Received: 13 March 2023 | Accepted: 16 November 2023

DOI: 10.1002/jad.12277

RESEARCH ARTICLE

Feasibility, acceptability, and depression outcomes of a

randomized controlled trial of Mindful Self‐Compassion for
Teens (MSC‐T) for adolescents with subsyndromal depression

Karen Bluth1 | Christine Lathren2 | Jinyoung Park3 | Chanee Lynch2 |

John Curry4 | April Harris‐Britt5 | Susan Gaylord2

1
Department of Psychiatry, University of North Abstract
Carolina School of Medicine, Frank Porter
Graham Child Development Institute, University Introduction: Adolescents are experiencing high rates of depressive symptoms, with
of North Carolina at Chapel Hill, Chapel Hill, negative consequences to their long‐term health. Group‐based, mindful self‐
North Carolina, USA compassion programs show promise in mitigating the development of more
2
Department of Physical Medicine and significant depression in at‐risk adolescents. However, the lack of well‐designed,
Rehabilitation, Program on Integrative Medicine,
active control conditions has limited the ability to examine the efficacy of such
University of North Carolina School of Medicine,
Chapel Hill, North Carolina, USA interventions.
3
Department of Psychology and Neuroscience,
Methods: Fifty‐nine adolescents (Mage = 15.81, 70% female) with subsyndromal
Duke University, Durham, North Carolina, USA depressive symptoms from the Southeastern US were randomized to group‐based
4
Department of Psychiatry and Behavioral Mindful Self‐Compassion for Teens (N = 30) or a newly developed active control
Sciences, Duke University, Durham, Healthy Lifestyles group (N = 29) during 2018 and 2019. Participants attended
North Carolina, USA 8 weekly “main” sessions followed by 6 monthly continuation sessions. The feasibility
5
AHB Center for Behavioral Health and Wellness, and acceptability of participation in both groups were measured using attrition,
Durham, North Carolina, USA
attendance, credibility, and satisfaction data. Depression scores were collected weekly,
and self‐compassion scores were collected five times across 36 weeks.
Correspondence
Results: Both groups were equally feasible and acceptable during the 8‐week program
Karen Bluth, Department of Psychiatry,
University of North Carolina School of Medicine, period; however, monthly continuation sessions were poorly attended in both groups.
Frank Porter Graham Child Development The risk of developing clinically significant depression was 2.6 times higher in the
Institute, University of North Carolina at Chapel
control group compared with the self‐compassion group (p = .037) across 36 weeks.
Hill, Chapel Hill, NC, USA.
Email: [email protected] Depression significantly decreased in the self‐compassion group, while it significantly
increased in the control group. Both groups increased significantly in reports of self‐
Funding information
compassion. These findings are on par with results noting the efficacy of cognitive‐
National Center for Complementary and
Integrative Health based interventions for high‐risk adolescents; follow‐up studies with larger sample
sizes should be conducted to confirm these findings.
Conclusions: Initial examination suggests Mindful Self‐Compassion for Teens
programming is feasible, acceptable, and efficacious in preventing the development
of clinically significant depression in adolescents with subsyndromal depression.
Future studies may benefit from refinements to the self‐compassion measurement
and/or the attention control condition; moreover, larger sample sizes are needed to
confirm results.

KEYWORDS
depression, health promotion, mental health, psychiatric disorders, stress and coping, well‐being

© 2023 Foundation for Professionals in Services to Adolescents.

322 | wileyonlinelibrary.com/journal/jad Journal of Adolescence. 2024;96:322–336.

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JOURNAL OF ADOLESCENCE | 323

1 | INTRODUCTION

Depression in adolescence has increased dramatically over the last decade, and precipitously during the Covid‐19
pandemic. According to the December 2021 Surgeon General's advisory, the United States is currently facing a youth
mental health crisis, and urgent action is needed (Protecting Youth Mental Health: The US Surgeon General's
Advisory, 2021). The increase in mental health challenges among youth is alarming; for example, in 2021, 42% of all
students surveyed (57% of females and 29% of males) indicated they experienced persistent feelings of sadness and
hopelessness to the degree that they could not engage in regular activities. Almost one‐fourth of all students seriously
considered suicide (30% of females and 14% of males), and 18% made a suicide plan (24% of females and 12% of males).
These stark findings reflect an almost 60% increase in overall depression and suicidal ideation over the last decade
(Youth Risk Behavior Survey: Data Summary and Trends Report, 2011–2021, 2023). Statistics for LGBTQ+ students are
even more disturbing; almost 70% experienced persistent feelings of sadness and hopelessness, 45% considered suicide,
37% made a suicide plan, and 22% reported attempting suicide (Youth Risk Behavior Survey: Data Summary and Trends
Report, 2011–2021, 2023). These trajectories are reflected globally; a meta‐analysis that included reports on 80,000
adolescents from East Asia, Central America, South America, Europe, the Middle East, and the United States indicated
that depression doubled during the pandemic, with one out of every four adolescents reporting that they are
experiencing depressive symptoms (Racine et al., 2021).
Adolescents struggling with depression are often set on a maladaptive behavior trajectory which may lead to
academic challenges, substance abuse, risky sexual behavior, impairment in relationship building, or suicidality (Anatale
& Kelly, 2015; Burke et al., 2018; Fergusson et al., 2007; Joosten et al., 2022). Depressive symptoms are associated with
sleep disturbances among adolescents (e.g., insomnia and hypersomnia), exacerbating the negative impacts on health
and social domains (Lovato & Gradisar, 2014). Most notably, these depressive‐related challenges emerging in
adolescence often persist beyond adolescence and into adulthood, resulting in an altered behavioral and educational
trajectory such as dropping out of high school, unemployment, substance use, and unplanned early pregnancy/
parenthood (Clayborne et al., 2019; Fletcher, 2008). Moreover, those experiencing depression as adolescents are more
likely to have poor somatic health outcomes later in life, such as migraine headaches (Naicker et al., 2013),
cardiovascular disease (Park et al., 2023), and obesity (Richardson et al., 2003). Subsequently, depression in adolescence
has been shown to predict poorer health, higher healthcare utilization, low levels of social support, and increased work
impairment due to physical health over the subsequent decade (Keenan‐Miller et al., 2007; Naicker et al., 2013). Those
youth who experience subsyndromal depression, defined as evidencing symptoms of major depression but not of the
severity to meet a diagnosis of major depression (Fergusson et al., 2005), have a higher risk, compared to nondepressed
adolescents, of developing major depressive disorder (MDD) as adolescents (Uchida et al., 2021) and adults (Alaie
et al., 2022; Garber, 2006; Lewinsohn et al., 2000).
Clearly, there is an urgent need for depression prevention programs. Some cognitive‐behavioral (e.g., Garber
et al., 2009), psycho‐educational (e.g., Beardslee et al., 2003), and interpersonal interventions (e.g., Young et al., 2006)
have shown significant prevention effects. Overall, however, a meta‐analysis of 47 studies evaluating 32 depression‐
prevention programs for youth reported that only 41% of the programs included in the study had significant reductions
in depressive symptoms postintervention, and the effect sizes were small (Stice et al., 2009). Additionally, many of the
trials had either waitlist or assessment‐only control conditions, which are likely to overestimate effect sizes (Stice
et al., 2007). Furthermore, only 4 of 47 trials produced significant reductions in future depression onset (Stice
et al., 2009).
The lessons learned from these depression‐prevention programs have implications for future program
design. For example, the most effective programs utilized professional interventionists (rather than classroom
teachers), assigned homework, and were relatively short in length (Stice et al., 2009). Also, the developmental
appropriateness of CBT for adolescents has been questioned, as these youth may not be able to fully grasp the
concepts foundational to CBT (Curry, 2014). More recently, depression prevention programs have been brought into
school environments, and a meta‐analysis of school‐based programs targeted to reduce depression has evidenced
decreased symptoms, but these outcomes did not last over time and were moderated by age, race, gender, and dose
(Feiss et al., 2019).
Self‐compassion interventions show promise in alleviating depressive symptoms among adolescents (Bluth
et al., 2016a, 2023). A personal resource that can be accessed at emotionally challenging times, self‐compassion in both
adults and adolescents has demonstrated inverse relationships with depressive symptoms with large effect sizes (see
meta‐analyses among adults: MacBeth & Gumley, 2012; adolescents: Marsh et al., 2018; Pullmer et al., 2019). Neff (2023)
has developed a widely used conceptualization of self‐compassion based on the interplay of six components, three
compassionate self‐responding components and three uncompassionate self‐responding components. These
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324 | BLUTH ET AL.

components include mindfulness, or maintaining awareness and perspective when faced with difficult emotions versus
overidentification, or exaggerating one's difficult emotions or thoughts in response to a situation; common humanity, or
understanding that experiencing difficult emotions are normal and part of the experience of being human versus
isolation, or feeling alone with one's difficult emotions; and self‐kindness, or taking an active role in engaging in self‐
supportive behavior versus self‐judgment, or judging oneself harshly in response to our suffering. High levels of
compassionate responding and low levels of uncompassionate responding are thought to work together in a dynamic
system to promote well‐being and resilience under stressful circumstances. Furthermore, evidence from a cross‐lagged
panel longitudinal study suggests that lack of self‐compassion may increase vulnerability to depressive symptoms
(Krieger et al., 2016).
To date, clinicians and researchers have designed many promising interventions with the goal of strengthening the skill of
self‐compassion for both community and clinical samples, with a meta‐analysis of 27 randomized controlled trials showing
moderate effect size for depressive symptoms (Ferrari et al., 2019). The way in which increasing self‐compassion in these
interventions results in decreased depressive symptoms is theorized to be through increasing emotion regulation and
lowering fears of self‐compassion and negative self‐relational processes (i.e., self‐criticism, perfectionism, and shame‐
proneness) (Finlay‐Jones, 2023). In adolescents, one mechanism of change that is theorized is self‐criticism, and youth
indicated as such in a qualitative study; additionally, they indicated that they would likely engage in an intervention that
focused on lessening self‐criticism (Egan et al., 2022).
A self‐compassion intervention for adolescents that teaches how to decrease self‐criticism and cultivate self‐
compassion is Mindful‐Self‐Compassion for Teens (MSC‐T), previously called Making Friends with Yourself, a
mindfulness‐based self‐compassion group program designed specifically for adolescents based on Neff's
conceptualization of self‐compassion. The MSC‐T curriculum, which includes didactics, group discussion, art, and
developmentally appropriate activities, is not restricted to clinical samples and has been shown to be feasible,
acceptable, and associated with decreases in depressive symptoms (Bluth & Eisenlohr‐Moul, 2017; Bluth
et al., 2016a, 2023).
However, despite promising initial findings, there is limited ability to draw conclusions about the efficacy
of MSC‐T in preventing depression. First, previous studies of MSC‐T did not include as eligibility criteria having
depressive symptoms (Bluth & Eisenlohr‐Moul, 2017; Bluth et al., 2016a, 2023), and therefore it is unclear whether
MSC‐T was contributing to decreasing depressive symptoms and also whether MSC‐T would be feasible for
adolescents with depressive symptoms. Second, follow‐up assessments were limited, and booster sessions were not
implemented. Booster sessions have been shown to increase the efficacy of an intervention in numerous
studies, including improving the recovery rate of those who remained depressed at the end of the acute stage in
an adolescent depression intervention (Clarke et al., 1999). Third, the evidence to date for MSC‐T and other self‐
compassion interventions for adolescents is derived from small, single‐armed studies or randomized studies that
utilize a waitlist control. Adequately powered randomized controlled trials, in which MSC‐T is compared with an
active control group, are needed to confirm that strengthening self‐compassion skills leads to decreased depression
and improved well‐being (Egan et al., 2022). However, the development of a feasible and credible control group that
mimics the nonspecific components of the intervention (e.g., schedule and duration of practice, therapeutic
environment, and social support) while avoiding the intervention's unique “active” ingredients has been challenging
for mind‐body interventions and complex psychosocial interventions in general (Aycock et al., 2018; Kinser &
Robins, 2013).
Additionally, research on adolescent depression interventions has identified several key issues within the field.
Interventions that target adolescents who are at high risk for depression, as opposed to a universal approach, alleviate the
significant future burdens and have been identified as a cost‐effective effective public health approach (Ssegonja et al., 2019).
Researchers have also identified the need to explore and address trajectories of symptoms postintervention, as well as ways to
mitigate waning intervention effects over time. Thus, examining self‐compassion interventions in adolescents at high risk of
depression and over extended time periods is a priority.
To begin to address these gaps, this study has the following aims: (1) using implementation and satisfaction data, examine
and compare the feasibility and acceptability of MSC‐T with a newly developed group‐based Healthy Lifestyles (HL)
educational control program for adolescents with subsyndromal depression; (2) examine time to incident depression at
6‐months postprogram completion in the adolescents assigned to MSC‐T, as compared to the adolescents in the HL control
program; and (3) examine the trajectory of depressive symptoms and self‐compassion scores over time between the two
groups. We hypothesize that (1) MSC‐T will be feasible and acceptable for adolescents with subsyndromal depression; (2) the
HL group will evidence a significantly shorter time to incident depression at 6‐months postprogram compared to the MSC‐T
group, and (3) depressive symptoms will evidence a greater decrease and self‐compassion will evidence a greater increase in
the MSC‐T group.
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JOURNAL OF ADOLESCENCE | 325

TABLE 1 Demographic information.

MSC‐T HL
Age (mean, SD) 15.81 (1.08) 15.60 (0.93)

Race

White 60% 70%

Black 10% 7%

Asian 13% 10%

More than one race 10% 10%

Prefer not to answer 3% 3%

Armenian 3% N/A

Ethnicity

Hispanic 7% 13%

Not Hispanic 90% 83%

Sex (female) 70% 70%

Note: There were no significant between‐group differences in age, t = −.79599, df = 56.792, p‐value = .4294, race, χ2 (df = 3) = 0.68, p = .88, and ethnicity, χ2 (df = 2) = 0.74, p = .69.
Abbreviations: HL, healthy lifestyles; MSC‐T, Mindful‐Self‐Compassion for Teens; SD, standard deviation.

2 | METHOD

2.1 | Participants
Participants were 59 adolescents with subsyndromal depression who were randomized to and attended at least one session of
either the MSC‐T program (N = 30) or the HL program (N = 29). Three cohorts of simultaneously running programs were
offered. Cohort 1 began in October 2018, Cohort 2 began in January 2019, and Cohort 3 began in October 2019. See Table 1
for demographic details by group.

2.2 | Procedures
All procedures were approved by the North Carolina‐Chapel Hill IRB. Participants were recruited to participate in a
study testing two stress management and resilience programs from the community via three primary ways: (1) referrals
from local guidance counselors and school personnel; (2) flyers posted in local schools and community settings (e.g.,
e‐flyers to local high school list serves, university and community boards in locations that provide services to teens and
to the community at large (e.g., libraries and coffee shops); (3) in person recruitment at community events, youth
programs (e.g., local teen centers), and an information table set up at a local high school during lunch hour. Interested
parents or adolescents contacted the study team through a study phone number, email, and/or through completing an
interest form on a secure study website.
Once connected to the study team, screening for eligibility occurred through a two‐step process. After verbal consent
from parents and adolescents for screening, high school students aged 13–17 with an internet‐enabled device were assessed
for subsyndromal depression using the Quick Inventory of Depression Symptomology (QIDS) screening questionnaire
(Trivedi et al., 2004), with a minimum score of 6 required for eligibility. This screening threshold was determined by the level
indicated for minimal mild depressive symptoms (Rush et al., 2003). After the initial screening, the parents/guardians
provided full consent and permission; adolescents also provided assent.
Next, adolescents met face‐to‐face with the study mental health team for a second eligibility process using the Diagnostic
Interview Schedule for Children (DISC‐IV) (Shaffer et al., 2000). Adolescents with major depression, active substance use
disorder and/or suicidal ideation, schizophrenia, bipolar disorder, severe autism or developmental delay, or those who had a
psychiatric hospitalization within the past 6 months were ineligible to participate. Participants who met all study criteria were
considered officially enrolled and completed baseline measures.
After approximately 15 eligible adolescents were enrolled and completed baseline measures, they were randomized to
either the intervention or control programs using a random numbers generator with a permuted block design (blocks of 2–4)
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326 | BLUTH ET AL.

to ensure that the numbers of participants allocated to the two arms over time were equal. Randomization was stratified by
gender. In all, three cohorts were randomized.
Both the MSC‐T intervention and HL active control program met in person, after school in a community setting
(i.e., a building on a local college campus for main 8‐week programs), for one 90‐min weekly session over 8 weeks. The
two programs were held on opposite sides of a large, multiclassroom building, and were timed to start 30 min apart, so
that the participants would not inadvertently encounter a participant who was attending the other program. The
sessions were audio‐recorded for fidelity assessment by a research team member. Both programs were co‐led by a
trained instructor and a mental health provider. A mental health provider was also present in each group session;
these were psychologist/social work interns or school counselors who work with adolescents. Their role was to
monitor for any mental health concerns during sessions and connect participants with the study mental health team as
needed.
For MSC‐T, the trained instructor completed a 6‐day intensive training to teach MSC‐T and 10 peer consultation
sessions offered through the Center for Mindful Self‐Compassion (www.centerformsc.org), a nonprofit organization
whose mission is to disseminate self‐compassion programs globally. The instructors were a former middle school
teacher, a middle school counselor, and a certified instructor of MSC‐T, all of whom had experience teaching
adolescents in groups. For the HL group, the trained instructor was either a health behavior specialist, a preventive
medicine specialist, or a high school teacher with experience teaching health‐related curricula. All instructors had
experience teaching adolescents and completed a 2‐h training process where the study team reviewed the curriculum
and course expectations with the instructors. Additionally, the study team emphasized the importance of not
mentioning any aspects of self‐compassion (i.e., mindfulness, common humanity, and self‐kindness) to the adolescent
participants.
In addition, monthly 90‐min booster sessions occurred for the 6 months after each 8‐week program. The purpose of these
sessions was to review skills and to encourage continued practice of skills learned in each program. Thus, adolescents who
completed the study were enrolled for approximately 8 months and were compensated up to $175 for completing
questionnaires. They were not compensated for attending program sessions. Also, parents were compensated up to $175 for
travel and parking costs.

2.2.1 | MSC‐T intervention group

Adolescents participated in 8 weekly after‐school sessions that included group discussions, exercises, guided meditations, and
practices designed to increase adolescents' skill in responding to difficulties with self‐compassion (see Table 2).

TABLE 2 MSC‐T intervention group.

Session 1: Participants are introduced to the concepts of mindfulness and self‐compassion and participate in a guided
Discovering mindful meditation. Through a hands‐on exercise, participants become familiar with the concept that we treat
self‐compassion ourselves more harshly than we treat our friends in times of difficulty.

Session 2: The concept of mindfulness is discussed. Participants experience mindfulness through sound meditation,
Paying attention on purpose eating meditation, and a body scan guided practice.

Session 3: The concept of kindness is introduced along with practices to cultivate kindness towards “someone who makes
Kindness you smile” as well as to oneself.

Session 4: Participants engage in an exercise which elucidates how to motivate oneself with compassion rather than with
Self‐compassion self‐criticism. Music meditation is introduced.

Session 5: The similarity and differences of these two ways of relating to oneself are presented. The concept of common
Self‐compassion versus self‐esteem humanity is illustrated through two separate exercises.

Session 6: Adolescents participate in an exercise which allows them to become more familiar with their core values, as
Living deeply well as with obstacles that may prevent them from living in accord with their core values.

Session 7: Adolescents are taught specific tools to deal with particularly emotionally challenging situations, i.e., those that
Managing difficult emotions potentially could increase anxiety or depression.

Session 8: The focus of this session is on how to integrate savoring, gratitude and self‐appreciation practices into daily life.
Embracing your life Wrap‐up of the program also includes writing a letter to oneself which includes what they would like to
remember about the program.

Note: Bluth (2017, 2020).

Abbreviation: MSC‐T, Mindful Self‐Compassion for Teens.
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JOURNAL OF ADOLESCENCE | 327

TABLE 3 Healthy lifestyles control group.

Session 1: The science of sleep and its effects on brain health. Participants watched brief video presentations, followed by
Sleep hygiene discussions on their own sleep habits and their experiences of sleep's impact on their well‐being.

Session 2: Eating well for a healthy body and healthy mind. Participants received didactic instruction on the role of nutrition on
Nutrition maintaining a healthy mind and body and participated in hands‐on activities involving preparing healthful foods
and beverages.

Session 3: Getting moving to feel better. Participants received didactic instruction on the role of exercise in enhancing
Exercise emotional and physical well‐being and learned and engaged in dance‐related activities from various decades.

Session 4: Overcoming School Stress. Participants discussed stress, its role in health and illness, and explored healthy strategies
Academic Stress for overcoming school‐related stress.

Session 5: Instagram, Twitter and beyond: How to manage this in your life without its overtaking your life. Participants watched
Social Media a brief video presentation on the role of social media in health, discussed their own habits related to social media,
and explored ways to manage use of social media in a healthy way.

Session 6: Shaping your Environment. Participants explored the role of creativity in mental and physical health, engaged in
Creativity creative activities and discussed personal creative endeavors.

Session 7: Exploring your Identity. Participants watched a brief video and explored the dynamics of diversity, via games and
Diversity discussion.

Session 8: Engaged Citizenship. Participants discussed the role of community service in enhancing mental and physical well‐
Community Service being and worked together to explore models for community engagement activities.

2.2.2 | HL control group

Adolescents participated in 8 weekly evening sessions that included group discussions, activities, and short video clips
designed to increase adolescents’ ability to maintain a healthy lifestyle. The weekly session content was initially developed
and piloted at beginning of the study (see Table 3).

2.3 | Measures
2.3.1 | Feasibility and acceptability measures

Feasibility measures were (1) attendance in main program by group; (2) attendance in booster sessions by group; (3)
retention by group, as measured by the percent of participants who stayed in program to completion.
Acceptability was assessed via the following two measures:

Feelings about the class (FATC)

Participants in each group completed a questionnaire that was developed for Gregory Clarke's “Coping with Stress” program,
with permission from the author (Clarke & Lewinsohn, 1995). This questionnaire was designed to assess participants' feelings
about the instructors and other class participants as well as overall satisfaction with the program. It was administered
electronically at the last session for both programs. Items 2, 3, and 4 were selected for analysis, as these three items were the
most representative of acceptability of the content of the intervention as well as feelings about the group itself. These
multiple‐choice items were: (1) How well do you like the group you are in (five responses ranged from “very much” to
“dislike it very much,” (2) If some members of your group decided to quit the class, would you like a chance to talk them out
of it (five responses ranged from “I would try very hard to persuade them to stay” to “I would definitely not try to persuade
them to stay”, and (3) Do you feel that working with your group helped you to meet most of your goals about preventing
depression? (five responses ranged from “Definitely” to “Definitely not”). The mean of the three items ranged from 1 to 5.
Cronbach α was .79 in this study for the three items.

Expectations of benefit/credibility (CRED)

This instrument, administered at the end of the first class, provides an assessment of expectation of benefit and credibility of
each intervention using an adaptation of a validated scale previously developed for psychological studies for purposes of
comparing two treatment arms (Borkovec & Nau, 1972). Participants respond to 6 items on a 9‐point scale ranging from 1
(not at all) to 9 (very much). The mean of the three items ranged from 1 to 9. Examples of items are “How much does what's
being taught in this course make sense to you in helping to you deal with teen issues?” and “How confident are you in
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328 | BLUTH ET AL.

recommending this course to a friend?” Content validity has been confirmed for the original and a modified version (Mertens
et al., 2017). Internal reliability is good with α from .84 and .85, and test‐retest reliability over 1 week has been established
(Devilly & Borkevec, 2000). Modified versions have been used with adolescents (e.g., Bluth et al., 2016b; Larsson et al., 1987)
and children (March et al., 2008). Internal consistency in this study was α = .86.

2.3.2 | Fidelity measures

MSC‐T rating instrument

Checklists were created for each of the eight sessions of the MSC‐T curriculum. Each session checklist contained the
prescribed elements of that session; that is, the key elements (i.e., meditations, topics, exercises) of the session. For example,
Session 5 had six prescribed elements: (1) Art Activity: Mindful Bowls, (2) Opening meditation: A Person Just Like Me, (3)
Topic: Self‐Compassion versus Self‐Esteem, (4) Informal Movement Practice: Crossing the Line, (5) Exercise: Japanese Bowls,
and (6) Home Practice discussion. For each prescribed element, the following rating scale was used: 0 (no evidence of that
element within the session), 1 (slight evidence), and 2 (definite evidence). See Supporting Information: File S1 for sample
MSC‐T fidelity rating instruments.

HL rating instrument
Checklists for the eight HL sessions were created similarly to that of the MSC‐T sessions. In addition to the key prescribed
elements in each session, proscribed elements were also included; these were elements that were not to be mentioned during
the session because they overlapped with one of the key self‐compassion components. For example, there were five prescribed
elements in Session 6: (1) The Story Game, (2) Why Be Creative, (3) Galaxy Jars, (4) Finger Knitting, (5) Reflection and
Discussion, and three proscribed elements in Session 6: (1) Elements of Mindfulness: Discussion of awareness of present
moment experience, nonjudgment/acceptance of present moment experience, letting go of whatever is upsetting you,
mindfulness or meditation; (2) Elements of self‐kindness: Suggestions relating to taking care of oneself, being kind to oneself,
and engaging in self‐soothing behaviors; (3) Common Humanity: Asking “Do others feel this way?” or “Have others
experienced this?”, encouraging sharing of emotional experiences (e.g., anxiety, depression, mood swings, and worry). For
each element, the following rating scale was used: 0 (no evidence of that element within the session), 1 (slight evidence), and
2 (definite evidence). See Supporting Information: File S2 for sample HL fidelity rating instruments.
A research team member evaluated the fidelity by using a random number generator to select a sample of 10 audio‐
recorded sessions for rating (5 MSC‐T sessions and 5 HL sessions, representing 21% of all sessions). To ensure a
representative sample, recordings from different session numbers and instructor teams were rated. A fidelity score for
prescribed elements was calculated by dividing the number of elements covered in the session by the total number of
elements. A higher percentage indicates higher fidelity for prescribed elements. A fidelity score for proscribed elements was
calculated by dividing the total number of proscribed elements mentioned in the sessions by the total number of proscribed
elements. A lower percentage indicates higher fidelity for proscribed elements.

2.3.3 | Outcome measures

PROMIS Pediatric Depression Short Form

The PROMIS Pediatric Short Form (Irwin et al., 2010) is a brief 8‐item survey designed to assess depression and was
administered to participants once weekly throughout the 36 weeks. This scale assesses both cognitive and affective depressive
symptoms (i.e., sadness, loneliness, worthlessness) over the past 7 days; items are reported as t‐scores, which are centered
around a mean of 50 and a SD of 10. Internal consistency and test‐retest reliability are high (Varni et al., 2014). The
American Psychological Association recommends a score between 60 and 70 to indicate moderate depression, and scores
over 70 to indicate severe depression, as stated in the DSM‐5 (Diagnostic and Statistical Manual of Mental Disorders, 2013).
For the current study, it was agreed that a cut‐off score of 65 (93rd percentile) would be appropriate. This scale was
administered at baseline and then weekly throughout the 36‐week study.

Self‐Compassion Scale (SCS)

On this 26‐item scale (Neff, 2003), participants indicated their responses to each item using a 5‐point scale ranging from 1
(almost never) to 5 (almost always). Construct validity was established through expected correlations with the self‐criticism
subscale of the Depression Experience Questionnaire, the Social Connectedness scale, and the attention, clarity, and repair
subscales of the Trait‐Meta Mood Scale. Convergent and divergent validity were established (Cunha et al., 2016) via positive
correlations with the Early Memories of Warmth and Safeness scale (Richter et al., 2009) and negative correlations with
psychopathology symptoms using the DASS‐21 (Lovibond & Lovibond, 1995). Cronbach alphas in previous scales with
 10959254, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jad.12277 by Rmit University Library, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
JOURNAL OF ADOLESCENCE | 329

adolescent samples range from .78 to .90 (e.g., Barry et al., 2015; Bluth & Blanton, 2014; Neff & McGehee, 2010; Tanaka
et al., 2011). Internal consistency in the current study was found to be excellent (α = .93). Participants completed this
questionnaire at five time points: preintervention, mid‐point of intervention, postintervention, 3 months postintervention,
and 6‐months postintervention.

2.4 | Statistical analyses

Time to incident depression was examined using exploratory nonparametric (Kaplan–Meier plots) and semi‐parametric
analyses (Cox proportional hazards models). To account for the missing values, a multiple imputation was conducted
with R MICE (Multivariate Imputation by Chained Equations) package using PMM (predictive mean matching) method
(Van Buuren & Groothuis‐Oudshoorn, 2011). Ten multiply imputed datasets were created. Next, a linear mixed‐effect
model was performed to compare the different trajectories of change in the PROMIS depression t‐score and the self‐
compassion score over time by the group using the lme4 package (Bates et al., 2015). Participants' IDs were entered as a
random intercept to account for the within‐subject correlations. The possible random effect of the cohort was also
accounted for in the model. Facilitators were included in the model as random effects nested in groups. The fixed effects
were comprised of time, group, as well as the interaction between time and group. The variable of interest was time and
group interaction which indicates the difference in the rate of change over time by group. Significance was calculated
using the lmerTest package (Kuznetsova et al., 2017). The model specification was as follows: outcome − time ×
group + (1|ID) + (1|Group/instructor) + (1|cohort).

3 | RE SULTS

3.1 | Feasibility
Attendance rates for the 8‐week main intervention sessions were similar between groups. Seventy‐three percent (73%)
of participants in the intervention group attended at least 6 of 8 weekly program sessions, as compared to 74% of
participants in the control group. However, attendance rates for the monthly booster sessions were much lower, with
47% of intervention group participants and 39% of control group participants attending at least 4 of 6 monthly
sessions.
Retention rates were also similar for both groups (see Figure 1 consort). After randomization, both groups had low
attrition rates, with only one participant notifying study personnel that they were withdrawing from the control group after
having started the course sessions, indicating that they found the content repetitive with a school health class. Therefore,
retention rate was 100% in the MSC‐T group and 97% in the HL group.

3.2 | Acceptability
A linear regression model was used to test whether there was a significant difference between groups in the CRED and FATC.
The results showed that there was no significant difference between groups in either CRED, t = 1.11, df = 46.89, p = .27,
Cohen's d = .31 (M = 6.26, SD = 1.44 for the MSC‐T, and M = 6.66, SD = 1.20 for HL), or FATC, t = 1.47, df = 38.74, p = .15,
Cohen's d = .45 (M = 2.25, SD = 0.78 for MSC‐T, and M = 2.63, SD = 0.95 for HL). Thus, both groups were considered equally
acceptable.

3.3 | Fidelity
Five randomly selected intervention session audio recordings (including at least one session from each cohort) were reviewed
and assessed for adherence to 32 prescribed elements on a scale of 0 (no evidence) to 2 (definite evidence). Ratings indicated
adherence to prescribed elements for the intervention group was 62/64 (97%).
Five randomly selected control session audio recordings (including at least one session from each cohort) were reviewed
and assessed for adherence to 33 prescribed elements and 45 proscribed elements on a scale of 0 (no evidence) to 2 (definite
evidence). Ratings indicated adherence to prescribed elements for the control group was 66/66 (100%), while inclusion of
proscribed elements was 3/45 (7%).
 10959254, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jad.12277 by Rmit University Library, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
330 | BLUTH ET AL.

FIGURE 1 Consort diagram.

3.4 | Time to incident depression

A log‐rank test showed a significant difference between the MSC‐T group and the control group, X2 (1, N = 60) = 4.7, p = .03. Overall,
the risk of developing depression at any time point was significantly higher for the control group compared to the MSC‐T group. The
Kaplan–Meier plot and the risk table confirm the different numbers of incident depression between the two groups (Figure 2). The
median survival time, the length of time when the number of participants still without moderate depression reaches 50%, was 31.85
weeks for the HL group. The MSC‐T group did not reach the median survival time, meaning over 50% of the participants remained
undiagnosed with depression by the end of the study (36 weeks). Seven participants in the MSC‐T group and 15 participants in the
HL group developed depression. Finally, the Cox regression showed that the risk of developing depression was HR = 2.60 times
higher for the control group compared to the MSC‐T group, coef = −0.96, SE = 0.46, p = .037.

3.5 | Trajectories of depressive symptoms and self‐compassion

A linear mixed‐effect model on depression t‐score showed that the time × group interaction was significant, β = −.16,
z = −3.11, p = .002. This means that the depression t‐score decreased at a higher rate over time in the MSC‐T group compared
to the HL group (Table 4). The two groups started to diverge from the beginning of the study, and their level of depression
became significantly different from around month 5 till the end of the study. There was no significant effect of time, β = .02,
z = .44, p = .66, and no significant group difference at baseline, β = −.23, z = −.09, p = .93 (see Figure 3).
A linear mixed‐effect model on the self‐compassion score showed that there was no significant time and group interaction
effect, meaning there was no significant difference in the trajectory of change in self‐compassion between the groups over
time, β = −.003, z = −.39, p = .70. There was significant time effect, at week 9 and week 23, β = .36–.55, z = 2.14 – 2.80,
p = .032–.005, indicating that self‐compassion increased significantly in both groups during intervention. There was no
significant difference in baseline self‐compassion between the groups, β = .04, z = .19, p = .85.
 10959254, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jad.12277 by Rmit University Library, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
JOURNAL OF ADOLESCENCE | 331

F I G U R E 2 Kaplan–Meier plot of time to incident depression using PROMIS depression scale, by group. The events are defined as the incident of first
depression, which was diagnosed using the PROMIS depression scale. The blue line indicates the MSC‐T group, and the red line indicates the HL control
group. HL, healthy lifestyles; MSC‐T, Mindful Self‐Compassion for Teens.

TABLE 4 Mixed‐effect model results on depression (PROMIS) and self‐compassion.

Outcomes β 95% CI z p‐Value
PROMIS t‐score

Time .02 [−0.05, 0.08] .43 .67

Baseline group (MSC‐T) .20 [−2.89, 3.29] .13 .90

Time × Group (MSC‐T) −.17 [−0.26, −0.08] −3.63 <.001

Self‐compassion

Time .01 [0.00–0.02] 2.40 .02

Baseline group (MSC‐T) .03 [−0.32, 0.39] .18 .86

Time × Group (MSC‐T) .00 [−0.02, 0.01] −.66 .51

Abbreviations: CI, confidence interval; MSC‐T, Mindful Self‐Compassion for Teens.

4 | DISCUSSION

This study sought to examine the feasibility, acceptability, and course of development of depression of a group‐based self‐
compassion intervention compared to an active healthy lifestyles education control intervention targeting adolescents with
subsyndromal depression. To our knowledge, this is the first study to explore whether self‐compassion skills can prevent the
development of clinically significant depression in high‐risk adolescents when compared to active control, as well as explore
the trajectories of depressive symptoms and self‐compassion in both groups longitudinally over a 36‐week period.
 10959254, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jad.12277 by Rmit University Library, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
332 | BLUTH ET AL.

F I G U R E 3 A mixed‐effect model predicted change in PROMIS depression t‐score over time for the MSC‐T and the HL group. HL, healthy lifestyles;
MSC‐T, Mindful Self‐Compassion for Teens.

To answer our first research question, which examined feasibility and acceptability of the two interventions, we assessed
attendance/retention data and acceptability data. Regarding feasibility, both groups had low attrition (only 1 participant
withdrew) and good attendance during the main intervention period (8 weeks). Specifically, approximately 75% of both
MSC‐T participants and HL participants attended at least six of eight main intervention sessions. Seventy‐five percent
attending at least 75% of sessions is similar to other in‐person adolescent interventions which found attendance to be
70%–75% (Chadi et al., 2016; Kohut et al., 2020; Mendelson et al., 2010; Sibinga et al., 2008, 2011). However, attendance
waned significantly across the 6 months postintervention booster sessions for both groups, with less than 50% of participants
in each group attending at least 4 of 6 monthly booster sessions. It may be that monthly booster sessions are not a priority for
busy adolescents who have already completed the “main” program. Also, once‐a‐month sessions may be spaced too far apart
to maintain a feeling of connection to the group or maybe less engaging given the topics often covered previously learned
material. Future studies should examine how dose impacts outcomes, discerning benefits of and number of booster sessions
needed for optimal impact. Qualitative data gathered through interviews or focus groups can ascertain reasons for lack of
attendance at booster sessions and can inform the necessity, form, and structure of booster sessions. For example, it may be
that conducting the booster sessions in a different format, such as virtually, would better meet the needs and interests of
adolescents, particularly given the convenience and familiarity of such formats. These virtual sessions could be held either
monthly for an hour or bi‐weekly or weekly for a shorter length of time, such as 15–20 min. Having more booster sessions
that are shorter and more frequent might be more developmentally appropriate for adolescents. Qualitative data would be
helpful in answering these questions. Finally, acceptability measures were equivalent between groups, suggesting that
adolescents found the content of the two programs equally interesting and expected similar benefits from them.
To address our second research question, which compared probability and rate of developing depression in MSC‐T and
the HL groups, we used Kaplan–Meier plots and Cox regression. We found adolescents in the HL control group were over
twice as likely to develop clinically significant depression over the course of the study's 36‐week period compared with
adolescents in the MSC‐T group. These findings are on par with results noting the efficacy of cognitive‐based interventions
for high‐risk adolescents (Clarke et al., 2001; Garber et al., 2009); follow‐up studies with larger sample sizes should be
conducted to confirm these findings. Given that self‐compassion interventions are inexpensive, scalable programs offered
outside of the mental health system (e.g., see Finlay‐Jones, 2023; Neff, 2023a), and therefore do not carry the stigma of seeing
a therapist (Kaushik et al., 2016), and can be taught by instructors with a wide range of backgrounds, these findings suggest
self‐compassion programming may be a highly promising public health tool to address the youth mental health crisis.
 10959254, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jad.12277 by Rmit University Library, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
JOURNAL OF ADOLESCENCE | 333

To address our third research question, which examined trajectories of depression and self‐compassion over time, we
inspected weekly PROMIS depression scores and self‐compassion scores over five‐time points across the 36‐week study
timeframe in both groups. We found significant differences in changes in depression scores over time between the HL control
group and the MSC‐T group. The HL group showed increases in depression scores over time, in contrast to the MSC‐T
group, which evidenced decreased depression scores over time. The decrease in depression is similar to that found in other
studies of MSC‐T (Bluth et al., 2023). Meanwhile, the increase in depression scores for the HL group over time is expected,
given the natural course of subsyndromal depression. It is interesting to note that the depression scores between the MSC‐T
group and the control continued to diverge postprogram, even though the participants did not regularly attend booster
sessions. This is not unexpected as it has been noted in other studies (Guo et al., 2020; Neff & Germer, 2013). It may be that
learning self‐compassion initiates a perspective shift that becomes clearer and more pronounced over time; in the months
after the program is over, the individual becomes increasingly aware of the many times in their daily lives when they are self‐
critical, and in these moments, draws on self‐compassion. This activation of one's self‐compassion may then elicit less self‐
criticism or other negative self‐relational processes, which is then linked with decreased depression.
Contrary to expectation, self‐compassion scores increased by a similar amount in both groups.
One possibility for this finding is that the HL curriculum indirectly overlapped with key aspects of the MSC‐T
curriculum. The developers and instructors of the HL attention‐control intervention were careful to avoid any overlap in
content between this course and MSC‐T; in fact, instructors were told explicitly to avoid any mention of mindfulness or
compassion. Nonetheless, it is possible that aspects of self‐compassion were inadvertently conveyed or naturally emerged
from engaging in group discussions about lifestyle topics. For example, as control group participants learned about healthy
ways to engage in social media or ways to manage academic stress, participants may have become more aware of their
feelings around these topics and felt more connected to peers who also struggle in these areas despite the fact that discussions
about feelings or about common humanity were not explicitly elicited.
As other examples, participants discussing how exercise (or lack thereof) impacts them physically and mentally and
sharing ideas on ways to increase their activity levels in daily life clearly offered insight on ways to take care of themselves
(e.g., self‐kindness). Also, when discussing academic stress, some participants agreed with one another about difficulties
associated with the pressure to take demanding course loads, thus evoking common humanity. Common humanity is a
natural outgrowth of group contexts and thus likely impossible to avoid completely. Peer groups, and the self‐awareness and
social connection that often ensues, may be a natural context for (at least some) mindfulness, common humanity, and self‐
kindness to emerge.
Interestingly, despite self‐compassion scores increasing in the control group, on average, depression scores increased over
time. This was unexpected, as previous work indicates depression and self‐compassion are inversely related. Although the
reasons for this result are unclear, it is plausible that the HL curriculum implicitly impacted some of the six individual
components of self‐compassion, leading to a rise in the total self‐compassion score, but without the same mental health
benefits associated with explicit, holistic self‐compassion training. Improvement in the individual components, however, may
not have impacted depression symptoms as they did not function as an interactive, synergistic system designed to cultivate
increases in the three compassionate components (mindfulness, common humanity, and self‐kindness) and decreases in the
three uncompassionate components (overidentification, isolation, and self‐criticism) of self‐compassion (Neff, 2023b).
In addition to the need to consider control group modifications, there are several other limitations that can be addressed
in future work. First, because this was a pilot examining feasibility and acceptability of two interventions for adolescents with
subsyndromal depression, the sample size was intentionally small; it also included primarily female‐identifying White
participants. A study with a larger, more heterogeneous sample is essential to confirm these results and expand
generalizability. Additionally, the current study design does not allow examination of the impact of booster session
attendance; in fact, findings suggest participants improved despite poor attendance. Future work in this area could examine if
booster sessions are beneficial and for whom using techniques such as SMART (sequential, multiple assignment, and
randomized trials) (Dai & Shete, 2016). If boosters do prove beneficial, qualitative data could be used to examine how to
improve booster participation. Finally, future studies can explore subscale analysis of the individual components of the self‐
compassion scale in both the intervention and control groups to answer the question as to what aspects of self‐compassion
are responsible for the increase in self‐compassion evidenced in this study.
Despite these limitations, the results of this study suggest that the MSC‐T curriculum is a promising depression
prevention program for youth with subsyndromal depression symptoms, as participation prevented progression to clinically
significant depression compared to a credible, feasible, and acceptable active control condition. MSC‐T is considered more
accessible than most therapeutic options because it can be offered in communities and school settings by a range of providers,
not just psychologists (Finlay‐Jones, 2023). Moreover, while self‐compassion has many clinical applications (Gilbert &
Procter, 2006), MSC‐T is suitable for use in nonclinical samples as well and, importantly, does not carry the stigma of
“mental illness” or the perceived pathology of “seeing a therapist.” Given this flexibility, continued exploration of MSC‐T to
address the mental health needs of youth is warranted.
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334 | BLUTH ET AL.

ACKNOWLEDGMENTS
This work was made possible through the support and hard work of many, including biostatisticians Chirayath M
Suchindran and Keturah Faurot, and research assistants Nandie Elhadidy, Michael Hearn, Zayne Dadressen, and Chloe
Brown. Thank you to the clinical staff members who completed eligibility reviews and safety checks at the AHB Center for
Behavioral Health and Wellness. We also greatly appreciate all our adolescent participants. This study was funded by a grant
1 R34 AT008822‐01A1from NCCIH/NIH.

CONFLICT OF INTERE ST STATEMENT

Author K. B. declares she receives compensation to teach and train teachers in the MSC‐T curriculum. All other authors have
no conflicts to declare.

DATA AVAILABILITY STATE MENT

The data that support the findings of this study are available from the corresponding author upon reasonable request. The
data that support the findings of this study are available from Dr. Susan Gaylord gaylords@med. unc. edu upon reasonable
request.

ETHICS STATE MENT

This study was approved by the UNC IRB, number 16‐1864, and is listed on clinical trials number NCT03270943.

ORCID
Karen Bluth http://orcid.org/0000-0001-7535-6405

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S U P P OR T I N G I N F OR M A TI O N
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How to cite this article: Bluth, K., Lathren, C., Park, J., Lynch, C., Curry, J., Harris‐Britt, A., & Gaylord, S. (2024). Feasibility,
acceptability, and depression outcomes of a randomized controlled trial of Mindful Self‐Compassion for Teens (MSC‐T) for
adolescents with subsyndromal depression. Journal of Adolescence, 96, 322–336. https://doi.org/10.1002/jad.12277