Preventive digital mental health interventions for children and young people: a review of the design and reporting of research

Patient and Public Involvement (PPI) and Responsible Research and Innovation (RRI) approaches in mental health projects involving young people: a scoping review protocol

BACKGROUND

Rather than being perceived as merely 'part of the problem', the perspectives and experiences of young people play a pivotal role in devising effective solutions for mental health challenges. Two distinct methodologies that aid in this endeavour are 'patient and public involvement' (PPI) and 'responsible research and innovation' (RRI). However, there is a tendency to conflate PPI and RRI practices, leading to ambiguity in their application. Moreover, the extent and nature of young people's involvement in mental health-related projects (namely: research, intervention, product development) employing these methodologies, and the subsequent implications thereof, remain unclear. Consequently, the proposed scoping review aims to identify and analyse literature pertaining to PPI and RRI approaches in mental health projects that engage young people in collaboration.

METHODS

The selected databases will be MEDLINE, PsycINFO, PsycArticles, Scopus, Web of Science, IBBS, CINAHL (EBSCO) and ASSIA. Comprehensive searches will span from the inception of each database. A pilot test will be conducted to assess the screening criteria and data extraction form, with two authors independently reviewing titles and abstracts. Full-text articles meeting the inclusion criteria will undergo narrative syntheses, with results presented in tabular format. Feedback on the findings from a youth perspective will be sought from young people within our broader research network, namely Sprouting Minds. The review will adhere to the guidelines outlined by the Joanna Briggs Institute (JBI) and follow the PRISMA-ScR procedures. Inclusion criteria will comprise English-language, primary research peer-reviewed articles focused on Patient and Public Involvement (PPI) or Responsible Research and Innovation (RRI), examining mental health-related research processes, interventions, and products developed in collaboration with young people. Studies employing quantitative, qualitative, and mixed-methods approaches will be considered, while non-journal publications will be excluded.

DISCUSSION

The intended scoping review aims to map the literature concerning mental health-related projects that engage with young people through PPI or RRI approaches. The outcomes hold promise for enriching the participatory research domain, particularly in studies centred on young people and their mental well-being. Furthermore, by delineating potential overlaps and distinctions between PPI and RRI, the findings stand to aid mental health researchers and practitioners in making informed decisions about the most suitable approach for their projects when partnering with young individuals.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (registration: DOI https://doi.org/10.17605/OSF.IO/N4EDB ).

Perceived acceptability and appropriateness of a web-based program targeting risk for anxiety in young children and their parents

OBJECTIVE

This mixed-methods study examined perceived acceptability and appropriateness of a novel digital mental health program targeting anxiety risk (i.e., perfectionism or error sensitivity) in 5-to-7-year-old children and their parents.

METHODS

Parent-child dyads participated in a modular, web-based cognitive-behavioral program targeting negative overreactions to making mistakes. The program, "Making Mistakes", consisted of a 6-month series of short video clips, journaling activities, and weekly reminders, and modules were delivered to caregivers and children separately. 86 dyads completed self-report measures, 18 of whom participated in semi-structured interviews, following completion of the primary program module. A standard thematic analysis was used to elucidate themes from the parent and child interview content.

RESULTS

Our quantitative and qualitative results were generally aligned. Children and parents viewed the novel digital mental health program as acceptable and appropriate, favoring the cognitive behavioral strategies such as modeling positive reactions to mistakes, responding positively to child mistakes, and emphasizing effort over outcome. Participants also provided helpful feedback related to program content, delivery, and engagement, as well as suggestions to enhance the program.

CONCLUSIONS

Findings have implications for design and content features of parent-based and dyad-based programs, as well as digital mental health programs focused on reducing anxiety risk.

New Brunswick's mental health action plan: A quantitative exploration of program efficacy in children and youth using the Canadian Community Health Survey

In 2011, the New Brunswick government released the New Brunswick Mental Health Action Plan 2011-2018 (Action Plan). Following the release of the Action Plan in 2011, two progress reports were released in 2013 and 2015, highlighting the implementation status of the Action Plan. While vague in their language, these reports indicated considerable progress in implementing the Action Plan, as various initiatives were undertaken to raise awareness and provide additional resources to facilitate early prevention and intervention in children and youth. However, whether these initiatives have yielded measurable improvements in population-level mental health outcomes in children and youth remains unclear. The current study explored the impact of the Action Plan by visualizing the trend in psychosocial outcomes and service utilization of vulnerable populations in New Brunswick before and after the implementation of the Action Plan using multiple datasets from the Canadian Community Health Survey. Survey-weighted ordinary least square regression analyses were performed to investigate measurable improvements in available mental health outcomes. The result revealed a declining trend in the mental wellness of vulnerable youth despite them consistently reporting higher frequencies of mental health service use. This study highlights the need for a concerted effort in providing effective mental health services to New Brunswick youth and, more broadly, Canadian youth, as well as ensuring rigorous routine outcome monitoring and evaluation plans are consistently implemented for future mental health strategies at the time of their initiation.

Understanding the impact of digital therapeutic engagement in promoting mental wellbeing for Pacific youth in Aotearoa New Zealand: an exploration of the literature

The Pacific population in Aotearoa New Zealand is youthful, with the majority (55%) being under the age of 25 (Statistics New Zealand, 2014). It is vital that youth mental health for Pacific is understood in relation to their overall wellbeing (Paterson et al., 2018). In parallel to this, the World Health Organization (2022) accentuates the need to protect and promote mental wellbeing for young people globally. Specifically, Pacific youth were far more likely than Aotearoa New Zealand European counterparts to have poorer mental health and higher numbers of suicidality and self-harming behaviours (Ataera-Minster & Trowland, 2018; Fa'alili-Fidow et al., 2016). Moreover, research confirms that Pacific people aged 15-24 years have higher levels of psychological distress of 38% compared to 35% of Pacific adults aged 45-64 years (Ataera-Minster & Trowland, 2018). There is a lack of evidence-based psychological approaches that are culturally appropriate and applicable for Pacific people in Aotearoa New Zealand. Considerably, substantial evidence supports the need to provide more accessible resources and interventions that are flexible, culturally adaptable and cost-effective for Pacific youth. This review aims to (1) provide an insight into Pacific people in Aotearoa New Zealand, (2) have an understanding of Pacific worldview & wellbeing, (3) highlight mental health for Aotearoa New Zealand youth & globally (4) identify therapeutic approaches, including digital mental health globally and in Aotearoa New Zealand.Understanding the perspectives of Pacific youth is a significant first step. Therefore, this article will examine the therapeutic approaches, specifically in the digital space, that are proven effective when promoting wellness for Pacific youth.

Outcomes of Best-Practice Guided Digital Mental Health Interventions for Youth and Young Adults with Emerging Symptoms: Part II. A Systematic Review of User Experience Outcomes

Although many young people demonstrate resilience and strength, research and clinical evidence highlight an upward trend in mental health concerns among those aged 12 to 25 years. Youth-specific digital mental health interventions (DMHIs) aim to address this trend by providing timely access to mental health support for young people (12-25 years). However, there is a considerable gap in understanding young people user experiences with digital interventions. This review, co-designed with Australia's leading mental health organization Beyond Blue, utilizes a systematic methodology to synthesize evidence on user experience in youth-oriented digital mental health interventions that are fully or partially guided. Five relevant online databases were searched for articles published from 2018 to 2023, yielding 22,482 articles for screening and 22 studies were included in the present analysis. User experience outcomes relating to satisfaction and engagement were assessed for each included intervention, with experience indicators relating to usefulness, usability, value, credibility, and desirability being examined. Elements associated with positive/negative outcomes were extracted. Elements shown to positively influence user experience included peer engagement, modern app-based delivery, asynchronous support, and personalized content. In contrast, users disliked static content, homework/log-keeping, the requirement for multiple devices, and social media integration. Asynchronous interventions showed high satisfaction but faced engagement issues, with combined asynchronous/synchronous interventions reporting better completion rates. DMHIs offer a promising platform for youth mental health support and has the potential to dramatically increase the reach of interventions through the adoption of technological and user experience best practices. While young people respond positively to many aspects of intervention modernization, such as interactive, app-based design, other concepts, such as social media integration, they need to be adopted by the field more cautiously to ensure trust and engagement.Trial Registration CRD42023405812.

On the Road to Individualizing Pharmacotherapy for Adolescents and Adults with Schizophrenia - Results from an Expert Consensus Following the Delphi Method

Introduction

Schizophrenia is a severe mental illness that usually begins in late adolescence or early adulthood. Current pharmacological treatments, while acceptably effective for many patients, are rarely clinically tailored or individualized. The lack of sufficient etiopathological knowledge of the disease, together with overall comparable effect sizes for efficacy between available antipsychotics and the absence of clinically actionable biomarkers, has hindered the advance of individualized medicine in the treatment of schizophrenia. Nevertheless, some degree of stratification based on clinical markers could guide treatment choices and help clinicians move toward individualized psychiatry. To this end, a panel of experts met to formally discuss the current approach to individualized treatment in schizophrenia and to define how treatment individualization could help improve clinical outcomes.

Methods

A task force of seven experts iteratively developed, evaluated, and refined questionnaire items, which were then evaluated using the Delphi method. Descriptive statistics were used to summarize and rank expert responses. Expert discussion, informed by the results of a scoping review on personalizing the pharmacologic treatment of adults and adolescents with schizophrenia, ultimately generated recommendations to guide individualized pharmacologic treatment in this population.

Results

There was substantial agreement among the expert group members, resulting in the following recommendations: 1) individualization of treatment requires consideration of the patient's diagnosis, clinical presentation, comorbidities, previous treatment response, drug tolerability, adherence patterns, and social factors; 2) patient preferences should be considered in a shared decision-making approach; 3) identified barriers to personalized care that need to be overcome include the lack of actionable biomarkers and mechanistic similarities between available treatments, but digital tools should be increasingly used to enhance individualized treatment.

Conclusion

Individualized care can help provide effective, tailored treatments based on an individual's clinical characteristics, disease trajectory, family and social environment, and goals and preferences.

Scoping Review: Digital Mental Health Interventions for Children and Adolescents Affected by War

OBJECTIVE

More than 200 million children and adolescents live in countries affected by violent conflict, are likely to have complex mental health needs, and struggle to access traditional mental health services. Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support. We performed a scoping review to map existing digital mental health interventions relevant for children and adolescents affected by war, to examine the strength of the evidence base, and to inform the development of future interventions.

METHOD

Based on a pre-registered strategy, we systematically searched MEDLINE, Embase, Global Health, APA PsychInfo, and Google Scholar from the creation of each database to September 30, 2022, identifying k = 6,843 studies. Our systematic search was complemented by extensive consultation with experts from the GROW Network.

RESULTS

The systematic search identified 6 relevant studies: 1 study evaluating digital mental health interventions for children and adolescents affected by war, and 5 studies for those affected by disasters. Experts identified 35 interventions of possible relevance. The interventions spanned from universal prevention to specialist-guided treatment. Most interventions directly targeted young people and parents or carers/caregivers and were self-guided. A quarter of the interventions were tested through randomized controlled trials. Because most interventions were not culturally or linguistically adapted to relevant contexts, their implementation potential was unclear.

CONCLUSION

There is very limited evidence for the use of digital mental health interventions for children and adolescents affected by war at present. The review provides a framework to inform the development of new interventions.

DIVERSITY & INCLUSION STATEMENT

We actively worked to promote sex and gender balance in our author group.

STUDY PREREGISTRATION INFORMATION

Digital mental health interventions for children and young people affected by war: a scoping review; https://osf.io/; hrny9.

Digital Mental Health for Schizophrenia and Other Severe Mental Illnesses: An International Consensus on Current Challenges and Potential Solutions

BACKGROUND

Digital approaches may be helpful in augmenting care to address unmet mental health needs, particularly for schizophrenia and severe mental illness (SMI).

OBJECTIVE

An international multidisciplinary group was convened to reach a consensus on the challenges and potential solutions regarding collecting data, delivering treatment, and the ethical challenges in digital mental health approaches for schizophrenia and SMI.

METHODS

The consensus development panel method was used, with an in-person meeting of 2 groups: the expert group and the panel. Membership was multidisciplinary including those with lived experience, with equal participation at all stages and coproduction of the consensus outputs and summary. Relevant literature was shared in advance of the meeting, and a systematic search of the recent literature on digital mental health interventions for schizophrenia and psychosis was completed to ensure that the panel was informed before the meeting with the expert group.

RESULTS

Four broad areas of challenge and proposed solutions were identified: (1) user involvement for real coproduction; (2) new approaches to methodology in digital mental health, including agreed standards, data sharing, measuring harms, prevention strategies, and mechanistic research; (3) regulation and funding issues; and (4) implementation in real-world settings (including multidisciplinary collaboration, training, augmenting existing service provision, and social and population-focused approaches). Examples are provided with more detail on human-centered research design, lived experience perspectives, and biomedical ethics in digital mental health approaches for SMI.

CONCLUSIONS

The group agreed by consensus on a number of recommendations: (1) a new and improved approach to digital mental health research (with agreed reporting standards, data sharing, and shared protocols), (2) equal emphasis on social and population research as well as biological and psychological approaches, (3) meaningful collaborations across varied disciplines that have previously not worked closely together, (4) increased focus on the business model and product with planning and new funding structures across the whole development pathway, (5) increased focus and reporting on ethical issues and potential harms, and (6) organizational changes to allow for true communication and coproduction with those with lived experience of SMI. This study approach, combining an international expert meeting with patient and public involvement and engagement throughout the process, consensus methodology, discussion, and publication, is a helpful way to identify directions for future research and clinical implementation in rapidly evolving areas and can be combined with measurements of real-world clinical impact over time. Similar initiatives will be helpful in other areas of digital mental health and similarly fast-evolving fields to focus research and organizational change and effect improved real-world clinical implementation.

Diversity, equity and inclusion considerations in mental health apps for young people: protocol for a scoping review

INTRODUCTION

After COVID-19, a global mental health crisis affects young people, with one in five youth experiencing mental health problems worldwide. Delivering mental health interventions via mobile devices is a promising strategy to address the treatment gap. Mental health apps are effective for adolescent and young adult samples, but face challenges such as low real-world reach and under-representation of minoritised youth. To increase digital health uptake, including among minoritised youth, there is a need for diversity, equity and inclusion (DEI) considerations in the development and evaluation of mental health apps. How well DEI is integrated into youth mental health apps has not been comprehensively assessed. This scoping review aims to examine to what extent DEI considerations are integrated into the design and evaluation of youth mental health apps and report on youth, caregiver and other stakeholder involvement.

METHODS AND ANALYSIS

We will identify studies published in English from 2009 to 29 September 2023 on apps for mental health in youth. We will use PubMed, Global Health, APA PsycINFO, SCOPUS, CINAHL PLUS and the Cochrane Database and will report according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Papers eligible for inclusion must be peer-reviewed publications in English involving smartphone applications used by adolescents or young adults aged 10-25, with a focus on depression, anxiety or suicidal ideation. Two independent reviewers will review and extract articles using a template developed by the authors. We will analyse the data using narrative synthesis and descriptive statistics. This study will identify gaps in the literature and provide a roadmap for equitable and inclusive mental health apps for youth.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings will be disseminated through academic, industry, community networks and scientific publications.

Accelerating implementation of adolescent digital health prevention programs: analysis of insights from Australian stakeholders

Background

Chronic disease risk factors are increasing amongst adolescents, globally. Digital health prevention programs, which provide education and information to reduce chronic disease risk factors need to be equitable and accessible for all. For their success, multiple highly engaged stakeholders should be involved in development and implementation. This study aimed to evaluate stakeholders' support for, and perspectives on potential public health impact of digital health prevention programs for adolescents and potential pathways for future implementation.

Methods

Qualitative semi-structured online interviews with stakeholders. Stakeholder mapping identified key individuals, groups and organizations across Australia that may influence the implementation of digital health prevention programs for adolescents. Recorded and transcribed interviews were analyzed within the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework, using deductive content analysis.

Findings

Nineteen interviews were conducted in 2023 with stakeholders from government, health, non-government organizations, youth services, education, community settings and others. Four overarching themes were identified: (i) existing digital health initiatives are not fit for purpose; (ii) the co-creation of digital health prevention programs is critical for successful implementation; (iii) digital health prevention programs must address equity and the unique challenges raised by technology and; (iv) system level factors must be addressed.

Interpretation

Stakeholders broadly supported digital health prevention programs, yet raised unique insights to ensure that future programs create public health impact by improving chronic disease risk factors among adolescents. These insights can be applied in future development of digital health prevention programs for adolescents to strengthen widespread implementation.

Predictors of participation in online self-management programs: A longitudinal observational study

PURPOSE/OBJECTIVE

Lack of patient participation and engagement remains a barrier to implementing effective online self-management and behavioral health interventions. Identifying patient characteristics associated with engagement rates may lead to interventions that improve engagement in traditional and online self-management programs. In this study, two online self-management and recovery programs were evaluated to identify factors that predict patient engagement.

RESEARCH METHOD/DESIGN

Predictors were collected in a questionnaire at baseline before 435 participants started either of the two interventions. One or two online lessons were completed per week with seven or eight total lessons to complete in each program, and each lesson took about 20-30 min to finish. Full patient engagement was defined as completing all lessons and assessments in the program and partial engagement as attempting at least one lesson or assessment.

RESULTS

Predictors of full patient engagement were self-rated confidence in completing the program or being over 60 years of age. Predictors of at least partial patient engagement were experienced ordering online or being over 50 years of age.

CONCLUSIONS/IMPLICATIONS

Identifying profiles of individuals who predict poor engagement may improve implementation and the health outcomes of intervention programs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A systematic review and meta-analysis of the effectiveness of co-designed, in-person, mental health interventions for reducing anxiety and depression symptoms

BACKGROUND

Co-design is recommended in mental health fields and has been associated with improved intervention efficacy. Despite its growing popularity, syntheses of evidence on the effectiveness of co-designed interventions are scarce, and little is known about their impact on anxiety and depression.

METHODS

The purpose of this systematic review and meta-analysis was to consolidate evidence on the effectiveness of in-person, co-designed mental health interventions for reducing anxiety and depression symptoms. An exhaustive search was conducted across six electronic databases (PubMed, PsycINFO, Embase, CINAHL, CENTRAL, and ProQuest) and grey literature. Criteria for inclusion comprised studies utilizing randomized or quasi-randomized methods, implementing non-digital/in-person, co-designed interventions for mental health enhancement, and assessing anxiety and/or depression. Intervention impacts were evaluated using random-effects meta-analyses.

RESULTS

The review identified 20 studies, with only three using the term 'co-design'. Other terminologies included 'co-developed' (n = 2), 'co-produced' (n = 2), and 'CBPR' (n = 11). Seventeen studies exhibited moderate risk of bias, while three demonstrated high risk. Meta-analyses demonstrated a moderate non-significant effect size of 0.5 (95 % CI: -0.8, 1.08; p = 0.08) on depression outcomes, and a small non-significant effect size of 0.12 (95 % CI: -0.1, 0.33; p = 0.23) on anxiety outcomes.

LIMITATIONS

The majority of studies lacked sufficient statistical power to detect between-group differences. Following GRADE criteria, confidence in estimates was low.

CONCLUSIONS

Notwithstanding widespread enthusiasm for co-design, the current evidence base is inadequate to confirm the impact of in-person, co-designed mental health interventions on anxiety and depression. More full-scale evaluation trials of higher quality are urgently needed, along with uniform terminology and measurement.

Evaluation of the Effectiveness of Suicide.ca, Quebec's Digital Suicide Prevention Strategy Platform: Cross-Sectional Descriptive Study

BACKGROUND

In 2017, the Quebec government assigned the Association québécoise de prévention du suicide (AQPS) to develop a digital suicide prevention strategy (DSPS). The AQPS responded by creating a centralized website that provides information on suicide and mental health, identifies at-risk individuals on the internet, and offers direct crisis intervention support via chat and text.

OBJECTIVE

This study aims to evaluate the effectiveness of suicide.ca, Quebec's DSPS platform.

METHODS

This study used a cross-sectional descriptive design. The study population comprised internet users from Quebec, Canada, who visited the suicide.ca platform between October 2020 and October 2021. Various data sources, such as Google Analytics, Firebase Console, and Customer Relation Management data, were analyzed to document the use of the platform. To understand the profile of suicide.ca users, frequency analyses were conducted using data from the self-assessment module questionnaires, the intervention service's triage questionnaire, and the counselors' intervention reports. The effectiveness of the platform's promotional activities on social media was assessed by examining traffic peaks. Google Analytics was used to evaluate the effectiveness of AQPS' strategy for identifying at-risk internet users. The impact of the intervention service was evaluated through an analysis of counselors' intervention reports and postintervention survey results.

RESULTS

The platform received traffic from a diverse range of sources, with promotional efforts on social media directly contributing to the increased traffic. The requirement of a user account posed a barrier to the use of the mobile app, and a triage question that involved personal information led to a substantial number of dropouts during the intervention service triage. AdWords campaigns and fact sheets addressing suicide risk factors played a crucial role in driving traffic to the platform. With regard to the profile of suicide.ca users, the findings revealed that the platform engaged individuals with diverse levels of suicidal risk. Notably, users of the chat service displayed a higher suicide risk than those who used the self-assessment module. Crisis chat counselors reported a positive impact on approximately half of the contacts, and overall, intervention service users expressed satisfaction with the support they received.

CONCLUSIONS

A centralized digital platform can be used to implement a DSPS, effectively reaching the general population, individuals with risk factors for suicide, and those facing suicidal issues.

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review

Background

Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.

Objectives

The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).

Search Methods

The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.

Selection Criteria

Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.

Data Collection and Analysis

Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.

Main Results

Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.

Authors' Conclusions

At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.

Primary care-based screening and recruitment for an adolescent depression prevention trial: Contextual considerations during a youth mental health crisis

Background

Rising rates of adolescent depression in the wake of COVID-19 and a youth mental health crisis highlight the urgent need for accessible mental healthcare and prevention within primary care. Digital mental health interventions (DMHIs) may increase access for underserved populations. However, these interventions are not well studied in adolescents, nor healthcare settings. The purpose of this study was to identify barriers and facilitators to screening and recruitment activities for PATH 2 Purpose (P2P): Primary Care and Community-Based Prevention of Mental Disorders in Adolescents, a multi-site adolescent depression prevention trial comparing two digital prevention programs within four diverse health systems in two U.S. states.

Method

This qualitative study is a component of a larger Hybrid Type I trial. We conducted semi-structured key informant interviews with clinical and non-clinical implementers involved with screening and recruitment for the P2P trial. Informed by the Consolidated Framework for Implementation Research (CFIR), interviews were conducted at the midpoint of the trial to identify barriers, facilitators, and needed adaptations, and to gather information on determinants that may affect future implementation.

Findings

Respondents perceived the P2P trial as valuable, well aligned with the mission of their health systems. However, several barriers were identified, many of which stemmed from influences outside of the healthcare settings. Universal and site-specific outer setting influences (COVID-19 pandemic, youth mental health crisis, local community conditions) interacted with Inner Setting and Innovation domains to create numerous challenges to the implementation of screening and recruitment.

Conclusion

Our findings emphasize the need for ongoing, comprehensive assessment of dynamic inner and outer setting contexts prior to and during implementation of clinical trials, as well as flexibility for adaptation to unique clinical contexts. The CFIR is useful for assessing determinants during times of rapid inner and outer setting change, such as those brought on by the COVID-19 pandemic, youth mental health crisis, and the corresponding exacerbation of resource strain within healthcare settings.

Clinical trial registration

PATH 2 Purpose: Primary Care and Community-Based Prevention of Mental Disorders in Adolescents https://www.clinicaltrials.gov/study/NCT04290754.

Digital mental health strategies used by young people in Aotearoa New Zealand during the COVID-19 pandemic: 'Just do it yourself, DIY'

Objective

With rising rates of mental health distress amongst youth during the COVID-19 pandemic, digital resources have been identified as a valuable tools for delivering support to young people. However, many of the websites and apps developed by professionals to support the youth do not take account of the importance young people place on exercising their own agency in managing their mental health. This article investigates how young people in Aotearoa New Zealand used digital resources to manage their mental health needs during the COVID-19 pandemic.

Methods

The study gathered information from semi-structured interviews with 34 young people aged 16-22 years. The data was analysed using reflexive thematic analysis.

Results

Six themes were identified including: searching for online information about mental health; evaluating digital mental health resources; controlling mood through online activity; looking for escape in the virtual world; staying connected online; and giving and receiving support.

Conclusion

Young people's practices demonstrated their investment in their own agency, a general reluctance to engage with professional resources and recognition of the need to balance the risks and benefits of the informal strategies they preferred. Young people appeared sceptical of professionally-designed mental health resources and interventions and preferred to adapt and re-purpose the wide range of platforms and networks available in their informal digital worlds.

Real-time personalized feedback in mHealth for adolescents

Mobile Health (mHealth) interventions have the potential to improve early identification, prevention, and treatment of mental health problems. Grow It! is a multiplayer smartphone app designed for youth aged 12-25, allowing them to monitor their emotions and engage in daily challenges based on Cognitive Behavioral Therapy (CBT) principles. Recently, a personalized mood profile was added to improve the app. We investigated whether real-time personalized feedback on mood enhances app engagement, user experience, and the effects on affective and cognitive well-being. Sample A (N = 1269, age = 18.60 SD = 3.39, 80.6% girls, 95.4% Dutch) played the original app without feedback on their mood, and an independent Sample B (N = 386, age = 16.04 SD = 3.21, 67.6% girls, 82.9% Dutch) received the renewed version with personalized real-time feedback on their mood. Participants who received personal feedback did not have higher app engagement (t(1750,400) = 1.39, P = .206, d = 0.07; t(692,905) = 0.36, P = .971, d = 0.0) nor higher user experience (t(177,596) = 0.21, P = .831, d = 0.02; (t(794) = 1.28, P = .202, d = 0.12; χ2 (659,141) = 2.83, P = .091). Players of the renewed version (Sample B) experienced significant improvements in affective (t(175) = 3.01, P = .003, d = 0.23) and cognitive well-being (t(175) = 3.48, P = <.001, d = 0.26) over the course of three weeks. The renewed version Grow It! has the potential to enhance youths' affective and cognitive well-being. However, adding real-time insights did not seem to affect app engagement nor user experience.

Development and codesign of flourish: A digital suicide prevention intervention for LGBTQ+ youth who have experienced online victimization

Background

LGBTQ+ youth experience disproportionately high rates of online victimization (OV), referring to harmful remarks, images, or behaviors in online settings, which is associated with suicidal risk. Current services have gaps in supporting LGBTQ+ youth facing OV events. To address these gaps, this study aims to develop Flourish, a digital suicide prevention intervention for LGBTQ+ youth who have experienced OV.

Methods

Qualitative interviews were conducted with 20 LGBTQ+ youth with past-year history of OV and lifetime history of suicidality, 11 of their parents, and 10 LGBTQ+-serving professionals. Subsequently, an iterative codesign process was conducted with 22 youth through individual and group design sessions, followed by usability testing. Data were recorded and transcribed. Qualitative interviews were analyzed using a qualitative description approach, and data from design sessions and usability testing were analyzed using rapid qualitative techniques.

Results

Interviews with youth, parents, and professionals suggested preferences for Flourish to be a partially automated, text message intervention leveraging web-based content that is a safe space for LGBTQ+ youth to seek support for OV through education, coping skills, and help-seeking resources. School and mental health services professionals considered the potential for implementing Flourish within youth services settings. Usability testing, assessed through the System Usability Scale, yielded an average rating of 91, indicating excellent perceived usability.

Conclusions

Flourish has potential to be an acceptable intervention to support LGBTQ+ youth following OV. Future steps will include testing the feasibility and efficacy of Flourish and further examining Flourish's potential for implementation within services for LGBTQ+ youth.

Web-Based Self-Compassion Training to Improve the Well-Being of Youth With Chronic Medical Conditions: Randomized Controlled Trial

BACKGROUND

Up to one-third of young people live with chronic physical conditions (eg, diabetes, asthma, and autoimmune disease) that frequently involve recurrent pain, fatigue, activity limitations, stigma, and isolation. These issues may be exacerbated as young people transition through adolescence. Accordingly, young people with chronic illness are at a high risk of psychological distress. Accessible, evidence-based interventions for young people with chronic illnesses are urgently needed to improve well-being, support adaptation, and enhance daily functioning. Self-compassion, which is an adaptive means of relating to oneself during times of difficulty, is a promising intervention target for this population.

OBJECTIVE

This study aims to test the efficacy of a 4-week, self-guided, web-based self-compassion training program for improving well-being among young Australians (aged 16-25 years) living with a chronic medical condition. The primary outcomes were self-compassion, emotion regulation difficulties, and coping; the secondary outcomes were well-being, distress, and quality of life. We also sought to test whether changes in primary outcomes mediated changes in secondary outcomes and gather feedback about the strengths and limitations of the program.

METHODS

We conducted a single-blind, parallel-group, randomized controlled trial comparing a 4-week, fully automated, web-based self-compassion training program with a waitlist control. Participants were recruited via the internet, and outcomes were self-assessed at 4 (T1) and 12 weeks (T2) after the baseline time point via a web-based survey. A mixed methods approach was used to evaluate the program feedback.

RESULTS

Overall, 151 patients (age: mean 21.15, SD 2.77 years; female patients: n=132, 87.4%) were randomized to the intervention (n=76, 50.3%) and control (n=75, 49.7%) groups. The loss-to-follow-up rate was 47.4%, and program use statistics indicated that only 29% (22/76) of young people in the experimental group completed 100% of the program. The main reported barrier to completion was a lack of time. As anticipated, treatment effects were observed for self-compassion (P=.01; partial η2=0.05; small effect); well-being (P≤.001; partial η2=0.07; medium effect); and distress (P=.003; partial η2=0.054; small-medium effect) at the posttest time point and maintained at follow-up. Contrary to our hypotheses, no intervention effects were observed for emotion regulation difficulties or maladaptive coping strategies. Improvements in adaptive coping were observed at the posttest time point but were not maintained at follow-up. Self-compassion, but not emotion regulation difficulties or coping, mediated the improvements in well-being.

CONCLUSIONS

Minimal-contact, web-based self-compassion training can confer mental health benefits on young people with chronic conditions. This group experiences substantial challenges to participation in mental health supports, and program engagement and retention in this trial were suboptimal. Future work should focus on refining the program content, engagement, and delivery to optimize engagement and treatment outcomes for the target group.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry 12619000572167; https://tinyurl.com/5n6hevt.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-020-8226-7.

Piloting a digital campaign to promote awareness of the Louisiana TelePrEP program among sexual and gender minority young adults

Despite the proven efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV acquisition, PrEP is underutilized by sexual and gender minority young adults in the 13 states in the United States "South." In this paper, we describe the process we used to develop a digital campaign to promote awareness and engagement of sexual and gender minority young adults in the Louisiana Department of Health's TelePrEP Program and provide campaign performance metrics. In Phase 1, we conducted formative research that informed campaign development and strategy. In total, 109 sexual and gender minority young adults completed a survey of PrEP constructs (e.g., facilitators, barriers). We also conducted three, sequential focus groups to iteratively generate, revise and refine the digital material. In collaboration with our strategic marketing partner (SMP), we developed 3 different ads and 1 video ad to promote on web and mobile-in app display, as well as Facebook, Instagram, and YouTube. Phase 2 focused on campaign implementation and evaluation (e.g., number of impressions, user activities on LA TelePrEP landing page). In the first few weeks of the campaign, data from tracking pixels indicated minimal activities on the landing page. We paused to revamp the campaign. Our SMP determined that a more young adult-focused landing page could bolster engagement. We created a new landing page and reran the campaign for 33 days. We saw substantially more user activities on the new landing page (n = 382) compared to the LA TelePrEP landing page (n = 185). Overall, we had 730,665 impressions and 475 link clicks. By collaborating with our SMP, we effectively and efficiently translated our community-engaged formative research into relevant and engaging digital content. This pilot study is one of the first to demonstrate the importance of using tracking pixels to monitor real-time user data to optimize performance of a digital PrEP campaign.

Developing A Mobile App With a Human-Centered Design Lens to Improve Access to Mental Health Care (Mentallys Project): Protocol for an Initial Co-Design Process

BACKGROUND

Co-design is one of the human-centered design approaches that allows end users to significantly and positively impact the design of mental health technologies. It is a promising approach to foster user acceptance and engagement in digital mental health solutions. Surprisingly, there is a lack of understanding of what co-design is in this field. In this paper, co-design is approached as a cocreation process involving persons with a lived experience of mental health problems, health professionals, and design experts who lead and facilitate the overall creative process.

OBJECTIVE

This paper describes an initial co-design research protocol for the development of a mobile app that aims to improve access to mental health care. It highlights the characteristics of a co-design approach in e-mental health rooted in human-centered design and led by design experts alongside health experts. The paper focuses on the first steps (phase 1) of the co-design process of the ongoing Mentallys project.

METHODS

This Mentallys project will be located in Montréal (Quebec, Canada). The method approach will be based on the "method stories," depicting the "making of" this project and reflecting adjustments needed to the protocol throughout the project in specific situations. Phase 1 of the process will focus on the desirability of the app. Targeted participants will include people with a lived experience of mental health problems, peer support workers and clinicians, and 3 facilitators (all design experts or researchers). Web-based sessions will be organized because of the COVID-19 pandemic, using Miro (RealtimeBoard Inc) and Zoom (Zoom Video Communications, Inc). Data collection will be based on the comments, thoughts, and new ideas of participants around the imaginary prototypes. Thematic analysis will be carried out after each session to inform a new version of the prototype.

RESULTS

We conducted 2 stages in phase 1 of the process. During stage 1, we explored ideas through group co-design workshops (divergent thinking). Six co-design workshops were held: 2 with only clinicians (n=7), 2 with peer support workers (n=5) and people with a lived experience of mental health problems (n=2), and 2 with all of them (n=14). A total of 6 facilitators participated in conducting activities in subgroups. During stage 2, ideas were refined through 10 dyad co-design sessions (convergent thinking). Stage 2 involved 3 participants (n=3) and 1 facilitator. Thematic analysis was performed after stage 1, while analytic questioning is being performed for stage 2. Both stages allowed several iterations of the prototypes.

CONCLUSIONS

The design of the co-design process, the leadership of the design expertise throughout the process, and the different forms of co-design activities are key elements in this project. We highly recommend that health researchers partner with professional designers or design researchers who are familiar with co-design.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47220.

The effect of brief digital mindfulness-based interventions on increasing online charitable behavior in Chinese adolescents

Digital mindfulness-based interventions (d-MBIs) have garnered significant research interest in recent years due to their psychological benefits. However, little is known about their impact on prosocial behaviors. This study investigates how d-MBIs impact prosocial behaviors where time spent is money, with Chinese adolescents as the subjects, through an online charity task (www.freerice.com). 119 students from a high school in China, who were inexperienced with mindfulness meditation, participated in this randomized controlled trial. The d-MBI group (N = 39) received online MBI guidance, while the face-to-face mindfulness-based intervention (f-MBI, N = 43) group underwent mindfulness intervention under personal tutors. The active control group (N = 37) completed a crossword task. Data analysis first involved repeated measures variance analysis, including pre-and post-intervention assessments. Subsequently, a two-way variance analysis was performed, with gender (female and male) and group (d-MBI, f-MBI, active control) as independent variables and the number of grains as dependent variables for the three groups of participants. Results showed that d-MBIs effectively improved empathy and compassion in Chinese adolescents, leading to increased rice donations to the United Nations World Food Program. These results underscore the positive effect of d-MBIs on prosociality and suggest their applicability in beneficial real-world situations involving prosocial behaviors, extending beyond previous research primarily conducted in artificial and hypothetical scenarios.

"The library is so much more than books": considerations for the design and implementation of teen digital mental health services in public libraries

Background

Adolescence is a vulnerable developmental period, characterized by high rates of mental health concerns, yet few adolescents receive treatment. Public libraries support adolescents by providing them with access to teen programming, technological resources, and have recently been providing mental health services. Digital mental health (DMH) services may help libraries provide scalable mental health solutions for their adolescent patrons and could be well positioned to address the mental health needs of historically underrepresented racial and ethnic (HURE) adolescents; however, little research has been conducted on the compatibility of DMH services with adolescent patron mental health needs or resource needs of library workers supporting them.

Methods

The research team formed a partnership with a public library, which serves a large HURE adolescent population. We conducted needs assessment and implementation readiness interviews with 17 library workers, including leadership, librarians, and workers with specialized areas of practice. Interview questions focused on library infrastructure, as well as library needs and preferences around the design and implementation of DMH services for adolescents. We used the Consolidated Framework for Implementation Research as guiding implementation determinant framework to code and analyze the interview transcripts.

Results

Our findings revealed library workers play an important role in guiding patrons to desired resources and share a goal of implementing adolescent DMH resources into the library and elevating marginalized adolescents' voices. Existing library resources, such as the library's role as a safe space for adolescents in the community, close relationships with external and community organizations, and availability of no-cost technological resources, could help facilitate the implementation of DMH services. Barriers related to community buy-in, mental health stigma, and library worker confidence in supporting adolescent mental health could affect service implementation.

Conclusions

Our findings suggest public libraries are highly promising settings to deploy DMH services for adolescents. We identified important determinants that may impact the implementation of DMH services in public library settings. Special considerations are needed to design services to meet the mental health needs of HURE adolescent populations and those adolescents' most experiencing health inequities.

An emerging framework for digital mental health design with Indigenous young people: a scoping review of the involvement of Indigenous young people in the design and evaluation of digital mental health interventions

BACKGROUND

Indigenous young people worldwide possess unique protective factors that support wellbeing. However, they experience mental illness at higher rates than their non-indigenous counterparts. Digital mental health (dMH) resources can increase access to structured, timely, and culturally tailored mental health interventions by reducing structural and attitudinal barriers to accessing treatment. The involvement of Indigenous young people in dMH resource development is recommended, however, no guidelines exist on how this can best be facilitated.

METHODS

A scoping review examining processes to involve Indigenous young people in developing or evaluating dMH interventions was conducted. Studies reported between 1990 and 2023 involving Indigenous young people aged 12-24 years, originating from Canada, the USA, New Zealand, and Australia, in the development or evaluation of dMH interventions were eligible for inclusion. Following a three-step search process, four electronic databases were searched. Data were extracted, synthesized, and described under three categories: dMH intervention attributes, study design, and alignment with research best practice. Best practice recommendations for Indigenous research and participatory design principles derived from the literature were identified and synthesised. Included studies were assessed against these recommendations. Consultation with two Senior Indigenous Research Officers ensured Indigenous worldviews informed analysis.

RESULTS

Twenty-four studies describing eleven dMH interventions met inclusion criteria. Studies included formative, design, pilot, and efficacy studies. Overall, most included studies demonstrated a high degree of Indigenous governance, capacity building, and community benefit. All studies adapted their research processes to ensure that local community protocols were followed and most aligned these within an Indigenous research paradigm. Formal agreements regarding existing and created intellectual property and implementation evaluations were rare. Outcomes were the primary focus of reporting, with limited detailed descriptions of governance and decision-making processes or strategies for managing predictable tensions between co-design stakeholders.

CONCLUSIONS

This study identified recommendations for undertaking participatory design with Indigenous young people and evaluated the current literature against these criteria. Common gaps were evident in the reporting of study processes. Consistent, in-depth reporting is needed to allow assessment of approaches for this hard-to-reach population. An emergent framework, informed by our findings, for guiding the involvement of Indigenous young people in the design and evaluation of dMH tools is presented.

TRIAL REGISTRATION

Available via osf.io/2nkc6.

Kindergarten children's reactions to the COVID-19 pandemic: Creating a sense of coherence

This article examines kindergarten children's experience of the COVID-19 pandemic. It aims to understand the children's thoughts, emotions, and coping strategies regarding the presence of the COVID-19 virus in their daily lives, using the salutogenic approach to study their sense of coherence and promote relevant professional instruction. Semi-structured in-depth interviews were held with 130 five- to six-year-old children with an equal number of boys and girls. All of the children were recruited from kindergartens affiliated with the state's secular education system. Data were structured into three themes: (1) the child's perception of the pandemic as manageable through significant accompanying and absent figures; (2) the child's comprehension of the virus as dangerous, age-differentiating, and contagious; and (3) the child's emotional processing of the pandemic as arousing fear of death and through images, such as "thorny" and "monster." The results demonstrate the young children's sense of coherence, characterized as extrapersonal perception, interpersonal coping, and intrapersonal emotional processing, and the need for greater acknowledgment of child-parent educators' informed interventions that could give children a partial feeling of the adult's awareness of their needs.

Using Digital Measurement-Based Care for the Treatment of Anxiety and Depression in Children and Adolescents: Observational Retrospective Analysis of Bend Health Data

BACKGROUND

A growing body of evidence supports the efficacy of measurement-based care (MBC) for children and adolescents experiencing mental health concerns, particularly anxiety and depression. In recent years, MBC has increasingly transitioned to web-based spaces in the form of digital mental health interventions (DMHIs), which render high-quality mental health care more accessible nationwide. Although extant research is promising, the emergence of MBC DMHIs means that much is unknown regarding their effectiveness as a treatment for anxiety and depression, particularly among children and adolescents.

OBJECTIVE

This study uses preliminary data from children and adolescents participating in an MBC DMHI administered by Bend Health Inc, a mental health care provider that uses a collaborative care model to assess changes in anxiety and depressive symptoms during participation in the MBC DMHI.

METHODS

Caregivers of children and adolescents participating in Bend Health Inc for anxiety or depressive symptoms reported measures of their children's symptoms every 30 days throughout the duration of participation in Bend Health Inc. Data from 114 children (age 6-12 years) and adolescents (age 13-17 years) were used for the analyses (anxiety symptom group: n=98, depressive symptom group: n=61).

RESULTS

Among children and adolescents participating in care with Bend Health Inc, 73% (72/98) exhibited improvements in anxiety symptoms and 73% (44/61) exhibited improvement in depressive symptoms, as indicated by either a decrease in symptom severity or screening out of completing the complete assessment. Among those with complete assessment data, group-level anxiety symptom T-scores exhibited a moderate decrease of 4.69 points (P=.002) from the first to the last assessment. However, members' depressive symptom T-scores remained largely stable throughout their involvement.

CONCLUSIONS

As increasing numbers of young people and families seek DMHIs over traditional mental health treatments due to their accessibility and affordability, this study offers promising early evidence that youth anxiety symptoms decrease during involvement in an MBC DMHI such as Bend Health Inc. However, further analyses with enhanced longitudinal symptom measures are necessary to determine whether depressive symptoms show similar improvements among those involved in Bend Health Inc.

Young Adults' Mental Health and Unmet Service Needs in the Context of the COVID-19 Pandemic Across Canada and France

While young adults experienced mental health challenges during the COVID-19 pandemic, little is known about how their mental health needs were subsequently met through access to mental health services (MHS). From October to December 2020, we conducted an online survey of young adults (18-29 years) living in Canada and France to investigate factors associated with unmet MHS needs. Of the 3222 participants expressing a need to access MHS (50.7% of the total sample), 58.2% in Canada and 74.8% in France reported unmet MHS needs. In both countries, those who identified as men and those who lost income due to COVID-19, were more likely to report unmet MHS needs. In Canada, participants from Quebec, those living in rural areas, and those who experienced ethno-racial discrimination had higher odds of reporting such unmet needs. Urgent investments are needed to improve access to MHS for young adults during and after the COVID-19 pandemic.

A Creative and Movement-Based Blended Intervention for Children in Outpatient Residential Care: A Mixed-Method, Multi-Center, Single-Arm Feasibility Trial

The COVID-19 pandemic led to psychological distress among children and adolescents. Due to multiple psychosocial burdens, the youth in residential care were especially exposed to an increased risk of mental health problems during the pandemic. In a multi-center, single-arm feasibility trial, N = 45 children and adolescents aged 7-14 years were allocated to a 6-week blended care intervention, conducted in six outpatient residential child welfare facilities. The intervention covered a once weekly face-to-face group session for guided creative (art therapy, drama therapy) and movement-oriented (children's yoga, nature therapy) activities. This was accompanied by a resilience-oriented mental-health app. Feasibility and acceptance analyses covered app usage data and qualitative data. Effectiveness was determined by pre-post comparisons in quantitative data on psychological symptoms and resources. Further, subgroups for poorer treatment outcome were explored. The intervention and app were considered to be feasible and were accepted by residential staff and the children. No significant pre-post changes were found across quantitative outcomes. However, being female, being in current psychosocial crisis, a migration background, or a mentally ill parent were correlated with change in score of outcomes from baseline. These preliminary findings pave the way for future research on blended care interventions among at-risk children and adolescents.

Co-designing a digital mental health platform, "Momentum", with young people aged 7-17: A qualitative study

Introduction

Digital mental health interventions (DMHIs) offer a promising alternative or adjunct treatment method to face-to-face treatment, overcoming barriers associated with stigma, access, and cost. This project is embedded in user experience and co-design to enhance the potential acceptability, usability and integration of digital platforms into youth mental health services.

Objective

To co-design a digital mental health platform that provides self-directed, tailored, and modularised treatment for young people aged 7-17 years experiencing anxiety, depression and other related problems.

Methods

Sixty-eight participants, aged 7-17 years, engaged in one of 20 co-design workshops. Eight workshops involved children (n  =  26, m  =  9.42 years, sd  =  1.27) and 12 involved adolescents (n  =  42, m  =  14.57 years, sd  =  1.89). Participants engaged in a variety of co-design activities (e.g., designing a website home page and rating self-report assessment features). Workshop transcripts and artefacts (e.g., participants' drawings) were thematically analysed using Gale et al.'s Framework Method in NVivo.

Results

Six themes were identified: Interactive; Relatable; Customisable; Intuitive; Inclusive; and Personalised, transparent and trustworthy content. The analysis revealed differences between children's and adolescents' designs and ideas, supporting the need for two different versions of the platform, with age-appropriate activities, features, terminology, and content.

Conclusions

This research showcased co-design as a powerful tool to facilitate collaboration with young people in designing DMHIs. Two sets of recommendations were produced: 1) recommendations for the design, functionality, and content of youth DMHIs, supported by child- and adolescent-designed strategies; and 2) recommendations for clinicians and researchers planning to conduct co-design and intervention development research with children and adolescents.

Interventions with Digital Tools for Mental Health Promotion among 11-18 Year Olds: A Systematic Review and Meta-Analysis

The availability of digital tools aiming to promote adolescent mental health is rapidly increasing. However, the field lacks an up-to-date and focused review of current evidence. This study thus looked into the characteristics and efficacy of digital, evidence-based mental health programs for youth (11-18 years). The selection procedure followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and resulted in 27 eligible studies. The high heterogeneity of the results calls for careful interpretation. Nevertheless, small, but promising, effects of digital tools were found with respect to promoting well-being, relieving anxiety, and enhancing protective factors. Some important factors influencing overall efficacy include the given setting, the level of guidance and support, and the adherence to the intervention.

Evaluation of the Use of Digital Mental Health Platforms and Interventions: Scoping Review

BACKGROUND

The increasing use of digital mental health (DMH) platforms and digital mental health interventions (DMHIs) is hindered by uncertainty over effectiveness, quality and usability. There is a need to identify the types of available evidence in this domain.

AIM

This study is a scoping review identifying evaluation of the (1) DMH platform/s used; and (2) DMHI/s applied on the DMH platform/s.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guided the review process. Empirical studies that focused on evaluation of the use and application of DMH platforms were included from journal articles (published 2012-2022). A literature search was conducted using four electronic databases (Scopus, ScienceDirect, Sage and ACM Digital Library) and two search engines (PubMed and Google Scholar).

RESULTS

A total of 6874 nonduplicate records were identified, of which 144 were analyzed and 22 met the inclusion criteria. The review included general/unspecified mental health and/or suicidality indications (n = 9, 40.9%), followed by depression (n = 5, 22.7%), psychosis (n = 3, 13.6%), anxiety and depression (n = 2, 9.1%), as well as anxiety, depression and suicidality (n = 1, 4.5%), loneliness (n = 1, 4.5%), and addiction (n = 1, 4.5%). There were 11 qualitative studies (50%), 8 quantitative studies (36.4%), and 3 mixed-methods studies (n = 3, 13.6%). The results contained 11 studies that evaluated the DMH platform/s and 11 studies that evaluated the DMHI/s. The studies focused on feasibility, usability, engagement, acceptability and effectiveness. There was a small amount of significant evidence (1 in each 11), notably the (cost-)effectiveness of a DMHI with significant long-term impact on anxiety and depression in adults.

CONCLUSION

The empirical research demonstrates the feasibility of DMH platforms and DMHIs. To date, there is mostly heterogeneous, preliminary evidence for their effectiveness, quality and usability. However, a scalable DMHI reported effectiveness in treating adults' anxiety and depression. The scope of effectiveness may be widened through targeted strategies, for example by engaging independent young people.

Assessing diversity and inclusivity is the next frontier in mental health recovery narrative research and practice (Preprint)

Demand for digital health interventions is increasing in many countries. The use of recorded mental health recovery narratives in digital health interventions is becoming more widespread in clinical practice. Mental health recovery narratives are first-person lived experience accounts of recovery from mental health problems, including struggles and successes over time. Helpful impacts of recorded mental health recovery narratives include connectedness with the narrative and validation of experiences. Possible harms include feeling disconnected and excluded from others. Diverse narrative collections from many types of narrators and describing multiple ways to recover are important to maximize the opportunity for service users to benefit through connection and to minimize the likelihood of harm. Mental health clinicians need to know whether narrative collections are sufficiently diverse to recommend to service users. However, no method exists for assessing the diversity and inclusivity of existing or new narrative collections. We argue that assessing diversity and inclusivity is the next frontier in mental health recovery narrative research and practice. This is important, but methodologically and ethically complex. In this viewpoint, we propose and evaluate one diversity and two inclusivity assessment methods. The diversity assessment method involves use of the Simpson Diversity Index. The two inclusivity assessment methods are based on comparator demographic rates and arbitrary thresholds, respectively. These methods were applied to four narrative collections as a case study. Refinements are needed regarding a narrative assessment tool in terms of its practicality and cultural adaptation.

Artificial intelligence-informed mobile mental health apps for young people: a mixed-methods approach on users' and stakeholders' perspectives

BACKGROUND

Novel approaches in mobile mental health (mHealth) apps that make use of Artificial Intelligence (AI), Ecological Momentary Assessments, and Ecological Momentary Interventions have the potential to support young people in the achievement of mental health and wellbeing goals. However, little is known on the perspectives of young people and mental health experts on this rapidly advancing technology. This study aims to investigate the subjective needs, attitudes, and preferences of key stakeholders towards an AI-informed mHealth app, including young people and experts on mHealth promotion and prevention in youth.

METHODS

We used a convergent parallel mixed-method study design. Two semi-structured online focus groups (n = 8) and expert interviews (n = 5) to explore users and stakeholders perspectives were conducted. Furthermore a representative online survey was completed by young people (n = 666) to investigate attitudes, current use and preferences towards apps for mental health promotion and prevention.

RESULTS

Survey results show that more than two-thirds of young people have experience with mHealth apps, and 60% make regular use of 1-2 apps. A minority (17%) reported to feel negative about the application of AI in general, and 19% were negative about the embedding of AI in mHealth apps. This is in line with qualitative findings, where young people displayed rather positive attitudes towards AI and its integration into mHealth apps. Participants reported pragmatic attitudes towards data sharing and safety practices, implying openness to share data if it adds value for users and if the data request is not too intimate, however demanded transparency of data usage and control over personalization. Experts perceived AI-informed mHealth apps as a complementary solution to on-site delivered interventions in future health promotion among young people. Experts emphasized opportunities in regard with low-threshold access through the use of smartphones, and the chance to reach young people in risk situations.

CONCLUSIONS

The findings of this exploratory study highlight the importance of further participatory development of training components prior to implementation of a digital mHealth training in routine practice of mental health promotion and prevention. Our results may help to guide developments based on stakeholders' first recommendations for an AI-informed mHealth app.

Effects of COVID-19 on Adolescent Mental Health and Internet Use by Ethnicity and Gender: A Mixed–Method Study

Evidence suggests that mental health problems in young people have been exacerbated by COVID-19, possibly related to a lack of social connection. Young people report using the internet for connecting with their peers and mental health support. However, how they may have used the internet for support during COVID-19 is not clear. We wanted to know how mood and internet use may have changed in young people during COVID-19 and if this was different for those with and without depression symptoms. 108 adolescents were recruited. Participants with high and low levels of depressive symptomatology answered questions about their mood, internet use, loneliness and life satisfaction during July and August 2020. We found that the high depression group reported significantly more loneliness and less life satisfaction than the low depression group. We found that most young people used the internet for mental health information during COVID-19 but that the high depression group used the internet more for mental health information than the low depression group. The high depression group also had a worsening of mood compared to the low depression group during COVID-19. We found that Black, Asian and Minority Ethnic participants reported increased use of the internet compared to White participants during COVID-19 and that the role of the family facilitated coping during COVID-19 for some adolescents, but for others, it made the lockdown more difficult. Finally, we found that adolescents perceived school anxiety as stressful as COVID-19. To conclude this study supports the use of the internet as a way to help young people with mental health challenges. It also suggests that the internet is a way to help young people from ethnic minorities, who otherwise might be hard to reach, during challenging times. This study also shows that supportive family units can be important during times of stress for young people and that school anxiety is a major issue for young people in today’s society even outside of the pandemic.

A Remote Assessment of Anxiety on Young People: Towards Their Views and Their Different Pet Interaction

The lockdown was imposed in Italy on 9 March 2020 due to the COVID-19 outbreak. Restrictions severely limiting individual freedom were indispensable to protect the population and reduce virus diffusion. Italian people had never before experienced similar restrictions that undoubtedly tested psychological health. After 1 week, we developed an electronic survey to collect demographic data and information on the presence of pets and the type of interaction with them and to administer a self-assessment anxiety test. A total of 3905 subjects, pet owners and non pet owners, filled in the electronic survey; 652 (16.7%, mean age 21.6) of them were young subjects, adolescents, and university students. The study first showed the feasibility and success of the technological solution used, capable of providing, at a distance, structured information on the participants and quantitative data on the psychological condition. Second, it reported that 23.1% of the youths showed anxiety above an attention level during the lockdown, in line with other studies. Third, it indicated, based on the outcome of the self-assessment test, that the pet presence could have a positive effect in mitigating the psychological impact and encourage to continue and deepen these investigations. Fourth, it reported positive feedback from the participants on the procedure, found useful during the pandemic and for the post-pandemic future. The study highlights the importance of investing in these solutions based on mobile technology and useful both for mental health and to deepen the investigation of the impact of the pet presence on the human psychology.

Understanding Mental Health Apps for Youth: A Focus Group Study with Latinx Youth (Preprint)

Background

An increasing number of mental health apps (MHapps) are being developed for youth. In addition, youth are high users of both technologies and MHapps. However, little is known about their perspectives on MHapps. MHapps might be particularly well suited to reach the youth underserved by traditional mental health resources, and incorporating their perspectives is especially critical to ensure such tools are useful to them.

Objective

The goal of this study was to develop and pilot a process for eliciting youth perspectives on MHapps in a structured and collaborative way. We also sought to generate learnings on the perspectives of Latinx youth on MHapps and their use in ways that might facilitate discovery, activation, or engagement in MHapps, especially in Latinx populations.

Methods

We created a series of focus groups consisting of 5 sessions. The groups introduced different categories of MHapps (cognitive behavioral therapy apps, mindfulness apps, and miscellaneous apps). Within each category, we selected 4 MHapps that participants chose to use for a week and provided feedback through both between-session and in-session activities. We recruited 5 youths ranging in age from 15 to 21 (mean 18, SD 2.2) years. All the participants identified as Hispanic or Latinx. After completing all 5 focus groups, the participants completed a brief questionnaire to gather their impressions of the apps they had used.

Results

Our focus group methodology collected detailed and diverse information about youth perspectives on MHapps. However, we did identify some aspects of our methods that were less successful at engaging the youth, such as our between-session activities. The Latinx youth in our study wanted apps that were accessible, relatable, youth centric, and simple and could be integrated with their offline lives. We also found that the mindfulness apps were viewed most favorably but that the miscellaneous and cognitive behavioral therapy apps were viewed as more impactful.

Conclusions

Eliciting youth feedback on MHapps is critical if these apps are going to serve a role in supporting their mental health and well-being. We refined a process for collecting feedback from the youth and identified factors that were important to a set of Latinx youth. Future work could be broader, that is, recruit larger samples of more diverse youth, or deeper, that is, collect more information from each youth around interests, needs, barriers, or facilitators or better understand the various impacts of MHapps by using qualitative and quantitative measures. Nevertheless, this study advances the formative understanding of how the youth, particularly Latinx youth, might be viewing these tools.

Rapid Evidence Review of Digital Cognitive-Behavioral Therapy for Adolescents With Depression

PURPOSE

We conducted a rapid evidence review to explore the benefits and harms of digital cognitive-behavioral therapy (dCBT) and the barriers to and facilitators of implementing dCBT for adolescents.

METHODS

We searched MEDLINE, PsycINFO, CENTRAL through December 6, 2021, for controlled trials conducted in settings highly applicable to the United States. Additionally, we searched relevant systematic reviews for eligible studies. Results were summarized qualitatively.

RESULTS

We included 12 trials (n = 1,575) that examined the effects of nine dCBT programs. Overall, dCBT was slightly superior to comparators in improving depression symptoms immediately post-intervention, but not at a longer follow-up. The use of dCBT did not appear to result in an increased risk for suicidal attempts or ideation; however, the number of events was very small. Potential barriers to implementing/maintaining dCBT are challenges engaging/retaining patients, developing infrastructure, and training therapists to facilitate dCBT. Data on harms or unintended negative consequences were not reported in the included studies.

CONCLUSIONS

A limited body of evidence suggests that dCBT programs might outperform control interventions for reducing depressive symptoms immediately post-intervention, but not at a longer follow-up. The safety of dCBT programs for adolescents with depression is understudied.

Recruitment and retention in mobile application-based intervention studies: a critical synopsis of challenges and opportunities

Use of mobile health applications (mHealth apps) is becoming increasingly popular for the management of chronic illnesses, but mHealth-based intervention studies often have limitations associated with subject recruitment and retention. In this synopsis, we focus on targeted aspects of mHealth-based intervention studies, specifically: (i) subject recruitment, (ii) cohort sizes, and (iii) retention rates. We used the Google Scholar (meta-search) and Galileo search engines to identify sample articles focusing on mHealth apps and interventions published between 2010 and 2020 and selected 21 papers for detailed review. Most studies recruited relatively small cohorts (minimum: 20, maximum: 510). Retention rates had high variance with only five studies managing >80% subject retention throughout the study duration, 10.4% being the lowest. Eighty-five percent of the studies expressed concerns regarding study duration, app usage, and lack of proper implementation. The use of mHealth interventions generally yielded positive outcomes, but most studies discussed facing challenges associated with recruitment and retention. There is a clear need to identify strategies for recruiting larger cohorts and improving retention rates, and ultimately increasing the reliability of mHealth app-based intervention studies. We advise that potential underutilized opportunities lie at the intersection of mHealth and social media to address the limitations identified in the synopsis.

Patient and public involvement to build trust in artificial intelligence: A framework, tools, and case studies

Artificial intelligence (AI) is increasingly taking on a greater role in healthcare. However, hype and negative news reports about AI abound. Integrating patient and public involvement (PPI) in healthcare AI projects may help in adoption and acceptance of these technologies.

We argue that AI algorithms should also be co-designed with patients and healthcare workers.

We specifically suggest (1) including patients with lived experience of the disease, and (2) creating a research advisory group (RAG) and using these group meetings to walk patients through the process of AI model building, starting with simple (e.g., linear) models.

We present a framework, case studies, best practices, and tools for applying participative data science to healthcare, enabling data scientists, clinicians, and patients to work together. The strategy of co-designing with patients can help set more realistic expectations for all stakeholders, since conventional narratives of AI revolve around dystopia or limitless optimism.

Hype and negative news reports about artificial intelligence (AI) abound. Involving patients in healthcare AI projects may help in adoption and acceptance of these technologies. We argue that AI algorithms should be co-designed with patients and healthcare workers.

We show examples of how to involve patients in AI research and how patients can build trust in algorithms. We share some best practices, case studies, a framework, and computational tools.

Avenues for future work include guidelines for patient and public involvement in AI healthcare research for funding bodies and regulatory agencies.

An understanding of what AI can and cannot do, and a realistic appraisal of risks and benefits, may help in adoption and democratize access to AI for healthcare.

Pet Presence Can Reduce Anxiety in the Elderly: The Italian Experience during COVID-19 Lockdown Assessed by an Electronic Survey

The lockdown imposed in Italy due to the COVID-19 outbreak required restrictions that severely limited individual freedom to protect the population and reduce virus diffusion. This situation psychologically challenged the entire Italian population but mostly the elderly. The "Digital mental health approach" employs digital tools to evaluate and prevent increasing mental health problems. "Anonymous online electronic surveys" are digital tools that assess rates of mental health outcomes (using for example self-assessment/awareness tools). Immediately at the beginning of restrictions, we designed an electronic survey a) to remotely investigate the psychological impact of the lockdown and b) to compare the anxiety between pet owners and not-pet owners. A total of 3905 subjects filled out the survey; we focused our study on 781 (20%) elderly subjects. Dividing elderly patients between pet-owners (n = 405) and not-pet owners (n = 376), the pet owners showed a Zung scale score significantly lower in respect to the not-pet owners. We observed that, during the COVID-19 outbreak, the pet presence could have a positive effect on anxiety in the elderly subject. These results: (A) encourage the use of mobile technologies for the assessment of psychological disorders that can be promptly employed in emergencies such as the COVID-19 outbreak; (B) highlight the positive effect of pet interaction to mitigate the psychological distress in elderly people.

The Grow It! app-longitudinal changes in adolescent well-being during the COVID-19 pandemic: a proof-of-concept study

Adolescent mental health and well-being have been adversely impacted by the COVID-19 pandemic. In this preregistered longitudinal study, we evaluated whether adolescents' well-being improved after playing the multiplayer serious game app Grow It! During the first lockdown (May-June 2020), 1282 Dutch adolescents played the Grow It! app (age = 16.67, SD = 3.07, 68% girls). During the second lockdown (December-May 2020 onwards), an independent cohort of 1871 adolescents participated (age = 18.66, SD = 3.70, 81% girls). Adolescents answered online questionnaires regarding affective and cognitive well-being, depressive symptoms, anxiety, and impact of COVID-19 at baseline. Three to six weeks later, the baseline questionnaire was repeated and user experience questions were asked (N = 462 and N = 733 for the first and second cohort). In both cohorts, affective and cognitive well-being increased after playing the Grow It! app (t = - 6.806, p < 0.001; t = - 6.77, p < 0.001; t = - 6.12, p < 0.001; t = - 5.93, p < 0.001; Cohen's d range 0.20-0.32). At the individual level, 41-53% of the adolescents increased in their affective or cognitive well-being. Adolescents with higher risk profiles (i.e., more depressive symptoms, lower atmosphere at home, and more COVID-19 impact) improved more strongly in their well-being. Positive user evaluations and app engagement were unrelated to changes in affective and cognitive well-being. This proof-of-concept study tentatively suggests that Grow It! supported adolescents during the pandemic.

Meeting Users Where They Are: User-centered Design of an Automated Text Messaging Tool to Support the Mental Health of Young Adults

Young adults have high rates of mental health conditions, but most do not want or cannot access formal treatment. We therefore recruited young adults with depression or anxiety symptoms to co-design a digital tool for self-managing their mental health concerns. Through study activities-consisting of an online discussion group and a series of design workshops-participants highlighted the importance of easy-to-use digital tools that allow them to exercise independence in their self-management. They described ways that an automated messaging tool might benefit them by: facilitating experimentation with diverse concepts and experiences; allowing variable depth of engagement based on preferences, availability, and mood; and collecting feedback to personalize the tool. While participants wanted to feel supported by an automated tool, they cautioned against incorporating an overtly human-like motivational tone. We discuss ways to apply these findings to improve the design and dissemination of digital mental health tools for young adults.

Effectiveness of digital mental health interventions for university students: an umbrella review

Background

Poor mental health among university students remains a pressing public health issue. Over the past few years, digital health interventions have been developed and considered promising in increasing psychological wellbeing among university students. Therefore, this umbrella review aims to synthesize evidence on digital health interventions targeting university students and to evaluate their effectiveness.

Methods

A systematic literature search was performed in April 2021 searching PubMed, Psychology and Behavioural Science Collection, Web of Science, ERIC, and Scopus for systematic reviews and meta-analyses on digital mental health interventions targeting university students. The review protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO [CRD42021234773].

Results

The initital literature search resulted in 806 records of which seven remained after duplicates were removed and evaluated against the inclusion criteria. Effectiveness was reported and categorized into the following six delivery types: (a) web-based, online/computer-delivered interventions (b) computer-based Cognitive Behavior Therapy (CBT), (c) mobile applications and short message service (d) virtual reality interventions (e) skills training (f) relaxation and exposure-based therapy. Results indicated web-based online/computer delivered-interventions were effective or at least partially effective at decressing depression, anxiety, stress and eating disorder symptoms. This was similar for skills-training interventions, CBT-based intervention and mobile applications. However, digital mental health interventions using virtual reality and relaxation, exposure-based therapy was inconclusive. Due to the variation in study settings and inconsistencies in reporting, effectiveness was greatly dependent on the delivery format, targeted mental health problem and targeted purpose group.

Conclusion

The findings provide evidence for the beneficial effect of digital mental health interventions for university students. However, this review calls for a more systematic approach in testing and reporting the effectiveness of digital mental health interventions.

Digital Prompts to Increase Engagement With the Headspace App and for Stress Regulation Among Parents: Feasibility Study

Background

Given the interrelated health of children and parents, strategies to promote stress regulation are critically important in the family context. However, the uptake of preventive mental health is limited among parents owing to competing family demands.

Objective

In this study, we aim to determine whether it is feasible and acceptable to randomize digital prompts designed to engage parents in real-time brief mindfulness activities guided by a commercially available app.

Methods

We conducted a 30-day pilot microrandomized trial among a sample of parents who used Android smartphones. Each day during a parent-specified time frame, participants had a 50% probability of receiving a prompt with a message encouraging them to engage in a mindfulness activity using a commercial app, Headspace. In the 24 hours following randomization, ecological momentary assessments and passively collected smartphone data were used to assess proximal engagement (yes or no) with the app and any mindfulness activity (with or without the app). These data were combined with baseline and exit surveys to determine feasibility and acceptability.

Results

Over 4 months, 83 interested parents were screened, 48 were eligible, 16 were enrolled, and 10 were successfully onboarded. Reasons for nonparticipation included technology barriers, privacy concerns, time constraints, or change of mind. In total, 80% (8/10) of parents who onboarded successfully completed all aspects of the intervention. While it is feasible to randomize prompt delivery, only 60% (6/10) of parents reported that the timing of prompts was helpful despite having control over the delivery window. Across the study period, we observed higher self-reported engagement with Headspace on days with prompts (31/62, 50% of days), as opposed to days without prompts (33/103, 32% of days). This pattern was consistent for most participants in this study (7/8, 87%). The time spent using the app on days with prompts (mean 566, SD 378 seconds) was descriptively higher than on days without prompts (mean 225, SD 276 seconds). App usage was highest during the first week and declined over each of the remaining 3 weeks. However, self-reported engagement in mindfulness activities without the app increased over time. Self-reported engagement with any mindfulness activity was similar on days with (40/62, 65% of days) and without (65/103, 63% of days) prompts. Participants found the Headspace app helpful (10/10, 100%) and would recommend the program to others (9/10, 90%).

Conclusions

Preliminary findings suggest that parents are receptive to using mindfulness apps to support stress management, and prompts are likely to increase engagement with the app. However, we identified several implementation challenges in the current trial, specifically a need to optimize prompt timing and frequency as a strategy to engage users in preventive digital mental health.

A cognitive behavioural therapy smartphone app for adolescent depression and anxiety: co-design of ClearlyMe

Adolescence is associated with heightened vulnerability to symptoms of depression and anxiety. In-person and computerised cognitive behavioural therapy (CBT) are effective treatment options, yet uptake and engagement remain low. Smartphone delivery of CBT offers an alternative, highly accessible method of delivering CBT. However, there is no freely available CBT smartphone application (app) specifically designed to reduce depression and anxiety symptoms in adolescents. The aim of this study was to design a new CBT smartphone app (ClearlyMe) that targets depressive and anxiety symptoms in adolescents. We engaged in a rigorous co-design process with adolescents (n=36), parents (n=15), and mental health professionals (n=32). Co-design involved: (1) discovery of users’ needs, views and preferences by conducting focus groups, (2) defining app features through ideation workshops and user consultations, (3) designing therapeutic CBT content and visual features, and (4) testing prototypes. Users were involved at every step and the process was iterative, with findings carried forward to ensure continued refinement of concepts and features. We found a preference for vibrant, cheerful colours and illustrations and non-endorsement of gamification and chatbots, which contrasted with findings from other studies. Preferences were largely consistent between the three user groups. However, adolescents preferred an app that could be used autonomously without professional support, whereas mental health professionals desired a product for use as a therapy adjunct to support CBT skill development. The importance of co-design, and particularly the inclusion of all stakeholders throughout the entire co-design process, is discussed in relation to the design of ClearlyMe.

Key learning aims

(1)

A Smartphone Serious Game for Adolescents (Grow It! App): Development, Feasibility, and Acceptance Study

Background

Anxiety and mood problems in adolescents often go unnoticed and may therefore remain untreated. Identifying and preventing the development of emotional problems requires monitoring and effective tools to strengthen adolescents' resilience, for example, by enhancing coping skills.

Objective

This study describes the developmental process, feasibility, and acceptance of Grow It!, a multiplayer serious game app for adolescents aged 12-25 years. The app consists of the experience sampling method (ESM) to monitor thoughts, behaviors, and emotions in daily life to enhance self-insight and daily cognitive behavioral therapy–based challenges to promote adaptive coping.

Methods

Our approach entails an iterative game design process combined with an agile method to develop the smartphone app. The incorporated game features (ie, challenges, chat functionality, and visual representation) in the Grow It! app were co-designed with adolescent end users to increase participant engagement and adherence.

Results

The Grow It! app was delivered for Android and iOS in May 2020. Grow It! was offered to adolescents during the COVID-19 crisis between May and December 2020. Participants of the Grow It! COVID-19 study (sample 1: N=685; mean age 16.19, SD 3.11 years; 193/685, 28.2% boys; sample 2: N=1035; mean age 18.78, SD 3.51 years; 193/1035, 18.64% boys) completed 31.5% (13.2/42) to 49.5% (10.4/21) of challenges. Compliance of ESM was suboptimal (35.1/210, 16.7% to 32.5/105, 30.9%). Follow-up questionnaires indicated an overall score of the app of 7.1 out of 10. Moreover, 72.6% (278/383) to 75.6% (487/644) would recommend the app to friends.

Conclusions

To our knowledge, Grow It! is the first gamified ESM app that both measures individual differences in emotional dynamics and offers an integrated cognitive behavioral therapy–based intervention. Our findings support the feasibility and acceptance, and therefore applicability, of the Grow It! app in adolescents. Further iterations of this serious game app will focus on the increase of compliance and on providing participants feedback through their personal mood profiles.

Determining Priorities in the Aboriginal and Islander Mental Health Initiative for Youth App Second Phase Participatory Design Project: Qualitative Study and Narrative Literature Review

Background

Digital mental health tools can promote access to culturally safe early intervention mental health services for Aboriginal and Torres Strait Islander young people. Participatory design methodology facilitates user engagement in the co-design of digital resources. However, several challenges have been identified that limit the methodological rigor of this approach.

Objective

This paper aims to present an in-depth account of the second phase of participatory design in the development of the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) app.

Methods

A first idea storyboard, generated from a formative phase of the AIMhi-Y project, was refined through a series of youth co-design workshops and meetings. A narrative review of the literature, 6 service provider interviews, and engagement with an expert reference group also informed the design process. Generative design activities, storyboarding, discussions, and voting strategies were used.

Results

The participatory design process identified the app features preferred by young people and service providers and assessed their alignment with current recommendations from the scientific literature. Findings from the co-design process are presented across 9 app characteristic domains. Integration of findings into app design proved complex. Although most preferred features identified by young people were included to some degree, other inclusions were restricted by budget, time, and the need to integrate best practice recommendations. A process of prioritization was required.

Conclusions

Participatory design is often cited in the development of digital mental health resources; however, methods are diverse and often lack detailed descriptions. This study reports the outcomes and strategies used to determine priorities in the second phase of the development of the AIMhi-Y app. We provide an example and the key learnings to inform others seeking to use participatory design with a similar cohort.

Effectiveness, User Engagement and Experience, and Safety of a Mobile App (Lumi Nova) Delivering Exposure-Based Cognitive Behavioral Therapy Strategies to Manage Anxiety in Children via Immersive Gaming Technology: Preliminary Evaluation Study

BACKGROUND

Childhood anxiety disorders are a prevalent mental health problem that can be treated effectively with cognitive behavioral therapy, in which exposure is a key component; however, access to treatment is poor. Mobile-based apps on smartphones or tablets may facilitate the delivery of evidence-based therapy for child anxiety, thereby overcoming the access and engagement barriers of traditional treatment. Apps that deliver therapeutic content via immersive gaming technology could offer an effective, highly engaging, and flexible treatment proposition.

OBJECTIVE

In this paper, we aim to describe a preliminary multi-method evaluation of Lumi Nova, a mobile app intervention targeting mild to moderate anxiety problems in children aged 7-12 years using exposure therapy delivered via an immersive game. The primary objective is to evaluate the effectiveness, user engagement and experience, and safety of the beta version of Lumi Nova.

METHODS

Lumi Nova was co-designed with children, parents, teachers, clinicians, game industry experts, and academic partnerships. In total, 120 community-based children with mild to moderate anxiety and their guardians were enrolled to participate in an 8-week pilot study. The outcome measures captured the app's effectiveness (anxiety symptoms, child-identified goal-based outcomes, and functional impairment), user engagement (game play data and ease-of-use ratings), and safety (mood ratings and adverse events). The outcome measures before and after the intervention were available for 30 children (age: mean 9.8, SD 1.7 years; girls: 18/30, 60%; White: 24/30, 80%). Additional game play data were automatically generated for 67 children (age: mean 9.6, SD 1.53 years; girls: 35/67, 52%; White: 42/67, 63%). Postintervention open-response data from 53% (16/30) of guardians relating to the primary objectives were also examined.

RESULTS

Playing Lumi Nova was effective in reducing anxiety symptom severity over the 8-week period of game play (t₂₉=2.79; P=.009; Cohen d=0.35) and making progress toward treatment goals (z=2.43; P=.02), but there were no improvements in relation to functional impairment. Children found it easy to play the game and engaged safely with therapeutic content. However, the positive effects were small, and there were limitations to the game play data.

CONCLUSIONS

This preliminary study provides initial evidence that an immersive mobile game app may safely benefit children experiencing mild to moderate anxiety. It also demonstrates the value of the rigorous evaluation of digital interventions during the development process to rapidly improve readiness for full market launch.

A Transdiagnostic, Emotion Regulation App (Eda) for Children: Design, Development, and Lessons Learned

BACKGROUND

Digital interventions, including mobile apps, represent a promising means of providing effective mental health support to children and young people. Despite the increased availability of mental health apps, there is a significant gap for this age group, especially for children (aged 10-12 years). Research investigating the effectiveness and development process of child mental health apps is limited, and the field faces persistent issues in relation to low user uptake and engagement, which is assumed to be a result of limited user involvement in the design process.

OBJECTIVE

This study aims to present the development and design process of a new mental health app for children that targets their emotion regulation abilities. We describe the creation of a new interdisciplinary development framework to guide the design process and explain how each activity informed different app features.

METHODS

The first 2 stages of the framework used a variety of methods, including weekly classroom observations over a 6-month period (20 in total); public engagement events with the target group (N=21); synthesis of the existing evidence as part of a meta-analysis; a series of co-design and participatory workshops with young users (N=33), clinicians (N=7), researchers (N=12), app developers (N=1), and designers (N=2); and finally, testing of the first high-tech prototype (N=15).

RESULTS

For the interdisciplinary framework, we drew on methods derived from the Medical Research Council framework for complex interventions, the patient-clinician framework, and the Druin cooperative inquiry. The classroom observations, public engagement events, and synthesis of the existing evidence informed the first key pillars of the app and wireframes. Subsequently, a series of workshops shaped and reshaped the content and app features, including games, psychoeducational films, and practice modules. On the basis of the prototype testing sessions, we made further adjustments to improve the app.

CONCLUSIONS

Although mobile apps could be highly suitable to support children's mental health on a wider scale, there is little guidance on how these interventions could be designed and developed. The involvement of young users across different design activities is very valuable. We hope that our interdisciplinary framework and description of the used methods will be helpful to others who are hoping to develop mental health apps for children and young people.