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We used Complier Average Causal Effect (CACE) estimation to determine if dosage variability modified treatment effects of relaxation techniques and mindfulness-based exercises in the INSPIRE cluster randomised trial. Analyses were split by phase of education (mindfulness primary:\n                    <jats:italic>k<\/jats:italic>\n                    \u2009=\u200965 primary schools,\n                    <jats:italic>N<\/jats:italic>\n                    \u2009=\u20093,630 pupils; mindfulness secondary:\n                    <jats:italic>k<\/jats:italic>\n                    \u2009=\u200929 secondary schools,\n                    <jats:italic>N<\/jats:italic>\n                    \u2009=\u20093,708 pupils; relaxation primary:\n                    <jats:italic>k<\/jats:italic>\n                    \u2009=\u200966 primary schools,\n                    <jats:italic>N<\/jats:italic>\n                    \u2009=\u20093,800 pupils; relaxation secondary:\n                    <jats:italic>k<\/jats:italic>\n                    \u2009=\u200926 secondary schools,\n                    <jats:italic>N<\/jats:italic>\n                    \u2009=\u20093,252 pupils) and considered compliance effects at the 50th (moderate) and 75th (high) percentiles in the distribution of intervention dosage (total minutes delivered). Despite null intent to treat findings, we observed compliance effects for both interventions. In primary schools, moderate (320\u00a0min) and high (376\u00a0min) compliance to relaxation techniques significantly\n                    <jats:italic>reduced<\/jats:italic>\n                    depressive symptoms (\n                    <jats:italic>d<\/jats:italic>\n                    =-1.52 and\n                    <jats:italic>d<\/jats:italic>\n                    =-1.48, respectively). In secondary schools, moderate (207\u00a0min) and high (285\u00a0min) compliance to mindfulness-based exercises also significantly\n                    <jats:italic>reduced<\/jats:italic>\n                    depressive symptoms (\n                    <jats:italic>d=<\/jats:italic>\n                    -1.15 and\n                    <jats:italic>d<\/jats:italic>\n                    =-1.40, respectively). Contrastingly, in primary schools, moderate (325\u00a0min) and high (393\u00a0min) compliance to mindfulness-based exercises significantly\n                    <jats:italic>increased<\/jats:italic>\n                    depressive symptoms (\n                    <jats:italic>d<\/jats:italic>\n                    \u2009=\u20090.32 and\n                    <jats:italic>d<\/jats:italic>\n                    \u2009=\u20090.48, respectively). In secondary schools, moderate (180\u00a0min) and high (275\u00a0min) compliance to relaxation techniques also significantly\n                    <jats:italic>increased<\/jats:italic>\n                    depressive symptoms (\n                    <jats:italic>d<\/jats:italic>\n                    \u2009=\u20090.67 and\n                    <jats:italic>d<\/jats:italic>\n                    \u2009=\u20090.83, respectively). The effects of universal, school-based mental health interventions promoting relaxation and mindfulness are contingent on the delivery of a minimally effective dose. However, these interventions may not be appropriate in all educational contexts and could result in iatrogenic effects.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Trial registration:<\/jats:bold>\n                    Trial registration number: ISRCTN16386254. Trial registration date:04\/09\/2018.\n                  <\/jats:p>","DOI":"10.1007\/s00787-026-03152-x","type":"journal-article","created":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T08:27:51Z","timestamp":1786523271000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Implementation dosage and depressive symptoms following school-based mindfulness and relaxation: Complier Average Causal Effect estimation in the INSPIRE cluster randomised trial"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4623-9538","authenticated-orcid":false,"given":"Emma","family":"Thornton","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Knowles","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margarita","family":"Panayiotou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joao","family":"Santos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emma","family":"Ashworth","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carla","family":"Mason","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Hayes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abigail","family":"Thompson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica","family":"Deighton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosie","family":"Mansfield","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"March","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Stallard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neil","family":"Humphrey","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,12]]},"reference":[{"key":"3152_CR1","unstructured":"NHS Digital (2023) Mental health of children and young people in England, 2023 - wave 4 follow up to the 2017 survey"},{"issue":"7","key":"3152_CR2","doi-asserted-by":"publisher","first-page":"606","DOI":"10.1177\/0004867414533834","volume":"48","author":"W Bor","year":"2014","unstructured":"Bor W et al (2014) Are child and adolescent mental health problems increasing in the 21st century? 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Storage and processing of all research data aligned with General Data Protection Regulation legislation. Eligible schools that expressed interest in taking part, were required to have a member of their senior leadership team sign a Memorandum of Understanding, and data-sharing agreement. Informed opt-in assent and opt-out consent was obtained in writing from participating children and their parent\/legal guardian prior to baseline data collection.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}]}}