being written, new evidence may have emerged. However, considering the substantial evidence gaps we identified we are confident that our conclusions may continue to be valid some time to come. Another limitation may be that our analysis is based on reviews, and that the results are impacted by the methodological choices and reporting by the authors of the individual reviews included in each OoO, but also by the inclusion criteria by the OoO. For example, this analysis does not include placebo-controlled pharmaceutical studies or comparisons of preventive treatments. As such, we would like to emphasise that there is a large body of evidence evaluating these treatment comparisons and that the results of these and the corresponding evidence gaps should be considered together with our analysis. Network analyses of indirect comparisons are an important contribution to this evidence base.²⁶ Furthermore, our analysis is based on treatments evaluated in specific diagnostic groups. Other reviews have summarised the effects of interventions in diverse patient groups (not restricted to diagnostic criteria). Thus, implementation of findings coming out of our analysis should take into consideration the findings of such transdiagnostic reviews.

Summary of results

We identified 200 treatment comparisons. The most striking finding of this review is the short follow-up times for most treatment comparisons. This is the case for pharmaceutical treatments in particular. Approximately 40% of all treatment comparisons included only short-term follow-up (<3 months), with only 10% of the treatment comparisons including a follow-up beyond 12 months. Thus, there is great uncertainty associated with the long-term effects of mental health treatments for children and young people.

We found large diversity in treatments evaluated. Our descriptive analysis shows that the largest diversity can be found for ADHD and less diversity was found for OCD. Furthermore, from the research that has been conducted so far it can be deducted that the etiology and assumed relevant interventions are understood differently depending on the diagnosis. Some conditions are, for instance, addressed mostly by combination treatments or pharmaceutical treatments alone whereas others are treated with psychological or psychosocial interventions. For example, most treatments for bipolar disorder were pharmacological, whereas treatments for children with PTSD/trauma were all psychological or psychosocial therapies. Treatments for ADHD and psychosis include a combination of both pharmaceutical and psychological or psychosocial treatments. This is an important contribution to the epistemology of mental health, and the understandings of what may reduce or increase mental health depending on the symptoms we identify (diagnosis).

The certainty of most treatment outcomes is low or very low. However, there are treatments with promising effects, which also seem to be effective across diagnostic groups. CBT demonstrates moderate to large effects (compared to treatment as usual) across four diagnostic groups. DBT therapy, physical activity and mindfulness interventions also result in small to moderate beneficial effects compared to TAU (moderate to low certainty). Combination therapies including CBT and pharmacological treatments was either found to have similar effects on primary symptoms compared to either CBT or pharmacological treatment alone, or to be more effective (low certainty).

Implications for research and practice

Practitioners and decision-makers should be aware of important research uncertainties and make these explicit in communication with patients and when developing guidelines. Our report may be an important platform for doing so.

For many treatment evaluations the evidence is limited. Nevertheless, some treatments have shown convincing treatment effects and should be considered as first choice when treating children and young people. Some treatments identified in our review may be well documented for use in adults and may therefore also be applied to younger people. Although this may be theoretically sound, the transferability to and the effectiveness for younger people is unclear and should be addressed. There is therefore a need for more high-quality research on the effectiveness of treatments with uncertain effects on children and young people. Future research efforts should also include long-term follow up assessments, as this is fundamental to patient safety.

We have made no judgements about the clinical importance of the effect-sizes we mapped in this review, as this is a decision which is best left up to health professionals and their patients. Furthermore, we did not review or make any judgements about which outcomes were evaluated in the treatment comparisons we mapped. For pragmatic reasons, our analysis depended on the primary outcome (change in symptoms) for each diagnostic group using statistical rule of thumb thresholds. It is important to emphasise that any changes in symptomatology should be supplemented with measuring other relevant outcomes. The opinions of patients and health professionals about the relevance of outcomes may differ from those of researchers. Thus, future studies should include the opinions of patients and should consider any established core outcome sets.²⁷^,²⁸

Conclusions

Our analysis provides essential information through a mapping review about the state of the art of existing evidence.

We identified a wide range of treatments evaluated for use in children and young people, including psychological, social, dietary, physical activity, skills training and pharmacological interventions. Based on this review, it can be observed that some diagnoses are treated mostly with pharmaceutical therapies (such as bipolar disorder) or pharmaceutical or psychological therapy alone or in combination (such as anxiety and psychosis) and others are treated with a broader spectrum of therapeutic approaches (such as depression and attention deficit / hyperactivity disorder).

With few exceptions, the evidence supporting most treatments is of low to very low certainty. CBT demonstrates moderate to large effects across four diagnostic groups with moderate to low certainty. DBT, physical activity and mindfulness interventions also demonstrate small to moderate beneficial effects compared to TAU (moderate to low certainty). Most concerningly, we observed that the majority of the existing treatment evaluations included very short follow-up measurements. Health professionals and policy makers should consider these uncertainties when communicating with patients. Future research efforts should target important research uncertainties identified in this review and plan for longer follow-up times.

Data availability

Underlying data

Zenodo: Included comparisons_mapping review_2022. https://doi.org/10.5281/zenodo.6948764.²⁹

This project contains the following underlying data:

- Treatment comparisons mapping review_2022_english.xlsx (comparisons included in the analysis of this paper).

Zenodo: Supporting materials_mapping review_2022. https://doi.org/10.5281/zenodo.6815213.³⁰

This project contains the following underlying data:

- Appendix_mapping_june 2022.docx (systematic reviews included in the OoOs).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Version 2

VERSION 2 PUBLISHED 03 Jan 2023

Author details Author details

¹ OsloMet, Faculty of Health Sciences, Oslo Metropolitan University, P.O. Box 4, St. Olavs plass, NO-0130 Oslo, Norway
² RBUP East and South, P.O. Box 4623 Nydalen, 0405 Oslo, Norway

Ingrid Borren
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

Brynhildur Axelsdottir
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

Mari Elvsåshagen
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

Karianne Hammerstrøm Nilsen
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Validation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

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Published: 08 May 2025, 12:2

https://doi.org/10.12688/f1000research.123561.2

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https://doi.org/10.12688/f1000research.123561.1

© 2025 Dahlgren A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Dahlgren A, Borren I, Axelsdottir B et al. Mental health interventions targeting children and young people: A mapping review of interventions, follow-up, and evidence gaps [version 2; peer review: 1 approved, 1 approved with reservations]. F1000Research 2025, 12:2 (https://doi.org/10.12688/f1000research.123561.2)

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Open Peer Review

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Reviewer Report 22 Mar 2025

Heather Eileen Menzies Munthe-Kaas, Norwegian Institute of Public Health, Oslo, Norway

Approved

https://doi.org/10.5256/f1000research.135677.r367865

This is a very interesting and well written article on an important topic. A few small comments from me:

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best

This is a very interesting and well written article on an important topic. A few small comments from me:

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider carefully the term “mental illness” since ADHD at least, is not considered a mental illness, but rather a neurodevelopmental disorder (paragraph 2)
Consider acknowledging that this group of conditions are not in the same category. For example, ADHD (neurodevelopmental disorder) and anxiety, depression, bipolar disorder (mood disorders) and the reason for grouping them in this paper (which is not problematic in itself, and is probably representative of the literature, but needs acknowledgment of here). The introduction would benefit from one or two additional sentences about why these specific mental health and neurodevelopmental disorders are included (e.g., they are grouped in existing reviews and OoOs).
Decision making only has a “-“ when it is used as an adjective (e.g., decision-making tools)
Consider using the term “user” or “client” instead of “patient”
Define “living evidence summaries”
Explain why “overviews of systematic reviews” is shortened to “OoOs” (e.g., also referred to as overview of overviews; OoOs). Also can make more clear that the authors have also conducted and published the included OoOs.
Missing at the end of the introduction a sentence situating this work in the greater picture of work and what gap this study is addressing.

Methods
Overall this section could use a bit more details and explanation as well as structure to better distinguish from what was done during OoOs and what is done here (and what was carried over from original SRs) perhaps using a flow chart or diagram to show information/data flow?

A subtitle indicating that you are describing methods for the OoOs and not the mapping review
Since the most recent of the OoOs is from February 2021, and this is a very active research field, is this mapping review really the best overview of all treatments (and longest follow up)? Can you explain this approach to summarizing and mapping the evidence when there is likely a large chunk of systematic reviews from the last 4-5 years missing here? Could you also write more about how far back the included SRs in the included OoOs go back to?
Data collection – could you describe sunburst diagrams and what exactly will be presented in them?
The members of this research team made the OoO GRADE assessments? How were the GRADE assessments taken from the original systematic reviews used?

Results

Table 5 – the table is likely perfectly accurate, but it does seem strange that all “very low certainty” are related to uncertain effects (assuming “?” means uncertain effects?) and no other effect estimates are “very low certainty” (e.g., it is possible to have very low certainty in an effect estimate that shows a moderate observed effect size). Also , where ** is used to indicate that it is difficult to assess the size of effect but the review authors report the intervention as effective – this is not rated as very low certainty as compared to low certainty?

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: stakeholder engagement in research, systematic review and qualitative evidence synthesis methods

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

CITE

Report a concern

Author Response 08 May 2025

Astrid Dahlgren

08 May 2025

Author Response
Peer-reviewer 2 Heather Eileen Menzies Munthe-Kaas
1. Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider
... Continue reading
Peer-reviewer 2 Heather Eileen Menzies Munthe-Kaas

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider carefully the term “mental illness” since ADHD at least, is not considered a mental illness, but rather a neurodevelopmental disorder (paragraph 2) Author response: This is a very valid point, and we agree that this should have been more carefully formulated. ADHD is indeed a neurodevelopment disorder of which some people with this condition will need therapy, training or support. We have now used “mental health” and “mental disorder” throughout the manuscript which are terminology that encompass both mental illness and neurodevelopment disorders.

Consider acknowledging that this group of conditions are not in the same category. For example, ADHD (neurodevelopmental disorder) and anxiety, depression, bipolar disorder (mood disorders) and the reason for grouping them in this paper (which is not problematic in itself, and is probably representative of the literature, but needs acknowledgment of here). The introduction would benefit from one or two additional sentences about why these specific mental health and neurodevelopmental disorders are included (e.g., they are grouped in existing reviews and OoOs). Author response: The diagnostic groups included in this paper are under the common descriptor “mental disorder” and is defined by the World Health Organisation as “a clinically significant disturbance of an individual’s cognition, emotional regulation, or behaviour” https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Although the etiology of the included disorders may be different, they are in many cases associated with distress or impairment in important areas of functioning and are often treated for their symptoms by methodologies with shared epistemology and by the same services and professionals. To make this clearer we have added a sentence to the introduction.

Decision making only has a “-“ when it is used as an adjective (e.g., decision-making tools)Author response: Thank you, this has been corrected.

Consider using the term “user” or “client” instead of “patient” Author response: We have changed “patient groups” to diagnostic groups to be more precise and have used “patient” where patient rights or roles are described.

Define “living evidence summaries”. Author response: A definition has been added to the manuscript.

Explain why “overviews of systematic reviews” is shortened to “OoOs” (e.g., also referred to as overview of overviews; OoOs). Also can make more clear that the authors have also conducted and published the included OoOs. Author response: We have now rephased to using overviews of overviews throughout the manuscript. We have stated under the sub-heading: “The evidence: Inclusion criteria and search strategy “ that we authored the OoOs.

Missing at the end of the introduction a sentence situating this work in the greater picture of work and what gap this study is addressing. Author response: This has now been added.

Methods:

Overall this section could use a bit more details and explanation as well as structure to better distinguish from what was done during OoOs and what is done here (and what was carried over from original SRs) perhaps using a flow chart or diagram to show information/data flow? Author response: The flowchart of data is shown in Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. We agree that this section needed to be restructured and have now done so to accommodate the peer-reviewers feedback.

Since the most recent of the OoOs is from February 2021, and this is a very active research field, is this mapping review really the best overview of all treatments (and longest follow up)? Can you explain this approach to summarizing and mapping the evidence when there is likely a large chunk of systematic reviews from the last 4-5 years missing here? Could you also write more about how far back the included SRs in the included OoOs go back to? Author response: Our mapping review was first published in this journal in January 2023, and as stated in the manuscript, the data collection took place between September 2021 and December 2022. Thus, our report was published very briefly after the data collection was completed. The OoOs we used for our synthesis were considered up-to date at the point of our data collection (these were either new first editions or had been semi-annually or annually updated) at the time. The database from which the OoO include their systematic reviews were updated monthly. To be included, a systematic review should be newer than five years but would not be replaced unless a systematic review considered to be more updated was identified- following the principle of the best available evidence to inform practice. All literature reviews suffer the risk of being outdated once they are published. Judgements about the relevance of the evidence and to what extent new research would change the conclusions is dependent on the research question, the intended use and the robustness of the existing evidence. At the time of the publication of this paper, we were interested in exploring the diversity of treatment interventions for the included mental disorders but also to describe the follow-up times in the existing studies. We also wanted to provide an overview of the effects of these interventions and their associated certainty of the evidence across diagnostic groups. Our conclusion is based on a very large evidence base of 116 systematic reviews including 200 treatment comparisons. Even though we expect new primary studies to have been published from the time our review was first published- we are confident that our conclusions have not been changed substantially:

Some mental illnesses are treated mostly with pharmacological, or psychological therapies or a combination of these. Some are treated with a broader spectrum of therapies.

The evidence supporting most treatments is of low to very low certainty.
Very few treatment evaluations include follow-up assessments beyond 12 months.

Some treatments are effective across populations, such as cognitive behavioral therapy

Data collection – could you describe sunburst diagrams and what exactly will be presented in them? Author response: A sentence has been added to improve clarity.

The members of this research team made the OoO GRADE assessments? How were the GRADE assessments taken from the original systematic reviews used? Author response: Yes, one or more of the author team was involved in the OoO published in the evidence portal. We extracted the GRADE-judgements for the primary outcome (in other words- we did not make any further assessments as part of this mapping review considering GRADE). In the methods section we also state that: The primary outcome was conceptualised as overall symptomatology associated with the relevant condition, such as anxiety symptoms for those with anxiety and depression symptoms for those with depression. In cases where the same outcome was assessed using different outcome measures, we extracted the outcome with the longest follow up and highest certainty.If a review did not report findings on overall symptoms, we reported other symptoms as proxy, for example inattention in treatment of ADHD when total symptoms were not available.

Results

Table 5 – the table is likely perfectly accurate, but it does seem strange that all “very low certainty” are related to uncertain effects (assuming “?” means uncertain effects?) and no other effect estimates are “very low certainty” (e.g., it is possible to have very low certainty in an effect estimate that shows a moderate observed effect size). Also , where ** is used to indicate that it is difficult to assess the size of effect but the review authors report the intervention as effective – this is not rated as very low certainty as compared to low certainty? Author response: The GRADE-framework recommends that outcomes of very low certainty are not reported as the confidence in the findings is too low. In our table this is indicated as “?” (https://www.gradeworkinggroup.org/publications.html). For two of the comparisons, there was uncertainty about the size of the effect, but not direction. Thus, we were not able to classify the size of effect according to the pre-defined thresholds. These outcomes have been highlighted in the table, both of these were downgraded for precision in the GRADE-assessments and considered to be of low certainty in the original OoOs
Peer-reviewer 2 Heather Eileen Menzies Munthe-Kaas

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider carefully the term “mental illness” since ADHD at least, is not considered a mental illness, but rather a neurodevelopmental disorder (paragraph 2) Author response: This is a very valid point, and we agree that this should have been more carefully formulated. ADHD is indeed a neurodevelopment disorder of which some people with this condition will need therapy, training or support. We have now used “mental health” and “mental disorder” throughout the manuscript which are terminology that encompass both mental illness and neurodevelopment disorders.

Consider acknowledging that this group of conditions are not in the same category. For example, ADHD (neurodevelopmental disorder) and anxiety, depression, bipolar disorder (mood disorders) and the reason for grouping them in this paper (which is not problematic in itself, and is probably representative of the literature, but needs acknowledgment of here). The introduction would benefit from one or two additional sentences about why these specific mental health and neurodevelopmental disorders are included (e.g., they are grouped in existing reviews and OoOs). Author response: The diagnostic groups included in this paper are under the common descriptor “mental disorder” and is defined by the World Health Organisation as “a clinically significant disturbance of an individual’s cognition, emotional regulation, or behaviour” https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Although the etiology of the included disorders may be different, they are in many cases associated with distress or impairment in important areas of functioning and are often treated for their symptoms by methodologies with shared epistemology and by the same services and professionals. To make this clearer we have added a sentence to the introduction.

Decision making only has a “-“ when it is used as an adjective (e.g., decision-making tools)Author response: Thank you, this has been corrected.

Consider using the term “user” or “client” instead of “patient” Author response: We have changed “patient groups” to diagnostic groups to be more precise and have used “patient” where patient rights or roles are described.

Define “living evidence summaries”. Author response: A definition has been added to the manuscript.

Explain why “overviews of systematic reviews” is shortened to “OoOs” (e.g., also referred to as overview of overviews; OoOs). Also can make more clear that the authors have also conducted and published the included OoOs. Author response: We have now rephased to using overviews of overviews throughout the manuscript. We have stated under the sub-heading: “The evidence: Inclusion criteria and search strategy “ that we authored the OoOs.

Missing at the end of the introduction a sentence situating this work in the greater picture of work and what gap this study is addressing. Author response: This has now been added.

Methods:

Overall this section could use a bit more details and explanation as well as structure to better distinguish from what was done during OoOs and what is done here (and what was carried over from original SRs) perhaps using a flow chart or diagram to show information/data flow? Author response: The flowchart of data is shown in Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. We agree that this section needed to be restructured and have now done so to accommodate the peer-reviewers feedback.

Since the most recent of the OoOs is from February 2021, and this is a very active research field, is this mapping review really the best overview of all treatments (and longest follow up)? Can you explain this approach to summarizing and mapping the evidence when there is likely a large chunk of systematic reviews from the last 4-5 years missing here? Could you also write more about how far back the included SRs in the included OoOs go back to? Author response: Our mapping review was first published in this journal in January 2023, and as stated in the manuscript, the data collection took place between September 2021 and December 2022. Thus, our report was published very briefly after the data collection was completed. The OoOs we used for our synthesis were considered up-to date at the point of our data collection (these were either new first editions or had been semi-annually or annually updated) at the time. The database from which the OoO include their systematic reviews were updated monthly. To be included, a systematic review should be newer than five years but would not be replaced unless a systematic review considered to be more updated was identified- following the principle of the best available evidence to inform practice. All literature reviews suffer the risk of being outdated once they are published. Judgements about the relevance of the evidence and to what extent new research would change the conclusions is dependent on the research question, the intended use and the robustness of the existing evidence. At the time of the publication of this paper, we were interested in exploring the diversity of treatment interventions for the included mental disorders but also to describe the follow-up times in the existing studies. We also wanted to provide an overview of the effects of these interventions and their associated certainty of the evidence across diagnostic groups. Our conclusion is based on a very large evidence base of 116 systematic reviews including 200 treatment comparisons. Even though we expect new primary studies to have been published from the time our review was first published- we are confident that our conclusions have not been changed substantially:

Some mental illnesses are treated mostly with pharmacological, or psychological therapies or a combination of these. Some are treated with a broader spectrum of therapies.

The evidence supporting most treatments is of low to very low certainty.
Very few treatment evaluations include follow-up assessments beyond 12 months.

Some treatments are effective across populations, such as cognitive behavioral therapy

Data collection – could you describe sunburst diagrams and what exactly will be presented in them? Author response: A sentence has been added to improve clarity.

The members of this research team made the OoO GRADE assessments? How were the GRADE assessments taken from the original systematic reviews used? Author response: Yes, one or more of the author team was involved in the OoO published in the evidence portal. We extracted the GRADE-judgements for the primary outcome (in other words- we did not make any further assessments as part of this mapping review considering GRADE). In the methods section we also state that: The primary outcome was conceptualised as overall symptomatology associated with the relevant condition, such as anxiety symptoms for those with anxiety and depression symptoms for those with depression. In cases where the same outcome was assessed using different outcome measures, we extracted the outcome with the longest follow up and highest certainty.If a review did not report findings on overall symptoms, we reported other symptoms as proxy, for example inattention in treatment of ADHD when total symptoms were not available.

Results

Table 5 – the table is likely perfectly accurate, but it does seem strange that all “very low certainty” are related to uncertain effects (assuming “?” means uncertain effects?) and no other effect estimates are “very low certainty” (e.g., it is possible to have very low certainty in an effect estimate that shows a moderate observed effect size). Also , where ** is used to indicate that it is difficult to assess the size of effect but the review authors report the intervention as effective – this is not rated as very low certainty as compared to low certainty? Author response: The GRADE-framework recommends that outcomes of very low certainty are not reported as the confidence in the findings is too low. In our table this is indicated as “?” (https://www.gradeworkinggroup.org/publications.html). For two of the comparisons, there was uncertainty about the size of the effect, but not direction. Thus, we were not able to classify the size of effect according to the pre-defined thresholds. These outcomes have been highlighted in the table, both of these were downgraded for precision in the GRADE-assessments and considered to be of low certainty in the original OoOs
Competing Interests: No competing interests were disclosed. Close
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Author Response 08 May 2025

Astrid Dahlgren

08 May 2025

Author Response
Peer-reviewer 2 Heather Eileen Menzies Munthe-Kaas
1. Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider
... Continue reading
Peer-reviewer 2 Heather Eileen Menzies Munthe-Kaas

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider carefully the term “mental illness” since ADHD at least, is not considered a mental illness, but rather a neurodevelopmental disorder (paragraph 2) Author response: This is a very valid point, and we agree that this should have been more carefully formulated. ADHD is indeed a neurodevelopment disorder of which some people with this condition will need therapy, training or support. We have now used “mental health” and “mental disorder” throughout the manuscript which are terminology that encompass both mental illness and neurodevelopment disorders.

Consider acknowledging that this group of conditions are not in the same category. For example, ADHD (neurodevelopmental disorder) and anxiety, depression, bipolar disorder (mood disorders) and the reason for grouping them in this paper (which is not problematic in itself, and is probably representative of the literature, but needs acknowledgment of here). The introduction would benefit from one or two additional sentences about why these specific mental health and neurodevelopmental disorders are included (e.g., they are grouped in existing reviews and OoOs). Author response: The diagnostic groups included in this paper are under the common descriptor “mental disorder” and is defined by the World Health Organisation as “a clinically significant disturbance of an individual’s cognition, emotional regulation, or behaviour” https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Although the etiology of the included disorders may be different, they are in many cases associated with distress or impairment in important areas of functioning and are often treated for their symptoms by methodologies with shared epistemology and by the same services and professionals. To make this clearer we have added a sentence to the introduction.

Decision making only has a “-“ when it is used as an adjective (e.g., decision-making tools)Author response: Thank you, this has been corrected.

Consider using the term “user” or “client” instead of “patient” Author response: We have changed “patient groups” to diagnostic groups to be more precise and have used “patient” where patient rights or roles are described.

Define “living evidence summaries”. Author response: A definition has been added to the manuscript.

Explain why “overviews of systematic reviews” is shortened to “OoOs” (e.g., also referred to as overview of overviews; OoOs). Also can make more clear that the authors have also conducted and published the included OoOs. Author response: We have now rephased to using overviews of overviews throughout the manuscript. We have stated under the sub-heading: “The evidence: Inclusion criteria and search strategy “ that we authored the OoOs.

Missing at the end of the introduction a sentence situating this work in the greater picture of work and what gap this study is addressing. Author response: This has now been added.

Methods:

Overall this section could use a bit more details and explanation as well as structure to better distinguish from what was done during OoOs and what is done here (and what was carried over from original SRs) perhaps using a flow chart or diagram to show information/data flow? Author response: The flowchart of data is shown in Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. We agree that this section needed to be restructured and have now done so to accommodate the peer-reviewers feedback.

Since the most recent of the OoOs is from February 2021, and this is a very active research field, is this mapping review really the best overview of all treatments (and longest follow up)? Can you explain this approach to summarizing and mapping the evidence when there is likely a large chunk of systematic reviews from the last 4-5 years missing here? Could you also write more about how far back the included SRs in the included OoOs go back to? Author response: Our mapping review was first published in this journal in January 2023, and as stated in the manuscript, the data collection took place between September 2021 and December 2022. Thus, our report was published very briefly after the data collection was completed. The OoOs we used for our synthesis were considered up-to date at the point of our data collection (these were either new first editions or had been semi-annually or annually updated) at the time. The database from which the OoO include their systematic reviews were updated monthly. To be included, a systematic review should be newer than five years but would not be replaced unless a systematic review considered to be more updated was identified- following the principle of the best available evidence to inform practice. All literature reviews suffer the risk of being outdated once they are published. Judgements about the relevance of the evidence and to what extent new research would change the conclusions is dependent on the research question, the intended use and the robustness of the existing evidence. At the time of the publication of this paper, we were interested in exploring the diversity of treatment interventions for the included mental disorders but also to describe the follow-up times in the existing studies. We also wanted to provide an overview of the effects of these interventions and their associated certainty of the evidence across diagnostic groups. Our conclusion is based on a very large evidence base of 116 systematic reviews including 200 treatment comparisons. Even though we expect new primary studies to have been published from the time our review was first published- we are confident that our conclusions have not been changed substantially:

Some mental illnesses are treated mostly with pharmacological, or psychological therapies or a combination of these. Some are treated with a broader spectrum of therapies.

The evidence supporting most treatments is of low to very low certainty.
Very few treatment evaluations include follow-up assessments beyond 12 months.

Some treatments are effective across populations, such as cognitive behavioral therapy

Data collection – could you describe sunburst diagrams and what exactly will be presented in them? Author response: A sentence has been added to improve clarity.

The members of this research team made the OoO GRADE assessments? How were the GRADE assessments taken from the original systematic reviews used? Author response: Yes, one or more of the author team was involved in the OoO published in the evidence portal. We extracted the GRADE-judgements for the primary outcome (in other words- we did not make any further assessments as part of this mapping review considering GRADE). In the methods section we also state that: The primary outcome was conceptualised as overall symptomatology associated with the relevant condition, such as anxiety symptoms for those with anxiety and depression symptoms for those with depression. In cases where the same outcome was assessed using different outcome measures, we extracted the outcome with the longest follow up and highest certainty.If a review did not report findings on overall symptoms, we reported other symptoms as proxy, for example inattention in treatment of ADHD when total symptoms were not available.

Results

Table 5 – the table is likely perfectly accurate, but it does seem strange that all “very low certainty” are related to uncertain effects (assuming “?” means uncertain effects?) and no other effect estimates are “very low certainty” (e.g., it is possible to have very low certainty in an effect estimate that shows a moderate observed effect size). Also , where ** is used to indicate that it is difficult to assess the size of effect but the review authors report the intervention as effective – this is not rated as very low certainty as compared to low certainty? Author response: The GRADE-framework recommends that outcomes of very low certainty are not reported as the confidence in the findings is too low. In our table this is indicated as “?” (https://www.gradeworkinggroup.org/publications.html). For two of the comparisons, there was uncertainty about the size of the effect, but not direction. Thus, we were not able to classify the size of effect according to the pre-defined thresholds. These outcomes have been highlighted in the table, both of these were downgraded for precision in the GRADE-assessments and considered to be of low certainty in the original OoOs
Peer-reviewer 2 Heather Eileen Menzies Munthe-Kaas

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider carefully the term “mental illness” since ADHD at least, is not considered a mental illness, but rather a neurodevelopmental disorder (paragraph 2) Author response: This is a very valid point, and we agree that this should have been more carefully formulated. ADHD is indeed a neurodevelopment disorder of which some people with this condition will need therapy, training or support. We have now used “mental health” and “mental disorder” throughout the manuscript which are terminology that encompass both mental illness and neurodevelopment disorders.

Consider acknowledging that this group of conditions are not in the same category. For example, ADHD (neurodevelopmental disorder) and anxiety, depression, bipolar disorder (mood disorders) and the reason for grouping them in this paper (which is not problematic in itself, and is probably representative of the literature, but needs acknowledgment of here). The introduction would benefit from one or two additional sentences about why these specific mental health and neurodevelopmental disorders are included (e.g., they are grouped in existing reviews and OoOs). Author response: The diagnostic groups included in this paper are under the common descriptor “mental disorder” and is defined by the World Health Organisation as “a clinically significant disturbance of an individual’s cognition, emotional regulation, or behaviour” https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Although the etiology of the included disorders may be different, they are in many cases associated with distress or impairment in important areas of functioning and are often treated for their symptoms by methodologies with shared epistemology and by the same services and professionals. To make this clearer we have added a sentence to the introduction.

Decision making only has a “-“ when it is used as an adjective (e.g., decision-making tools)Author response: Thank you, this has been corrected.

Consider using the term “user” or “client” instead of “patient” Author response: We have changed “patient groups” to diagnostic groups to be more precise and have used “patient” where patient rights or roles are described.

Define “living evidence summaries”. Author response: A definition has been added to the manuscript.

Explain why “overviews of systematic reviews” is shortened to “OoOs” (e.g., also referred to as overview of overviews; OoOs). Also can make more clear that the authors have also conducted and published the included OoOs. Author response: We have now rephased to using overviews of overviews throughout the manuscript. We have stated under the sub-heading: “The evidence: Inclusion criteria and search strategy “ that we authored the OoOs.

Missing at the end of the introduction a sentence situating this work in the greater picture of work and what gap this study is addressing. Author response: This has now been added.

Methods:

Overall this section could use a bit more details and explanation as well as structure to better distinguish from what was done during OoOs and what is done here (and what was carried over from original SRs) perhaps using a flow chart or diagram to show information/data flow? Author response: The flowchart of data is shown in Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. We agree that this section needed to be restructured and have now done so to accommodate the peer-reviewers feedback.

Since the most recent of the OoOs is from February 2021, and this is a very active research field, is this mapping review really the best overview of all treatments (and longest follow up)? Can you explain this approach to summarizing and mapping the evidence when there is likely a large chunk of systematic reviews from the last 4-5 years missing here? Could you also write more about how far back the included SRs in the included OoOs go back to? Author response: Our mapping review was first published in this journal in January 2023, and as stated in the manuscript, the data collection took place between September 2021 and December 2022. Thus, our report was published very briefly after the data collection was completed. The OoOs we used for our synthesis were considered up-to date at the point of our data collection (these were either new first editions or had been semi-annually or annually updated) at the time. The database from which the OoO include their systematic reviews were updated monthly. To be included, a systematic review should be newer than five years but would not be replaced unless a systematic review considered to be more updated was identified- following the principle of the best available evidence to inform practice. All literature reviews suffer the risk of being outdated once they are published. Judgements about the relevance of the evidence and to what extent new research would change the conclusions is dependent on the research question, the intended use and the robustness of the existing evidence. At the time of the publication of this paper, we were interested in exploring the diversity of treatment interventions for the included mental disorders but also to describe the follow-up times in the existing studies. We also wanted to provide an overview of the effects of these interventions and their associated certainty of the evidence across diagnostic groups. Our conclusion is based on a very large evidence base of 116 systematic reviews including 200 treatment comparisons. Even though we expect new primary studies to have been published from the time our review was first published- we are confident that our conclusions have not been changed substantially:

Some mental illnesses are treated mostly with pharmacological, or psychological therapies or a combination of these. Some are treated with a broader spectrum of therapies.

The evidence supporting most treatments is of low to very low certainty.
Very few treatment evaluations include follow-up assessments beyond 12 months.

Some treatments are effective across populations, such as cognitive behavioral therapy

Data collection – could you describe sunburst diagrams and what exactly will be presented in them? Author response: A sentence has been added to improve clarity.

The members of this research team made the OoO GRADE assessments? How were the GRADE assessments taken from the original systematic reviews used? Author response: Yes, one or more of the author team was involved in the OoO published in the evidence portal. We extracted the GRADE-judgements for the primary outcome (in other words- we did not make any further assessments as part of this mapping review considering GRADE). In the methods section we also state that: The primary outcome was conceptualised as overall symptomatology associated with the relevant condition, such as anxiety symptoms for those with anxiety and depression symptoms for those with depression. In cases where the same outcome was assessed using different outcome measures, we extracted the outcome with the longest follow up and highest certainty.If a review did not report findings on overall symptoms, we reported other symptoms as proxy, for example inattention in treatment of ADHD when total symptoms were not available.

Results

Table 5 – the table is likely perfectly accurate, but it does seem strange that all “very low certainty” are related to uncertain effects (assuming “?” means uncertain effects?) and no other effect estimates are “very low certainty” (e.g., it is possible to have very low certainty in an effect estimate that shows a moderate observed effect size). Also , where ** is used to indicate that it is difficult to assess the size of effect but the review authors report the intervention as effective – this is not rated as very low certainty as compared to low certainty? Author response: The GRADE-framework recommends that outcomes of very low certainty are not reported as the confidence in the findings is too low. In our table this is indicated as “?” (https://www.gradeworkinggroup.org/publications.html). For two of the comparisons, there was uncertainty about the size of the effect, but not direction. Thus, we were not able to classify the size of effect according to the pre-defined thresholds. These outcomes have been highlighted in the table, both of these were downgraded for precision in the GRADE-assessments and considered to be of low certainty in the original OoOs
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 06 Sep 2023

Hiran Thabrew, University of Auckland, Auckland Hospital, Auckland, New Zealand

Approved with Reservations

https://doi.org/10.5256/f1000research.135677.r199270

Thank you for the opportunity to review this interesting paper summarizing results of a mapping review of interventions for common child and adolescent mental health problems.

The strengths of this paper are:

The use of a comprehensive national database of evidence.
The inclusion of most common child and adolescent mental health problems.
The clearly presented information about how the study was conceptualized, designed and implemented, including adequate supplementary material with which the review may be replicated.
Clear tables and figures to summarize results.
Inclusion of length of follow-up data to highlight the short-term nature of most studies.

Areas for improvement are as follows:

My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is despite the source OoOs including studies with any type of comparator:

Statement from mapping review: "The OoOs excluded studies where pharmacological interventions were not compared to active interventions, thus placebo-controlled studies were excluded."

Statement from protocol of ADHD review: "Comparator(s)/control: Any interventions or treatment as usual (TAU)."

I'm not sure why placebo controlled studies were excluded from the mapping review, and as a result, its findings are technically interesting, but of limited clinical benefit. A key example is how methlyphenidate pharmacotherapy for ADHD is not explicitly mentioned in Table 5, even though it is the mainstay of treatment for this condition worldwide. Greater explanation of this issue (or, dare I ask for it, a reworking of the analysis including all types of studies) would be useful.
Using colors more consistently in the sunburst diagrams (Figures 2-10) to make it easier for the reader to compare the weight of evidence for each type of therapy across different conditions (e.g., medication is blue in one diagram, yellow in another).
Please explain the colors and question marks used in Table 5.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Child and adolescent mental health clinician and researcher

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

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Author Response 08 May 2025

Astrid Dahlgren

08 May 2025

Author Response
Peer-reviewer .1 Hiran Thabrew
1. My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is
... Continue reading
Peer-reviewer .1 Hiran Thabrew

My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is despite the source OoOs including studies with any type of comparator:

Author response: This limitation was only for pharmaceutical therapy compared with placebo- not other mental health interventions. The reason for this was that the evidence base for this review was a series of overviews of systematic reviews (OoO) conducted as part of the development of a national evidence portal commissioned by the Norwegian directorate of health to inform clinical practice in Norway as part of the launching of Clinical Pathways mental health for children and young people. In this context the relevance of placebo-controlled pharmaceutical studies was judged by policymakers and mental health practitioners to be low as pharmaceutical treatment are only advised to be considered when other treatments are found not to be effective. Therefore, the focus was on pharmaceutical treatments compared to other active treatments used alone or in combination with other treatments.
As the peer-reviewer rightly states, the OoOs searched for and included placebo-controlled comparisons for pharmaceutical therapies, but the findings of these comparisons were only reported descriptively as supplemental material in the OoOs without full data extraction and GRADE-assessments.
In regard to the peer- reviewer’s comments about Methylphenidate, we agree that this is a treatment of relevance to clinical practice and is also one of the most commonly used pharmaceutical treatments in Norway for young people under 18 with ADHD.
Methylphenidate is included in the review as 1 of 57 unique treatments for ADHD in figure 2: Unique intervention categories evaluated for attention deficit / hyperactivity disorder (ADHD).
Table 5 reports treatment comparisons that have been tested for more than 1 diagnosis and on a higher aggregated level as evaluated in the systematic reviews (in this case “stimulants” or in the broader term “pharmacological treatment”). Where type of pharmaceutical treatment is reported in the systematic reviews this has been described by us in the notes to table 5. See for example under “Combination therapies”. We hope this helps to clarify the peer-reviewers concerns.

2. Please explain the colors and question marks used in Table 5.
Author response: Explanation for colour-coding is as follows: Yellow is used for low certainty, red for very low certainty and green for moderate certainty. A sentence has been added to the manuscript.
Peer-reviewer .1 Hiran Thabrew

My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is despite the source OoOs including studies with any type of comparator:

Author response: This limitation was only for pharmaceutical therapy compared with placebo- not other mental health interventions. The reason for this was that the evidence base for this review was a series of overviews of systematic reviews (OoO) conducted as part of the development of a national evidence portal commissioned by the Norwegian directorate of health to inform clinical practice in Norway as part of the launching of Clinical Pathways mental health for children and young people. In this context the relevance of placebo-controlled pharmaceutical studies was judged by policymakers and mental health practitioners to be low as pharmaceutical treatment are only advised to be considered when other treatments are found not to be effective. Therefore, the focus was on pharmaceutical treatments compared to other active treatments used alone or in combination with other treatments.
As the peer-reviewer rightly states, the OoOs searched for and included placebo-controlled comparisons for pharmaceutical therapies, but the findings of these comparisons were only reported descriptively as supplemental material in the OoOs without full data extraction and GRADE-assessments.
In regard to the peer- reviewer’s comments about Methylphenidate, we agree that this is a treatment of relevance to clinical practice and is also one of the most commonly used pharmaceutical treatments in Norway for young people under 18 with ADHD.
Methylphenidate is included in the review as 1 of 57 unique treatments for ADHD in figure 2: Unique intervention categories evaluated for attention deficit / hyperactivity disorder (ADHD).
Table 5 reports treatment comparisons that have been tested for more than 1 diagnosis and on a higher aggregated level as evaluated in the systematic reviews (in this case “stimulants” or in the broader term “pharmacological treatment”). Where type of pharmaceutical treatment is reported in the systematic reviews this has been described by us in the notes to table 5. See for example under “Combination therapies”. We hope this helps to clarify the peer-reviewers concerns.

2. Please explain the colors and question marks used in Table 5.
Author response: Explanation for colour-coding is as follows: Yellow is used for low certainty, red for very low certainty and green for moderate certainty. A sentence has been added to the manuscript.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 08 May 2025

Astrid Dahlgren

08 May 2025

Author Response
Peer-reviewer .1 Hiran Thabrew
1. My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is
... Continue reading
Peer-reviewer .1 Hiran Thabrew

My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is despite the source OoOs including studies with any type of comparator:

Author response: This limitation was only for pharmaceutical therapy compared with placebo- not other mental health interventions. The reason for this was that the evidence base for this review was a series of overviews of systematic reviews (OoO) conducted as part of the development of a national evidence portal commissioned by the Norwegian directorate of health to inform clinical practice in Norway as part of the launching of Clinical Pathways mental health for children and young people. In this context the relevance of placebo-controlled pharmaceutical studies was judged by policymakers and mental health practitioners to be low as pharmaceutical treatment are only advised to be considered when other treatments are found not to be effective. Therefore, the focus was on pharmaceutical treatments compared to other active treatments used alone or in combination with other treatments.
As the peer-reviewer rightly states, the OoOs searched for and included placebo-controlled comparisons for pharmaceutical therapies, but the findings of these comparisons were only reported descriptively as supplemental material in the OoOs without full data extraction and GRADE-assessments.
In regard to the peer- reviewer’s comments about Methylphenidate, we agree that this is a treatment of relevance to clinical practice and is also one of the most commonly used pharmaceutical treatments in Norway for young people under 18 with ADHD.
Methylphenidate is included in the review as 1 of 57 unique treatments for ADHD in figure 2: Unique intervention categories evaluated for attention deficit / hyperactivity disorder (ADHD).
Table 5 reports treatment comparisons that have been tested for more than 1 diagnosis and on a higher aggregated level as evaluated in the systematic reviews (in this case “stimulants” or in the broader term “pharmacological treatment”). Where type of pharmaceutical treatment is reported in the systematic reviews this has been described by us in the notes to table 5. See for example under “Combination therapies”. We hope this helps to clarify the peer-reviewers concerns.

2. Please explain the colors and question marks used in Table 5.
Author response: Explanation for colour-coding is as follows: Yellow is used for low certainty, red for very low certainty and green for moderate certainty. A sentence has been added to the manuscript.
Peer-reviewer .1 Hiran Thabrew

My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is despite the source OoOs including studies with any type of comparator:

Author response: This limitation was only for pharmaceutical therapy compared with placebo- not other mental health interventions. The reason for this was that the evidence base for this review was a series of overviews of systematic reviews (OoO) conducted as part of the development of a national evidence portal commissioned by the Norwegian directorate of health to inform clinical practice in Norway as part of the launching of Clinical Pathways mental health for children and young people. In this context the relevance of placebo-controlled pharmaceutical studies was judged by policymakers and mental health practitioners to be low as pharmaceutical treatment are only advised to be considered when other treatments are found not to be effective. Therefore, the focus was on pharmaceutical treatments compared to other active treatments used alone or in combination with other treatments.
As the peer-reviewer rightly states, the OoOs searched for and included placebo-controlled comparisons for pharmaceutical therapies, but the findings of these comparisons were only reported descriptively as supplemental material in the OoOs without full data extraction and GRADE-assessments.
In regard to the peer- reviewer’s comments about Methylphenidate, we agree that this is a treatment of relevance to clinical practice and is also one of the most commonly used pharmaceutical treatments in Norway for young people under 18 with ADHD.
Methylphenidate is included in the review as 1 of 57 unique treatments for ADHD in figure 2: Unique intervention categories evaluated for attention deficit / hyperactivity disorder (ADHD).
Table 5 reports treatment comparisons that have been tested for more than 1 diagnosis and on a higher aggregated level as evaluated in the systematic reviews (in this case “stimulants” or in the broader term “pharmacological treatment”). Where type of pharmaceutical treatment is reported in the systematic reviews this has been described by us in the notes to table 5. See for example under “Combination therapies”. We hope this helps to clarify the peer-reviewers concerns.

2. Please explain the colors and question marks used in Table 5.
Author response: Explanation for colour-coding is as follows: Yellow is used for low certainty, red for very low certainty and green for moderate certainty. A sentence has been added to the manuscript.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2 PUBLISHED 03 Jan 2023

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Version 2 (revision) 08 May 25
Version 1 03 Jan 23	read	read

Hiran Thabrew, University of Auckland, Auckland Hospital, Auckland, New Zealand
Heather Eileen Menzies Munthe-Kaas, Norwegian Institute of Public Health, Oslo, Norway

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22 Mar 2025 | for Version 1

Heather Eileen Menzies Munthe-Kaas, Norwegian Institute of Public Health, Oslo, Norway

6 Views Cite this report Responses(1)

Approved

This is a very interesting and well written article on an important topic. A few small comments from me:

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider carefully the term “mental illness” since ADHD at least, is not considered a mental illness, but rather a neurodevelopmental disorder (paragraph 2)
Consider acknowledging that this group of conditions are not in the same category. For example, ADHD (neurodevelopmental disorder) and anxiety, depression, bipolar disorder (mood disorders) and the reason for grouping them in this paper (which is not problematic in itself, and is probably representative of the literature, but needs acknowledgment of here). The introduction would benefit from one or two additional sentences about why these specific mental health and neurodevelopmental disorders are included (e.g., they are grouped in existing reviews and OoOs).
Decision making only has a “-“ when it is used as an adjective (e.g., decision-making tools)
Consider using the term “user” or “client” instead of “patient”
Define “living evidence summaries”
Explain why “overviews of systematic reviews” is shortened to “OoOs” (e.g., also referred to as overview of overviews; OoOs). Also can make more clear that the authors have also conducted and published the included OoOs.
Missing at the end of the introduction a sentence situating this work in the greater picture of work and what gap this study is addressing.

A subtitle indicating that you are describing methods for the OoOs and not the mapping review
Since the most recent of the OoOs is from February 2021, and this is a very active research field, is this mapping review really the best overview of all treatments (and longest follow up)? Can you explain this approach to summarizing and mapping the evidence when there is likely a large chunk of systematic reviews from the last 4-5 years missing here? Could you also write more about how far back the included SRs in the included OoOs go back to?
Data collection – could you describe sunburst diagrams and what exactly will be presented in them?
The members of this research team made the OoO GRADE assessments? How were the GRADE assessments taken from the original systematic reviews used?

Results

Table 5 – the table is likely perfectly accurate, but it does seem strange that all “very low certainty” are related to uncertain effects (assuming “?” means uncertain effects?) and no other effect estimates are “very low certainty” (e.g., it is possible to have very low certainty in an effect estimate that shows a moderate observed effect size). Also , where ** is used to indicate that it is difficult to assess the size of effect but the review authors report the intervention as effective – this is not rated as very low certainty as compared to low certainty?

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

stakeholder engagement in research, systematic review and qualitative evidence synthesis methods

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (1)

Author Response

08 May 2025

Astrid Dahlgren

Peer-reviewer 2 Heather Eileen Menzies Munthe-Kaas

Terminology – in this manuscript the terms “mental health” mental illness” and “mental disorders” are used. Best to choose one, and consider carefully the term “mental illness” since ADHD at least, is not considered a mental illness, but rather a neurodevelopmental disorder (paragraph 2) Author response: This is a very valid point, and we agree that this should have been more carefully formulated. ADHD is indeed a neurodevelopment disorder of which some people with this condition will need therapy, training or support. We have now used “mental health” and “mental disorder” throughout the manuscript which are terminology that encompass both mental illness and neurodevelopment disorders.
Consider acknowledging that this group of conditions are not in the same category. For example, ADHD (neurodevelopmental disorder) and anxiety, depression, bipolar disorder (mood disorders) and the reason for grouping them in this paper (which is not problematic in itself, and is probably representative of the literature, but needs acknowledgment of here). The introduction would benefit from one or two additional sentences about why these specific mental health and neurodevelopmental disorders are included (e.g., they are grouped in existing reviews and OoOs). Author response: The diagnostic groups included in this paper are under the common descriptor “mental disorder” and is defined by the World Health Organisation as “a clinically significant disturbance of an individual’s cognition, emotional regulation, or behaviour” https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Although the etiology of the included disorders may be different, they are in many cases associated with distress or impairment in important areas of functioning and are often treated for their symptoms by methodologies with shared epistemology and by the same services and professionals. To make this clearer we have added a sentence to the introduction.
Decision making only has a “-“ when it is used as an adjective (e.g., decision-making tools)Author response: Thank you, this has been corrected.
Consider using the term “user” or “client” instead of “patient” Author response: We have changed “patient groups” to diagnostic groups to be more precise and have used “patient” where patient rights or roles are described.
Define “living evidence summaries”. Author response: A definition has been added to the manuscript.
Explain why “overviews of systematic reviews” is shortened to “OoOs” (e.g., also referred to as overview of overviews; OoOs). Also can make more clear that the authors have also conducted and published the included OoOs. Author response: We have now rephased to using overviews of overviews throughout the manuscript. We have stated under the sub-heading: “The evidence: Inclusion criteria and search strategy “ that we authored the OoOs.
Missing at the end of the introduction a sentence situating this work in the greater picture of work and what gap this study is addressing. Author response: This has now been added.

Methods:

Overall this section could use a bit more details and explanation as well as structure to better distinguish from what was done during OoOs and what is done here (and what was carried over from original SRs) perhaps using a flow chart or diagram to show information/data flow? Author response: The flowchart of data is shown in Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. We agree that this section needed to be restructured and have now done so to accommodate the peer-reviewers feedback.
Since the most recent of the OoOs is from February 2021, and this is a very active research field, is this mapping review really the best overview of all treatments (and longest follow up)? Can you explain this approach to summarizing and mapping the evidence when there is likely a large chunk of systematic reviews from the last 4-5 years missing here? Could you also write more about how far back the included SRs in the included OoOs go back to? Author response: Our mapping review was first published in this journal in January 2023, and as stated in the manuscript, the data collection took place between September 2021 and December 2022. Thus, our report was published very briefly after the data collection was completed. The OoOs we used for our synthesis were considered up-to date at the point of our data collection (these were either new first editions or had been semi-annually or annually updated) at the time. The database from which the OoO include their systematic reviews were updated monthly. To be included, a systematic review should be newer than five years but would not be replaced unless a systematic review considered to be more updated was identified- following the principle of the best available evidence to inform practice. All literature reviews suffer the risk of being outdated once they are published. Judgements about the relevance of the evidence and to what extent new research would change the conclusions is dependent on the research question, the intended use and the robustness of the existing evidence. At the time of the publication of this paper, we were interested in exploring the diversity of treatment interventions for the included mental disorders but also to describe the follow-up times in the existing studies. We also wanted to provide an overview of the effects of these interventions and their associated certainty of the evidence across diagnostic groups. Our conclusion is based on a very large evidence base of 116 systematic reviews including 200 treatment comparisons. Even though we expect new primary studies to have been published from the time our review was first published- we are confident that our conclusions have not been changed substantially:
1. Some mental illnesses are treated mostly with pharmacological, or psychological therapies or a combination of these. Some are treated with a broader spectrum of therapies.
2. The evidence supporting most treatments is of low to very low certainty.
  Very few treatment evaluations include follow-up assessments beyond 12 months.
3. Some treatments are effective across populations, such as cognitive behavioral therapy
Data collection – could you describe sunburst diagrams and what exactly will be presented in them? Author response: A sentence has been added to improve clarity.
The members of this research team made the OoO GRADE assessments? How were the GRADE assessments taken from the original systematic reviews used? Author response: Yes, one or more of the author team was involved in the OoO published in the evidence portal. We extracted the GRADE-judgements for the primary outcome (in other words- we did not make any further assessments as part of this mapping review considering GRADE). In the methods section we also state that: The primary outcome was conceptualised as overall symptomatology associated with the relevant condition, such as anxiety symptoms for those with anxiety and depression symptoms for those with depression. In cases where the same outcome was assessed using different outcome measures, we extracted the outcome with the longest follow up and highest certainty.If a review did not report findings on overall symptoms, we reported other symptoms as proxy, for example inattention in treatment of ADHD when total symptoms were not available.

Results

Table 5 – the table is likely perfectly accurate, but it does seem strange that all “very low certainty” are related to uncertain effects (assuming “?” means uncertain effects?) and no other effect estimates are “very low certainty” (e.g., it is possible to have very low certainty in an effect estimate that shows a moderate observed effect size). Also , where ** is used to indicate that it is difficult to assess the size of effect but the review authors report the intervention as effective – this is not rated as very low certainty as compared to low certainty? Author response: The GRADE-framework recommends that outcomes of very low certainty are not reported as the confidence in the findings is too low. In our table this is indicated as “?” (https://www.gradeworkinggroup.org/publications.html). For two of the comparisons, there was uncertainty about the size of the effect, but not direction. Thus, we were not able to classify the size of effect according to the pre-defined thresholds. These outcomes have been highlighted in the table, both of these were downgraded for precision in the GRADE-assessments and considered to be of low certainty in the original OoOs

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

13 Views

06 Sep 2023 | for Version 1

Hiran Thabrew, University of Auckland, Auckland Hospital, Auckland, New Zealand

13 Views Cite this report Responses(1)

Approved With Reservations

The use of a comprehensive national database of evidence.
The inclusion of most common child and adolescent mental health problems.
The clearly presented information about how the study was conceptualized, designed and implemented, including adequate supplementary material with which the review may be replicated.
Clear tables and figures to summarize results.
Inclusion of length of follow-up data to highlight the short-term nature of most studies.

Areas for improvement are as follows:

My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is despite the source OoOs including studies with any type of comparator:

Statement from mapping review: "The OoOs excluded studies where pharmacological interventions were not compared to active interventions, thus placebo-controlled studies were excluded."

Statement from protocol of ADHD review: "Comparator(s)/control: Any interventions or treatment as usual (TAU)."

I'm not sure why placebo controlled studies were excluded from the mapping review, and as a result, its findings are technically interesting, but of limited clinical benefit. A key example is how methlyphenidate pharmacotherapy for ADHD is not explicitly mentioned in Table 5, even though it is the mainstay of treatment for this condition worldwide. Greater explanation of this issue (or, dare I ask for it, a reworking of the analysis including all types of studies) would be useful.
Using colors more consistently in the sunburst diagrams (Figures 2-10) to make it easier for the reader to compare the weight of evidence for each type of therapy across different conditions (e.g., medication is blue in one diagram, yellow in another).
Please explain the colors and question marks used in Table 5.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Child and adolescent mental health clinician and researcher

Respond to this report

Responses (1)

Author Response

08 May 2025

Astrid Dahlgren

Peer-reviewer .1 Hiran Thabrew

My main concern about this paper is the limitation of included studies to those which had used an active comparator (not placebo). This is despite the source OoOs including studies with any type of comparator:

Author response: This limitation was only for pharmaceutical therapy compared with placebo- not other mental health interventions. The reason for this was that the evidence base for this review was a series of overviews of systematic reviews (OoO) conducted as part of the development of a national evidence portal commissioned by the Norwegian directorate of health to inform clinical practice in Norway as part of the launching of Clinical Pathways mental health for children and young people. In this context the relevance of placebo-controlled pharmaceutical studies was judged by policymakers and mental health practitioners to be low as pharmaceutical treatment are only advised to be considered when other treatments are found not to be effective. Therefore, the focus was on pharmaceutical treatments compared to other active treatments used alone or in combination with other treatments.
As the peer-reviewer rightly states, the OoOs searched for and included placebo-controlled comparisons for pharmaceutical therapies, but the findings of these comparisons were only reported descriptively as supplemental material in the OoOs without full data extraction and GRADE-assessments.
In regard to the peer- reviewer’s comments about Methylphenidate, we agree that this is a treatment of relevance to clinical practice and is also one of the most commonly used pharmaceutical treatments in Norway for young people under 18 with ADHD.
Methylphenidate is included in the review as 1 of 57 unique treatments for ADHD in figure 2: Unique intervention categories evaluated for attention deficit / hyperactivity disorder (ADHD).
Table 5 reports treatment comparisons that have been tested for more than 1 diagnosis and on a higher aggregated level as evaluated in the systematic reviews (in this case “stimulants” or in the broader term “pharmacological treatment”). Where type of pharmaceutical treatment is reported in the systematic reviews this has been described by us in the notes to table 5. See for example under “Combination therapies”. We hope this helps to clarify the peer-reviewers concerns.

2. Please explain the colors and question marks used in Table 5.
Author response: Explanation for colour-coding is as follows: Yellow is used for low certainty, red for very low certainty and green for moderate certainty. A sentence has been added to the manuscript.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Mental health interventions targeting children and young people: A mapping review of interventions, follow-up, and evidence gaps

Abstract

Background

Methods

Results

Conclusions

Keywords

Revised Amendments from Version 1

Introduction

Objectives

Methods

Design

Description of the included overviews of systematic reviews

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

Data extraction and evidence included in the analysis of the mapping review

Table 1. Rule of thumb thresholds used for effect sizes.

Evidence not included in the mapping review

Results

Treatment comparisons and follow-up

Table 2. Number of treatment comparisons by diagnostic group.

Interventions evaluated by diagnostic group

Figure 2. Unique intervention categories evaluated for attention deficit / hyperactivity disorder (ADHD).

Figure 3. Unique intervention categories evaluated for anxiety.

Figure 4. Unique intervention categories evaluated for bipolar disorder.

Time of follow-up

Table 3. The longest follow-up times (by any outcome).

Figure 5. Unique intervention categories evaluated for depression.

Table 4. Follow-up times by diagnostic group and outcome category.

Figure 6. Unique intervention categories evaluated for obsessive compulsive disorder (OCD).

Treatment uncertainty and comparative effectiveness

Table 5. Overview of shared treatment comparisons, intervention effects and certainty of the evidence.

Figure 7. Unique intervention categories evaluated for psychosis.

Figure 8. Unique intervention categories evaluated for self-harm.

Figure 9. Unique intervention categories evaluated for post-traumatic stress disorder (PTSD).

Figure 10. Unique intervention categories evaluated for trauma.

Discussion

Limitations and strengths

Summary of results

Implications for research and practice

Conclusions

Data availability

Underlying data

References

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