Intervention Studies Supporting Positive Effects of the Program (with Abstracts)

Hart, A. et al. (2019). Decreasing Depression and Anxiety in College Youth Using the Creating Opportunities for Personal Empowerment Program (COPE). Journal of the American Psychiatric Nurses Association, 25(2), 89–98.

Abstract:

BACKGROUND: College is a time of major transition in the lives of many young adults. Roughly 30% of college students have reported that anxiety and depressive symptoms negatively affect their lives and academic functioning. Currently, anxiety has surpassed depression as the reason college students seek help at counseling centers. Unfortunately, only one third of students receive treatment for anxiety and only 25% of students receive treatment for their depression.

OBJECTIVES: The objectives of this pilot project were to (a) assess levels of depression and anxiety in identified “at risk” college students who present to the college Student Health Services (Primary Care), (b) implement a new cognitive behavioral therapy–based intervention titled “Creating Opportunities for Personal Empowerment” (COPE), and (c) evaluate the effectiveness of the intervention on students’ levels of depression and anxiety as well as satisfaction with the intervention.

DESIGN: A one group pre- and post-test design was used. Results: Students who received COPE demonstrated clinically meaningful improvement in depressive and anxiety symptoms as measured by the Beck Depression Inventory–II and the State–Trait Anxiety Inventory.

CONCLUSION: COPE is an effective brief program for reducing depression and anxiety in college-age youth. Implementation of evidenced-based programs into the college experience could lead to less severe depression and anxiety and better academic performance, ultimately increasing the likelihood of students successfully completing their academic programs.

Erlich, Kimberly J. et al. (2018). Outcomes of a Brief Cognitive Skills-Based Intervention (COPE) for Adolescents in the Primary Care Setting. Journal of Pediatric Health Care, 2018, 12.001

Abstract:

INTRODUCTION: Approximately 25% of adolescents have behavioral disorders, yet few receive treatment. Primary care (PC) screening for depression and anxiety is recommended; however treatments, such as cognitive behavioral therapy (CBT), are rarely available in PC settings. Our aim was to determine whether the use of a CBT-based intervention (COPE for Teens) is associated with improved outcomes on measures of depression and anxiety, and to understand the patient experience.

METHODS: Health record data were examined, including questionnaires on depression (PHQ-A), anxiety (GAD-7), and experience with COPE. Differences between pre- and post-intervention scores were evaluated by paired t-tests. Questionnaire data were analyzed via thematic coding.

RESULTS: Thirty-seven patients (73% female; ages 12-18) completed pre- and post-intervention measures. Comparison showed decrease in PHQ-A scores by 2.1 (p = 0.0067) and GAD-7 scores by 2.3 (p= 0.0081). Questionnaire data demonstrate satisfaction with COPE.

DISCUSSION: Among these 37 adolescents, COPE provided effective PC-based behavioral treatment and a positive experience. Increased availability of COPE could improve care for adolescents.

Melnyk, B.M., Jacobson, D., Kelly, S.A., Belyea, M.J., Shaibi, G.Q., Small, L., O’Haver, J.A., & Marsiglia, F.F.  (Just Published). Twelve-Month Effects of the COPE Healthy Lifestyles TEEN Program on Overweight and Depression in High School Adolescents. Journal of School Health.

Abstract:

BACKGROUND: We evaluated the 12-month effects of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) program versus an attention control program (Healthy Teens) on overweight/obesity and depressive symptoms in high school adolescents.

METHODS: A cluster randomized controlled trial was conducted. Participants were 779 culturally diverse adolescents in the US Southwest. COPE is a cognitive-behavioral skills-building intervention with 20 min of physical activity integrated into a health course and taught by teachers once a week for 15 weeks. Outcome measures included body mass index (BMI) and depressive symptoms.

RESULTS: COPE teens had a significantly lower BMI at 12 months (F1,698 = 11.22, p = .001) than Healthy Teens (24.95 versus 25.48). There was a significant decrease in the proportion of overweight and obese COPE teens from baseline to 12 months (χ2 = 5.40, p = .02) as compared with Healthy Teens. For youth who began the study with extremely elevated depressive symptoms, COPE teens had significantly lower depression at 12 months compared with Healthy Teens (COPE M = 42.39; Healthy Teens M = 57.90); (F1,12 = 5.78, p = .03).

CONCLUSIONS: COPE can improve long-term physical and mental health outcomes in teens.

Kozlowski, J., Lusk, P, & Melnyk, B.M. (2015). Pediatric nurse practitioner management of child anxiety in the rural primary care clinic with the evidence-based COPE. Journal of Pediatric Health Care, 29(3), 274-282.

Abstract:

INTRODUCTION: Anxiety is the most common mental health disorder in children. Many communities have shortages of mental health providers, and the majority of children with anxiety are not receiving the evidence-based treatment they need. The purpose of this pilot study was to assess the feasibility and effects of a brief seven-session cognitive behavioral skills-building intervention, Creating Opportunities for Personal Empowerment (COPE), which was delivered to anxious children by a pediatric nurse practitioner in a primary care setting.

METHODS: A pre-experimental, one-group, pretest and post test design was used.

RESULTS: Children who participated had a significant decrease in anxiety symptoms (13.88 points, SD = 17.96, 95% confidence interval [CI] =
1.13-28.89), as well as an increase in knowledge of cognitive-behavioral coping skills (M = 11.38, CI = 5.99-8.26, p = .00) and improved functioning (at school and at home). Evaluations by parents and children were positive.

DISCUSSION: COPE is a promising evidence-based intervention for children with anxiety with feasible delivery by pediatric nurse practitioners in primary care. J Pediatr Health Care. (2015).

Hickman, C., Jacobson, D., & Melnyk, B.M.  (2014). Randomized controlled trial of the acceptability, feasibility, and preliminary effects of a cognitive behavioral skills building intervention in adolescents with chronic daily headaches: A pilot study. Journal of Pediatric Health Care, 29(1), 5-16. July 10, 2014 [Epub ahead of print]. DOI: 10.1016/j.pedhc.2014.05.001

Abstract:

INTRODUCTION: The treatment challenge of adolescents with chronic daily headaches (CDHs) creates an urgent need for evidence-based interventions. Therefore the purpose of this pilot study was to evaluate the acceptability, feasibility, and preliminary effects of a brief cognitive behavioral skills building intervention with 36 adolescents, 13 to 17 years of age, who had CDHs and mild to moderate depressive symptoms.

METHODS: Participants were randomly assigned either to the Creating Opportunities for Personal Empowerment–Headache Education Program (COPE-HEP) or to a headache education comparison group.

RESULTS: Adolescents and parents found the COPE-HEP to be highly acceptable. Medium to large positive effects were demonstrated on the adolescents’ depression in both groups and on anxiety and beliefs in the COPE-HEP group. COPE-HEP offered additional benefits of a larger decrease in adolescent anxiety over time and stronger beliefs in the teens’ ability to manage their headaches.

DISCUSSION: Adolescents with CDHs and elevated depressive/anxiety symptoms should be offered headache hygiene education
plus cognitive-behavioral skills building interventions.

Melnyk, B.M., Kelly, S., & Lusk, P.  (2014). Outcomes and feasibility of a manualized cognitive-behavioral skills building intervention: Group COPE for depressed and anxious adolescents in school settings. Journal of Child and Adolescent Psychiatric Nursing, January 29, 2014. [Epub ahead of print] doi: 10.1111/jcap.12058

Abstract:

PROBLEM: Despite the increasing prevalence of depressive and anxiety disorders in adolescents, less than 25% of affected teens receive any treatment.

METHODS: A preexperimental one-group pre- and posttest pilot study design with 4-week follow-up was used to assess the feasibility and preliminary effects of the COPE (Creating Opportunities for Personal Empowerment) brief-focused manualized seven-session cognitive-behavioral skills building group intervention delivered in two high schools to 16 adolescents referred by a school-based nurse practitioner for depression or elevated anxiety symptoms.

FINDINGS: Adolescents reported significant decreases in depression and anxiety on the Beck Youth Inventory as well as increases in personal beliefs about managing negative emotions. Evaluations indicated that the group COPE intervention was a positive experience for the teens.

CONCLUSIONS: COPE is a promising brief-focused cognitive behavioral therapy based intervention that can be delivered effectively to teens in school settings using a group format.

Melnyk, B.M., Kelly, S., Jacobson, D., Arcoleo, K., & Shaibi, G. (2013). Improving physical activity, mental health outcomes and academic retention of college students with freshman 5 to thrive: COPE/healthy lifestyles. Journal of the American Academy of Nurse Practitioner, 26(6), 314-322; June 18, 2013.  [Epub ahead of print]; 

Abstract:

PURPOSE: To assess the preliminary effects of a new course entitled Freshman 5 to Thrive/COPE Healthy Lifestyles on the cognitive beliefs, knowledge, mental health outcomes, healthy lifestyle choices, physical activity, and retention of college freshmen.

DATA SOURCES: Measures included demographics, nutrition knowledge, healthy lifestyle beliefs, healthy lifestyle perceived difficulty, healthy lifestyle choices, Beck Youth Inventories-II (anxiety, depression, anxiety, and destructive behavior), step count via pedometer, and college retention.

CONCLUSIONS: The experimental COPE (Creating Opportunities for Personal Empowerment) group had greater intentions to live a healthy lifestyle (p = .02) versus the comparison group. COPE students also significantly increased their physical activity (p = .003) from baseline to post intervention and had a higher college retention rate than students who did not take the course. In addition, there was a significant decrease in depressive and anxiety symptoms in COPE students whose baseline scores were elevated.

IMPLICATION FOR PRACTICE: The Freshman 5 to Thrive Course is a promising intervention that can be used to enhance healthy lifestyle behaviors and improve mental health outcomes in college freshmen.

Melnyk, B.M., Jacobson, D., Kelly, S., Belyea, M., Shaibi, G., Small, L., O’Haver, J., & Marsiglia, F.F. (2013). Promoting healthy lifestyles in high school adolescents: A randomized controlled trial.  American Journal of Preventive Medicine, 45(4), 407-415. September 10, 2013. [Epub ahead of print] dx.doi.org/10.1016/j.amepre.2013.05.013

Abstract:

BACKGROUND: Although obesity and mental health disorders are two major public health problems in adolescents that affect academic performance, few rigorously designed experimental studies have been conducted in high schools.

PURPOSE: The goal of the study was to test the efficacy of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) Program, versus an attention control program (Healthy Teens) on: healthy lifestyle behaviors, BMI, mental health, social skills, and academic performance of high school adolescents immediately after and at 6 months post-intervention.

DESIGN: A cluster RCT was conducted. Data were collected from January 2010 to May of 2012 and analyzed in 2012-2013.

SETTING/PARTICIPANTS: A total of 779 culturally diverse adolescents in the U.S. Southwest participated in the trial.

INTERVENTION: COPE was a cognitive-behavioral skills-building intervention with 20 minutes of physical activity integrated into a health course, taught by teachers once a week for 15 weeks. The attention control program was a 15-session, 15-week program that covered common health topics.

MAIN OUTCOME MEASURES: Primary outcomes assessed immediately after and 6 months post-intervention were healthy lifestyle behaviors and BMI. Secondary outcomes included mental health, alcohol and drug use, social skills, and academic performance.

RESULTS: Post-intervention, COPE teens had a greater number of steps per day (p=0.03) and a lower BMI (p=0.01) than did those in Healthy Teens, and higher average scores on all Social Skills Rating System subscales (p-values <0.05). Teens in the COPE group with extremely elevated depression scores at pre-intervention had significantly lower depression scores than the Healthy Teens group (p=0.02). Alcohol use was 12.96% in the COPE group and 19.94% in the Healthy Teens group (p=0.04). COPE teens had higher health course grades than did control teens. At 6 months post-intervention, COPE teens had a lower mean BMI than teens in Healthy Teens (COPE=24.72, Healthy Teens=25.05, adjusted M=-0.34, 95% CI=-0.56, -0.11). The proportion of those overweight was significantly different from pre-intervention to 6-month follow-up (chi-square=4.69, p=0.03), with COPE decreasing the proportion of overweight teens, versus an increase in overweight in control adolescents. There also was a trend for COPE Teens to report less alcohol use at 6 months (p=0.06).

CONCLUSIONS: COPE can improve short- and more long-term outcomes in high school teens.

Lusk, P., & Melnyk, B.M. (2011). The brief cognitive-behavioral COPE intervention for depressed adolescents: Outcomes and feasibility of delivery in 30-minute outpatient visits. Journal of the American Psychiatric Nurses Association, 17(3), 226-236.

Abstract:

BACKGROUND: Despite a U.S. prevalence of 9%, less than 25% of depressed adolescents receive treatment because
of time constraints in clinical practice and lack of mental health providers available to deliver it.

OBJECTIVE: To assess the feasibility and effects of a brief manualized seven-session cognitive–behavioral skills building intervention entitled COPE (Creating Opportunities for Personal Empowerment) delivered to 15 depressed adolescents in routine
30-minute mental health medication management outpatient visits.

STUDY DESIGN: A pre-experimental one group pre- and post-test design was used.

RESULTS: Adolescents reported significant decreases in depression, anxiety, anger, and destructive behavior as well as increases in self-concept and personal beliefs about managing negative emotions. Evaluations indicated that COPE was a positive experience for teens and parents.

CONCLUSION: COPE is a promising brief cognitive–behavior therapy–based intervention that can be delivered within 30-minute individual outpatient visits. With this intervention, advanced practice nurses can work with practice time limitations and still provide evidence-based treatment for depressed teens.

Ritchie, T.  (2011). Evaluation of the Impact of the Creating Opportunity for Personal Empowerment (COPE) Healthy Lifestyles Thinking, Emotions, Exercise, and Nutrition (TEEN) Program in a Rural High School Health Class. (DNP Capstone Project). West Virginia University, Morgantown, West Virginia.

Abstract:

BACKGROUND: More than 12.5 million children in the United States are overweight. More specifically, in 2007, 31% of 9th grade students in West Virginia were overweight. Healthy People 2010 identified obesity as among the top ten health issues and set a goal to reduce the proportion of children and adolescents who were overweight to 5%. This goal was not attained because most current interventions to prevent and treat obesity have not been effective in changing the weight status of children and adolescents. However, cognitive behavioral interventions, combined with parent education have been found to be an effective strategy in weight loss among adolescents.

OBJECTIVES: The primary goal of this project was to increase healthy lifestyle behaviors in 9th graders in a rural health class after receiving the COPE TEEN program. Secondary outcomes included that teens would: have stronger beliefs about the ability to engage in a healthy lifestyle, perceive living a healthy lifestyle as less difficult, increase the amount of time spent in physical activity, have a higher self-esteem, lose weight if overweight at the start of the program, and that parents would be able to help their teen achieve healthy lifestyle goals. A third outcome was to determine the feasibility of this program as part of the health class curriculum in a rural high school.

DESIGN: This study used a pre-experimental design with pre- and post-testing. The COPE intervention was incorporated into the health class curriculum for ninth grade students during the 2009 fall and spring semesters. Cognitive behavior skills building (CBSB) sessions were conducted once a week for 15 weeks during the regular scheduled health class. Each weekly class involved 30 minutes of CBSB education, followed by 20 minutes of physical activity. The intervention included a parent education component by newsletter three times during the program. Pre- and post- measurements included: BMI (calculated from height and weight), BMI %, teen healthy lifestyles behavior, cognitive beliefs, perceived difficulty in leading a healthy lifestyle, self-esteem, and parent’s healthy lifestyle behaviors, beliefs, and perceived difficulty in leading a healthy lifestyle. Other data included a post-intervention exit questionnaire consisting of five open-ended questions about the participants’ perception of the helpfulness of the COPE program.

SUBJECTS: Fifty-five students began the program and forty- nine (89%) completed the entire 15 week program. All the students were enrolled in the ninth grade health class with a mean age of 14.67 years.

RESULTS: Teens healthy lifestyles behavior improved during the 15 week COPE Program with a statistically significant improvement in the students’ healthy behavior scores from Time 1 (M=51.32, SD=11.15) to Time 2 (M=57.45, SD=9.71), t (43) 3.93, p=.000 (two-tailed). There was a statistically significant difference in self-esteem of a sub-group of eight teens with low esteem at baseline. Self-esteem scores improved in this group from Time 1 (M=20.41, SD=5.98) to Time 2 (M=21.54 SD=5.63) p=.010. Although not statistically significant, there was an increase in healthy lifestyles beliefs as well as a decrease in perceived difficulty among the COPE teen participants, which resulted in positive effect sizes for the intervention. The parents of the adolescents participating in the program had increased healthy lifestyle behaviors and beliefs and a decrease in perceived difficulty to engage in a healthy lifestyle. Forty-nine percent of the students lost a total of 143.6 pounds and 6% maintained their weight. BMI % improved in seven teens resulting in them moving from a category of obese to overweight or overweight to healthy weight. Only one student had an increase in BMI %.

CONCLUSION: The COPE Program which consists of education with cognitive behavioral skills building combined with physical activity and parent newsletters is an effective strategy in improving healthy lifestyles behaviors and weight management among teens, and can be easily incorporated into the curriculum of a rural high school health class.

Melnyk, B.M., Jacobson, D., Kelly, S., O’Haver, J., Small, L., & Mays, M.Z. (2009). Improving the mental health, healthy lifestyle choices and physical health of Hispanic adolescents: A randomized controlled pilot study. Journal of School Health, 79(12), 575-584.

Abstract:

BACKGROUND: Obesity and mental health disorders are 2 major public health problems in American adolescents, with prevalence even higher in Hispanic teens. Despite the rapidly increasing incidence and adverse health outcomes associated with overweight and mental health problems, very few intervention studies have been conducted with adolescents to improve both their healthy lifestyles and mental health outcomes. Even fewer studies have been conducted with Hispanic youth. The purpose of this study was to evaluate the preliminary efficacy of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles

TEEN (Thinking, Emotions, Exercise, and Nutrition) program, a manualized educational and cognitive behavioral skills-building program, on Hispanic adolescents' healthy lifestyle choices as well as mental and physical health outcomes.

METHODS: A cluster randomized controlled pilot study was conducted with 19 Hispanic adolescents enrolled in 2 health classes in a southwestern high school. One class received COPE and the other received an attention control program.

RESULTS: Adolescents in the COPE program increased their healthy lifestyle choices and reported a decrease in depressive and anxiety symptoms from baseline to post-intervention follow-up. A subset of 7 overweight adolescents in the COPE program had a decrease in triglycerides and an increase in high-density lipoproteins. In addition, these overweight adolescents reported increases in healthy lifestyle beliefs and nutrition knowledge along with a decrease in depressive symptoms.

CONCLUSION: The COPE TEEN program is a promising school-based strategy for improving both physical and mental health outcomes in adolescents.

Melnyk, B.M., Small, L., Morrison-Beedy, D., Strasser, A., Spath, L., Kreipe, R., Crean, H., Kelly, S., & Jacobson, D. (2007). The COPE healthy lifestyles TEEN program: Feasibility, preliminary efficacy and lessons learned from an after school group intervention with overweight adolescents. Journal of Pediatric Health Care, 21(5), 315-322.

Abstract:

INTRODUCTION: There has been a paucity of theory-based interventions to improve health outcomes in overweight adolescents. Therefore, two intervention studies were conducted to: (a) determine the feasibility of implementing the Creating Opportunities for Personal Empowerment (COPE) Healthy Lifestyles Thinking, Emotions, Exercise, and Nutrition (TEEN) program with overweight adolescents; (b) obtain feedback that could be used to refine the program; and (c) examine the preliminary efficacy of the COPE program on the adolescents' weight and body mass index (BMI).

METHOD: Phase I and Phase II clinical trials were conducted with 23 overweight teens. The Phase 1 trial used a pre-experimental design with one group of 11 urban adolescents. The Phase 2 trial was conducted with 12 suburban teens using a randomized controlled pilot study. COPE teens received a 15-session cognitive-behavioral skills building program that included physical activity, while the control group received an attention control program. Weight change and BMI were the key outcomes.

RESULTS: COPE teens experienced a significantly greater reduction in weight and BMI than did teens in the control group, who gained weight over time. Although the COPE program was well received by all of the teens, retention of subjects across time and parent involvement in the program were challenges in the urban high school.

DISCUSSION: These studies provide preliminary data to indicate that the implementation of COPE is feasible and may lead to a reduction in weight and BMI in overweight teens. Implementing COPE within the context of the school day may be more successful in sustaining adolescent involvement in the program versus using an after-school format.

Ritchie, T.  (2011). Evaluation of the Impact of the Creating Opportunity for Personal Empowerment (COPE) Healthy Lifestyles Thinking, Emotions, Exercise, and Nutrition (TEEN) Program in a Rural High School Health Class. (DNP Capstone Project). West Virginia University, Morgantown, West Virginia.

Abstract:

BACKGROUND: More than 12.5 million children in the United States are overweight. More specifically, in 2007, 31% of 9th grade students in West Virginia were overweight. Healthy People 2010 identified obesity as among the top ten health issues and set a goal to reduce the proportion of children and adolescents who were overweight to 5%. This goal was not attained because most current interventions to prevent and treat obesity have not been effective in changing the weight status of children and adolescents. However, cognitive behavioral interventions, combined with parent education have been found to be an effective strategy in weight loss among adolescents.

OBJECTIVES: The primary goal of this project was to increase healthy lifestyle behaviors in 9th graders in a rural health class after receiving the COPE TEEN program. Secondary outcomes included that teens would: have stronger beliefs about the ability to engage in a healthy lifestyle, perceive living a healthy lifestyle as less difficult, increase the amount of time spent in physical activity, have a higher self-esteem, lose weight if overweight at the start of the program, and that parents would be able to help their teen achieve healthy lifestyle goals. A third outcome was to determine the feasibility of this program as part of the health class curriculum in a rural high school.

DESIGN: This study used a pre-experimental design with pre- and post-testing. The COPE intervention was incorporated into the health class curriculum for ninth grade students during the 2009 fall and spring semesters. Cognitive behavior skills building (CBSB) sessions were conducted once a week for 15 weeks during the regular scheduled health class. Each weekly class involved 30 minutes of CBSB education, followed by 20 minutes of physical activity. The intervention included a parent education component by newsletter three times during the program. Pre- and post- measurements included: BMI (calculated from height and weight), BMI %, teen healthy lifestyles behavior, cognitive beliefs, perceived difficulty in leading a healthy lifestyle, self-esteem, and parent’s healthy lifestyle behaviors, beliefs, and perceived difficulty in leading a healthy lifestyle. Other data included a post-intervention exit questionnaire consisting of five open-ended questions about the participants’ perception of the helpfulness of the COPE program.

SUBJECTS: Fifty-five students began the program and forty- nine (89%) completed the entire 15 week program. All the students were enrolled in the ninth grade health class with a mean age of 14.67 years.

RESULTS: Teens healthy lifestyles behavior improved during the 15 week COPE Program with a statistically significant improvement in the students’ healthy behavior scores from Time 1 (M=51.32, SD=11.15) to Time 2 (M=57.45, SD=9.71), t (43) 3.93, p=.000 (two-tailed). There was a statistically significant difference in self-esteem of a sub-group of eight teens with low esteem at baseline. Self-esteem scores improved in this group from Time 1 (M=20.41, SD=5.98) to Time 2 (M=21.54 SD=5.63) p=.010. Although not statistically significant, there was an increase in healthy lifestyles beliefs as well as a decrease in perceived difficulty among the COPE teen participants, which resulted in positive effect sizes for the intervention. The parents of the adolescents participating in the program had increased healthy lifestyle behaviors and beliefs and a decrease in perceived difficulty to engage in a healthy lifestyle. Forty-nine percent of the students lost a total of 143.6 pounds and 6% maintained their weight. BMI % improved in seven teens resulting in them moving from a category of obese to overweight or overweight to healthy weight. Only one student had an increase in BMI %.

CONCLUSION: The COPE Program which consists of education with cognitive behavioral skills building combined with physical activity and parent newsletters is an effective strategy in improving healthy lifestyles behaviors and weight management among teens, and can be easily incorporated into the curriculum of a rural high school health class.

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