The CLIMATE schools combined study: a cluster randomised controlled trial of a universal Internet-based prevention program for youth substance misuse, depression and anxiety

The Triple E project: a factorial randomised controlled trial to enhance engagement with eHealth approaches to improve health risk behaviours among adolescents

BACKGROUND

Digital, or eHealth, interventions are highly promising approaches to help adolescents improve their health behaviours and reduce their risk of chronic disease. However, they often have low uptake and retention. There is also a paucity of high-quality research into the predictors of eHealth engagement, and a lack of studies that have systematically evaluated existing engagement strategies in adolescent populations. This paper describes the protocol for a randomised controlled trial which primarily aims to assess the effectiveness of different strategies in increasing engagement with a healthy lifestyles app, Health4Life. Associations between the engagement strategies and improvements in adolescent health behaviours (healthy eating, physical activity, sleep, recreational screen time, smoking, alcohol use) will also be examined, along with potential predictors of adolescents' intentions to use health apps and their use of the Health4Life app.

METHODS

The current study will aim to recruit 336 adolescent and parent/guardian dyads (total sample N = 672) primarily through Australia wide online advertising. All adolescent participants will have access to the Health4Life app (a multiple health behaviour change, self-monitoring mobile app). The trial will employ a 24 factorial design, where participants will be randomly allocated to receive 1 of 16 different combinations of the four engagement strategies to be evaluated: text messages, access to a health coach, access to additional gamified app content, and provision of parent/guardian information resources. Adolescents and parents/guardians will both complete consent processes, baseline assessments, and a follow-up assessment after 3 months. All participants will also be invited to complete a qualitative interview shortly after follow-up. The primary outcome, app engagement, will be assessed via an App Engagement Index (Ei) using data collected in the Health4Life app and the Mobile App Rating Scale - User version.

DISCUSSION

This research will contribute significantly to building our understanding of the types of strategies that are most effective in increasing adolescents' engagement with health apps and which factors may predict adolescents' use of health apps.

TRIAL REGISTRATION

The trial is registered at the Australian New Zealand Clinical Trials Registry (ACTRN12623000399695). Date registered: 19/04/2023.

Refining the Universal, School-Based OurFutures Mental Health Program to Be Trauma Informed, Gender and Sexuality Diversity Affirmative, and Adherent to Proportionate Universalism: Mixed Methods Participatory Design Process

BACKGROUND

Mental disorders are the leading cause of disease burden among youth. Effective prevention of mental disorders during adolescence is a critical public health strategy to reduce both individual and societal harms. Schools are an important setting for prevention; however, existing universal school-based mental health interventions have shown null, and occasionally iatrogenic, effects in preventing symptoms of common disorders, such as depression and anxiety.

OBJECTIVE

This study aims to report the adaptation process of an established, universal, school-based prevention program for depression and anxiety, OurFutures Mental Health. Using a 4-stage process; triangulating quantitative, qualitative, and evidence syntheses; and centering the voices of young people, the revised program is trauma-informed; lesbian, gay, bisexual, transgender, nonbinary, queer, questioning, and otherwise gender and sexuality diverse (LGBTQA+) affirmative; relevant to contemporary youth; and designed to tailor intervention dosage to those who need it most (proportionate universalism).

METHODS

Program adaptation occurred from April 2022 to July 2023 and involved 4 stages. Stage 1 comprised mixed methods analysis of student evaluation data (n=762; mean age 13.5, SD 0.62 y), collected immediately after delivering the OurFutures Mental Health program in a previous trial. Stage 2 consisted of 3 focus groups with high school students (n=39); regular meetings with a purpose-built, 8-member LGBTQA+ youth advisory committee; and 2 individual semistructured, in-depth interviews with LGBTQA+ young people via Zoom (Zoom Video Communications) or WhatsApp (Meta) text message. Stage 3 involved a clinical psychologist providing an in-depth review of all program materials with the view of enhancing readability, improving utility, and normalizing emotions while retaining key cognitive behavioral therapy elements. Finally, stage 4 involved fortnightly consultations among researchers and clinicians on the intervention adaptation, drawing on the latest evidence from existing literature in school-based prevention interventions, trauma-informed practice, and adolescent mental health.

RESULTS

Drawing on feedback from youth, clinical psychologists, and expert youth mental health researchers, sourced from stages 1 to 4, a series of adaptations were made to the storylines, characters, and delivery of therapeutic content contained in the weekly manualized program content, classroom activities, and weekly student and teacher lesson summaries.

CONCLUSIONS

The updated OurFutures Mental Health program is a trauma-informed, LBGTQA+ affirmative program aligned with the principles of proportionate universalism. The program adaptation responds to recent mixed findings on universal school-based mental health prevention programs, which include null, small beneficial, and small iatrogenic effects. The efficacy of the refined OurFutures Mental Health program is currently being tested through a cluster randomized controlled trial with up to 1400 students in 14 schools across Australia. It is hoped that the refined program will advance the current stalemate in universal school-based prevention of common mental disorders and ultimately improve the mental health and well-being of young people in schools.

The InterSECT Framework: a proposed model for explaining population-level trends in substance use and emotional concerns

Across high-income countries, adolescent emotional concerns have been increasing in prevalence over the past two decades and it is unclear why this is occurring, including whether and how substance use relates to these changing trends. On the other hand, substance use has been generally declining, and little is known about the role of emotional concerns in these trends. Several studies have explored the changes in co-occurring substance use and emotional concerns among adolescents over time, with mixed results and inconsistent messaging about the implications of the findings. In response, we developed a theoretical framework for exploring the intersection between trends in substance use and emotional concerns (InterSECT Framework). This framework includes a discussion and related examples for 3 core hypotheses: (1) strengthening of co-occurrence, or the "hardening" hypothesis; (2) co-occurrence staying the same, or the "consistency" hypothesis; and (3) weakening of co-occurrence, or the "decoupling" hypothesis. This framework seeks to guide the conceptualization, evaluation, and understanding of changes in the co-occurrence of substance use and emotional concerns over time, including outlining a research agenda informed by pre-existing research and youth perspectives.

Effectiveness of a universal, school-based, online programme for the prevention of anxiety, depression, and substance misuse among adolescents in Australia: 72-month outcomes from a cluster-randomised controlled trial

BACKGROUND

The CSC study found that the universal delivery of a school-based, online programme for the prevention of mental health and substance use disorders among adolescents resulted in improvements in mental health and substance use outcomes at 30-month follow-up. We aimed to compare the long-term effects of four interventions-Climate Schools Combined (CSC) mental health and substance use, Climate Schools Substance Use (CSSU) alone, Climate Schools Mental Health (CSMH) alone, and standard health education-on mental health and substance use outcomes among adolescents at 72-month follow-up into early adulthood.

METHODS

This long-term study followed up adolescents from a multicentre, cluster-randomised trial conducted across three states in Australia (New South Wales, Queensland, and Western Australia) enrolled between Sept 1, 2013, and Feb 28, 2014, for up to 72 months after baseline assessment. Adolescents (aged 18-20 years) from the original CSC study who accepted contact at 30-month follow-up and provided informed consent at 60-month follow-up were eligible. The interventions were delivered in school classrooms through an online delivery format and used a mixture of peer cartoon storyboards and classroom activities that were focused on alcohol, cannabis, anxiety, and depression. Participants took part in two web-based assessments at 60-month and 72-month follow-up. Primary outcomes were alcohol use, cannabis use, anxiety, and depression, measured by self-reported surveys and analysed by intention to treat (ie, in all students who were eligible at baseline). This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000723785), including the extended follow-up study.

FINDINGS

Of 6386 students enrolled from 71 schools, 1556 (24·4%) were randomly assigned to education as usual, 1739 (27·2%) to CSSU, 1594 (25·0%) to CSMH, and 1497 (23·4%) to CSC. 311 (22·2%) of 1401 participants in the control group, 394 (26·4%) of 1495 in the CSSU group, 477 (37·%) of 1289 in the CSMH group, and 400 (32·5%) of 1232 in the CSC group completed follow-up at 72 months. Adolescents in the CSC group reported slower year-by-year increases in weekly alcohol use (odds ratio 0·78 [95% CI 0·66-0·92]; p=0·0028) and heavy episodic drinking (0·69 [0·58-0·81]; p<0·0001) than did the control group. However, significant baseline differences between groups for drinking outcomes, and no difference in the predicted probability of weekly or heavy episodic drinking between groups were observed at 72 months. Sensitivity analyses increased uncertainty around estimates. No significant long-term differences were observed in relation to alcohol use disorder, cannabis use, cannabis use disorder, anxiety, or depression. No adverse events were reported during the trial.

INTERPRETATION

We found some evidence that a universal online programme for the prevention of anxiety, depression, and substance use delivered in early adolescence is effective in reducing the use and harmful use of alcohol into early adulthood. However, confidence in these findings is reduced due to baseline differences, and we did not see a difference in the predicted probability of drinking between groups at 72-month follow-up. These findings suggest that a universal prevention programme in adolescence is not sufficient to have lasting effects on mental health and substance use disorders in the long term. In addition to baseline differences, substantial attrition warrants caution in interpretation and the latter factor highlights the need for future long-term follow-up studies to invest in strategies to increase engagement.

FUNDING

Australian National Health and Medical Research Council.

Alcohol initiation before age 15 predicts earlier hazardous drinking: A survival analysis of a 7-year prospective longitudinal cohort of Australian adolescents

BACKGROUND AND AIMS

Early alcohol use may predict later alcohol problems, but the magnitude of this effect and impact of delayed onset remain uncertain. This study measured age-based differences in progression from first full alcoholic drink to hazardous drinking in one of the largest and most recent prospective cohorts of Australian adolescents.

DESIGN, SETTINGS, PARTICIPANTS AND MEASUREMENT

A 7-year (2012-19) prospective longitudinal cohort of 2082 Australian adolescents was established from the Climate and Preventure (cohort 1) and Climate Schools Combined (cohort 2) studies. Participants completed surveys annually from ages 13 to 20 years. Interval censored survival analyses were conducted with first episode of hazardous drinking [three or more on proxy Alcohol Use Disorders Identification Test (AUDIT-C)] as the survival end-point, controlling for age, sex and mental health symptomatology. Onset of hazardous drinking was expressed as hazard ratios (HRs), and median survival time (years) was used to model first onset of hazardous alcohol use in survival curves.

FINDINGS

Compared with those aged 15 or older, those who had their first full drink at 12 or younger had significantly elevated risk of hazardous drinking onset during the study period [log (HR): 9.3; 95% confidence interval (CI) = 7.0-12.0, P < 0.001]. Compared with those who had their first full drink at ages 13-14, those who delayed until 15 or older had significantly later onset of hazardous drinking; 1.63 years for males (95% CI = 1.31-1.92, P < 0.001) and 1.50 for females (95% CI = 1.15-1.81, P < 0.001), resulting in a median age of onset of hazardous drinking of > 19 for both sexes (male: 19.05 years, 95% CI = 18.74-19.38; female: 19.47 years, 95% CI = 19.19-19.75). First drink at ages 13-14 was associated with the earliest onset of hazardous drinking (males: 17.43 years; females: 17.98 years).

CONCLUSIONS

In Australia, alcohol initiation prior to age 15 appears to be associated with an earlier onset of hazardous drinking than initiation after age 15.

Structure of psychopathology in adolescents and its association with high-risk personality traits

The present study examined high-risk personality traits and associations with psychopathology across multiple levels of a hierarchical-dimensional model of psychopathology in a large adolescent, general population sample. Confirmatory factor analyses were run using data from two randomized controlled trials of Australian adolescents (N = 8,654, mean age = 13.01 years, 52% female). A higher-order model - comprised of general psychopathology, fear, distress, alcohol use/harms, and conduct/inattention dimensions - was selected based on model fit, reliability, and replicability. Indirect-effects models were estimated to examine the unique associations between high-risk personality traits (anxiety sensitivity, negative thinking, impulsivity, and sensation seeking) and general and specific dimensions and symptoms of psychopathology. All personality traits were positively associated with general psychopathology. After accounting for general psychopathology, anxiety sensitivity was positively associated with fear; negative thinking was positively associated with distress; impulsivity was positively associated with conduct/inattention; and sensation seeking was positively associated with alcohol use/harms and conduct/inattention, and negatively associated with fear. Several significant associations between personality traits and individual symptoms remained after accounting for general and specific psychopathology. These findings contribute to our understanding of the underlying structure of psychopathology among adolescents and have implications for the development of personality-based prevention and early intervention programs.

Evaluating the effectiveness of a universal eHealth school-based prevention programme for depression and anxiety, and the moderating role of friendship network characteristics

BACKGROUND

Lifetime trajectories of mental ill-health are often established during adolescence. Effective interventions to prevent the emergence of mental health problems are needed. In the current study we assessed the efficacy of the cognitive behavioural therapy (CBT)-informed Climate Schools universal eHealth preventive mental health programme, relative to a control. We also explored whether the intervention had differential effects on students with varying degrees of social connectedness.

METHOD

We evaluated the efficacy of the Climate Schools mental health programme (19 participating schools; average age at baseline was 13.6) v. a control group (18 participating schools; average age at baseline was 13.5) which formed part of a large cluster randomised controlled trial in Australian schools. Measures of internalising problems, depression and anxiety were collected at baseline, immediately following the intervention and at 6-, 12- and 18-months post intervention. Immediately following the intervention, 2539 students provided data on at least one outcome of interest (2065 students at 18 months post intervention).

RESULTS

Compared to controls, we found evidence that the standalone mental health intervention improved knowledge of mental health, however there was no evidence that the intervention improved other mental health outcomes, relative to a control. Student's social connectedness did not influence intervention outcomes.

CONCLUSION

These results are consistent with recent findings that universal school-based, CBT-informed, preventive interventions for mental health have limited efficacy in improving symptoms of anxiety and depression when delivered alone. We highlight the potential for combined intervention approaches, and more targeted interventions, to better improve mental health outcomes.

Longitudinal and self-attributed change in alcohol use among young adults during the COVID-19 pandemic in Australia

INTRODUCTION

The COVID-19 pandemic introduced a unique concern regarding the potential for pandemic-related increases in alcohol use. However, most studies which have measured pandemic-related changes to date utilise self-attribution measures of changes in alcohol use using cross-sectional designs, which rely on accurate self-attributions for validity. There has been minimal investigation of correspondence of self-attributed and longitudinally measured changes in alcohol use during the pandemic. The current study seeks to examine this correspondence.

METHODS

A total of 856 participants originally recruited from Australian secondary schools completed follow-up surveys of an ongoing study at two timepoints (2018-2019, mean age 18.6 and 2020-2021, mean age 19.9; 65.3% female). Alcohol use was measured as any drinking (1+ drinks) and binge drinking (5+ drinks) frequency in the past 6 months. The correspondence and relationship between 'longitudinal change' measured from the first to the second timepoint and 'self-attributed change' measured at the second timepoint were examined.

RESULTS

For both any drinking and binge drinking frequency, moderate correspondence was observed between self-attributed and longitudinal change in drinking (37.1% and 39.3%). Most participants with longitudinal increases in any drinking or binge drinking frequency failed to correctly self-attribute this increase.

DISCUSSION AND CONCLUSIONS

The findings suggest that self-attributed increases do not correspond well with longitudinally measured increases in pandemic-related drinking and may underestimate increases measured longitudinally. Method of measurement needs to be taken into account if data are to be used to identify sub-groups at risk of alcohol use increases and facilitate appropriate direction of public health efforts.

A Web-Based Alcohol and Other Drug Prevention Program (Strong & Deadly Futures) for Aboriginal and Torres Strait Islander School Students: Protocol for a Cluster Randomized Controlled Trial

Background

There are no available school-based alcohol and drug prevention programs with evidence of effectiveness among Aboriginal and Torres Strait Islander youth. To address this, we codeveloped the Strong & Deadly Futures well-being and alcohol and drug prevention program in partnership with an Indigenous creative design agency and 4 Australian schools.

Objective

This paper presents the protocol to evaluate the effectiveness of Strong & Deadly Futures in reducing alcohol and other drug use and improving well-being among Aboriginal and Torres Strait Islander youth.

Methods

The target sample will be 960 year 7 and 8 students from 24 secondary schools in Australia, of which approximately 40% (384/960) will identify as Aboriginal or Torres Strait Islander. The study design is a 2-group, parallel cluster randomized controlled trial with allocation concealment. Recruited schools will be block randomized (ratio 1:1), stratified by geographical remoteness, by an independent statistician. Schools will be randomized to receive Strong & Deadly Futures, a web-based alcohol and drug prevention and social and emotional well-being program that delivers curriculum-aligned content over 6 lessons via an illustrated story, or health education as usual (control). Control schools will be supported to implement Strong & Deadly Futures following trial completion. Surveys will be administered at baseline, 6 weeks, 12 months, and 24 months (primary end point) post baseline. Primary outcomes are alcohol use (adapted from the National Drug Strategy Household Survey), tobacco use (Standard High School Youth Risk Behavior Survey), and psychological distress (Kessler-5 Psychological Distress Scale). Secondary outcomes are alcohol and drug knowledge and intentions, alcohol-related harms, binge drinking, cannabis use, well-being, empowerment, appreciation of cultural diversity, and truancy.

Results

The trial was funded by the National Health and Medical Research Council in January 2019, approved by the Human Research Ethics Committee of the University of Sydney (2020/039, April 2020), the Aboriginal Health and Medical Research Council of New South Wales (1620/19, February 2020), the Western Australian Aboriginal Health Ethics Committee (998, October 2021), and the ethics committees of each participating school, including the New South Wales Department of Education (2020170, June 2020), Catholic Education Western Australia (RP2020/39, November 2020), and the Queensland Department of Education (550/27/2390, August 2021). Projected dates of data collection are 2022-2024, and we expect to publish the results in 2025. A total of 24 schools have been recruited as of submission of the manuscript.

Conclusions

This will be the first cluster randomized controlled trial of a culturally inclusive, school-based alcohol and drug prevention program for Aboriginal and Torres Strait Islander youth; therefore, it has significant potential to address alcohol and other drug harms among Aboriginal and Torres Strait Islander youth.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620001038987; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380038&isReview=true

International Registered Report Identifier (IRRID)

PRR1-10.2196/34530

A systematic mapping review of interventions to improve adolescent mental health literacy, attitudes and behaviours

AIM

The onset of mental illness is most common in adolescence, therefore mental health promotion efforts frequently target this age group. Evaluation literature in this area is largely segmented into specific domains in terms of settings, countries, and/or groups of young people, but an overall understanding and comparison across these areas is lacking. The current review aims to provide such an overview of interventions/programs which attempt to improve adolescents' mental health literacy, attitudes/stigma and behaviours.

METHODS

A systematic mapping review synthesized the strengths and weaknesses of published interventions/programs to improve mental health outcomes in youth. Ten databases and grey literature sources were searched, and results were categorized according to sample, location/setting, type of information presented, delivery and testing procedures, mental health outcome/s evaluated, and limitations.

RESULTS

One hundred and forty articles met the inclusion criteria; 126 were original records and 14 were reviews. Mental health literacy and attitudes/stigma were examined most frequently, and studies were predominantly conducted in school-based environments and high income economies. Intervention/program effectiveness varied across outcome/s measured, setting, and control group usage, with mental health literacy exhibiting the most positive changes overall. Common limitations included no long-term follow up or control group inclusion.

CONCLUSIONS

Despite generally positive changes seen throughout studies in this area, effectiveness differed across a range of methodological domains. Most research is conducted in schools and higher income economies, but the lack of investigation in other contexts (i.e., internet or community) or lower income countries suggests our understanding in this area is constrained.

Strong and Deadly Futures: Co-Development of a Web-Based Wellbeing and Substance Use Prevention Program for Aboriginal and Torres Strait Islander and Non-Aboriginal Adolescents

School-based programs can effectively prevent substance use; however, systematic reviews and consultation with stakeholders identified a need for effective, culturally inclusive programs for Aboriginal and/or Torres Strait Islander (hereafter Aboriginal) youth. This paper describes the development of Strong & Deadly Futures, a six-lesson, curriculum-aligned wellbeing and substance use prevention program that was designed for, and with, the Aboriginal youth. Formative reviews and consultation recommended that the program (i) combine effective components of mainstream prevention with cultural elements, highlighting Aboriginal cultural strengths; (ii) avoid stigma and celebrates the cultural diversity by catering to both Aboriginal and non-Aboriginal students; and (iii) use digital technology to enhance engagement, implementation and scalability. Guided by an Appreciative Inquiry approach, the program was developed in partnership with an Indigenous Creative Design Agency, and four schools in New South Wales and Queensland, Australia. Aboriginal (n = 41) and non-Aboriginal students (n = 36) described their role models, positive aspects of their community and reasons to avoid substance use; these formed the basis of an illustrated story which conveyed the key learning outcomes. Feedback from teachers, students and content experts supported the acceptability of the program, which will be evaluated in a subsequent randomised controlled trial.

Age-varying associations between lifestyle risk factors and major depressive disorder: a nationally representative cross-sectional study of adolescents

PURPOSE

Lifestyle risk factors, such as alcohol use, smoking, high body mass index, poor sleep, and sedentary behavior, represent major public health issues for adolescents. These factors have been associated with increased rates of major depressive disorder (MDD). The purpose of this paper is to investigate critical peaks in the prevalence of MDD at certain ages and to examine how these peaks might be amplified or attenuated by the presence of lifestyle risk factors.

METHODS

A nationally representative sample of adolescents aged 11-17 years old (n = 2967) and time-varying effect models were used to investigate the associations between lifestyle risk factors and the prevalence of MDD by sex.

RESULTS

The estimated prevalence of MDD significantly increased among adolescents from 4% (95% CI 3-6%) at 13 years of age to 19% (95% CI 15-24%) at 16 years of age. From the age of 13, males were significantly less likely to have a diagnosis of MDD than females with the maximum sex difference occurring at the age of 15 (OR 0.24, 95% CI 0.13-0.47). All lifestyle risk factors were at some point significantly associated with MDD, but these associations did not differ by sex, except for body mass index.

DISCUSSION

These findings suggest that interventions designed to prevent the development of depression should be implemented in early adolescence, ideally before or at the age of 13 and particularly among young females given that the prevalence of MDD begins to rise and diverge from young males. Interventions should also simultaneously address lifestyle risk factors and symptoms of major depression.

A randomised double-blind trial of cognitive training for the prevention of psychopathology in at-risk youth

BACKGROUND

The aim of this study was to evaluate the effectiveness of online cognitive training as a means of reducing psychopathology in at-risk youth.

METHODS

In a double-blind randomised controlled trial, 228 youths (mean age = 18.6, 74.6% female) were randomly allocated to either an intervention group (n = 114; online cognitive training focused on executive functioning) and a control group (n = 114; online cognitive training focused on other cognitive abilities). Participants were assessed online at baseline, post-training, 3-, 6- and 12-month follow-up. The primary outcome of the study was overall psychopathology as measured by the Strengths and Difficulties Questionnaire. Secondary outcomes were executive functioning ability (assessed using the n-back, trail-making and Stroop tasks), day-to-day functioning and risky drinking.

RESULTS

Mixed model intention-to-treat analyses indicated that psychopathology increased and day-to-day functioning decreased, regardless of intervention group. Those in the intervention group improved more than those in the control group in terms of the n-back task, but this was not statistically significant after adjusting for multiple comparisons. There were no statistically significant effects on risky drinking, or the trail-making and Stroop tasks.

CONCLUSION

This study failed to provide evidence for the efficacy of cognitive training as a stand-alone intervention for psychopathology.

Practitioner review: Co-design of digital mental health technologies with children and young people

BACKGROUND

There is increasing interest in digital technologies to help improve children and young people's mental health, and the evidence for the effectiveness for these approaches is rising. However, there is concern regarding levels of user engagement, uptake and adherence. Key guidance regarding digital health interventions stress the importance of early user input in the development, evaluation and implementation of technologies to help ensure they are engaging, feasible, acceptable and potentially effective. Co-design is a process of active involvement of stakeholders, requiring a change from the traditional approaches to intervention development. However, there is a lack of literature to inform the co-design of digital technologies to help child and adolescent mental health.

METHODS

We reviewed the literature and practice in the co-design of digital mental health technologies with children and young people. We searched Medline, PsycInfo and Web of Science databases, guidelines, reviews and reference lists, contacted key authors for relevant studies, and extracted key themes on aspects of co-design relevant to practice. We supplemented this with case studies and methods reported by researchers working in the field.

RESULTS

We identified 25 original articles and 30 digital mental health technologies that were designed/developed with children and young people. The themes identified were as follows: principles of co-design (including potential stakeholders and stages of involvement), methods of involving and engaging the range of users, co-designing the prototype and the challenges of co-design.

CONCLUSIONS

Co-design involves all relevant stakeholders throughout the life and research cycle of the programme. This review helps to inform practitioners and researchers interested in the development of digital health technologies for children and young people. Future work in this field will need to consider the changing face of technology, methods of engaging with the diversity in the user group, and the evaluation of the co-design process and its impact on the technology.

Study protocol of the Health4Life initiative: a cluster randomised controlled trial of an eHealth school-based program targeting multiple lifestyle risk behaviours among young Australians

INTRODUCTION

Lifestyle risk behaviours, including alcohol use, smoking, poor diet, physical inactivity, poor sleep (duration and/or quality) and sedentary recreational screen time ('the Big 6'), are strong determinants of chronic disease. These behaviours often emerge during adolescence and co-occur. School-based interventions have the potential to address risk factors prior to the onset of disease, yet few eHealth school-based interventions target multiple behaviours concurrently. This paper describes the protocol of the Health4Life Initiative, an eHealth school-based intervention that concurrently addresses the Big 6 risk behaviours among secondary school students.

METHODS AND ANALYSIS

A multisite cluster randomised controlled trial will be conducted among year 7 students (11-13 years old) from 72 Australian schools. Stratified block randomisation will be used to assign schools to either the Health4Life intervention or an active control (health education as usual). Health4Life consists of (1) six web-based cartoon modules and accompanying activities delivered during health education (once per week for 6 weeks), and a smartphone application (universal prevention), and (2) additional app content, for students engaging in two or more risk behaviours when they are in years 8 and 9 (selective prevention). Students will complete online self-report questionnaires at baseline, post intervention, and 12, 24 and 36 months after baseline. Primary outcomes are consumption of sugar-sweetened beverages, moderate-to-vigorous physical activity, sleep duration, sedentary recreational screen time and uptake of alcohol and tobacco use.

ETHICS AND DISSEMINATION

This study has been approved by the University of Sydney (2018/882), NSW Department of Education (SERAP no. 2019006), University of Queensland (2019000037), Curtin University (HRE2019-0083) and relevant Catholic school committees. Results will be presented to schools and findings disseminated via peer-reviewed journals and scientific conferences. This will be the first evaluation of an eHealth intervention, spanning both universal and selective prevention, to simultaneously target six key lifestyle risk factors among adolescents.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000431123), 18 March 2019.

Bidirectional relationships in the development of internalising symptoms and alcohol use in adolescence

INTRODUCTION AND AIMS

Previous literature has demonstrated an inconsistent relationship between alcohol use and internalising symptoms (anxiety, depression) in youth. This study aimed to clarify this link examining the bidirectional relationships between internalising symptoms and alcohol use in a community sample of adolescents, taking into account the effect of gender and externalising symptoms.

DESIGN AND METHODS

Parallel latent growth models were run to prospectively explore the bidirectional relationships between internalising symptoms and alcohol use when assessed five times over 2 years, among 1557 (67% female) adolescents from age 13.5 years.

RESULTS

Results showed that higher initial levels of internalising symptoms predicted increasing alcohol use frequency; however, this association was no longer significant once externalising symptoms and gender were accounted for. No bidirectional associations between internalising symptoms and alcohol use were found.

DISCUSSION AND CONCLUSIONS

This study adds to the literature examining the bidirectional relationships between internalising symptoms and alcohol use in adolescence. Findings highlight the importance of both gender and externalising symptoms in the development of this type of comorbidity and may help explain discrepant findings in the existing literature. Future prevention efforts for internalising problems and alcohol use should consider gender and externalising symptoms.

Combined prevention for substance use, depression, and anxiety in adolescence: a cluster-randomised controlled trial of a digital online intervention

BACKGROUND

Substance use, depression, and anxiety in adolescence are major public health problems requiring new scalable prevention strategies. We aimed to assess the effectiveness of a combined online universal (ie, delivered to all pupils) school-based preventive intervention targeting substance use, depression, and anxiety in adolescence.

METHODS

We did a multicentre, cluster-randomised controlled trial in secondary schools in Australia, with pupils in year 8 or 9 (aged 13-14 years). Participating schools were randomly assigned (1:1:1:1) to one of four intervention conditions: (1) Climate Schools-Substance Use, focusing on substance use only; (2) Climate Schools-Mental Health, focusing on depression and anxiety only; (3) Climate Schools-Combined, focusing on the prevention of substance use, depression, and anxiety; or (4) active control. The interventions were delivered in school classrooms in an online delivery format and used a mixture of peer cartoon storyboards and classroom activities that were focused on alcohol, cannabis, anxiety, and depression. The interventions were delivered for 2 years and primary outcomes were knowledge related to alcohol, cannabis, and mental health; alcohol use, including heavy episodic drinking; and depression and anxiety symptoms at 12, 24, and 30 months after baseline. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000723785) and an extended follow-up is underway.

FINDINGS

Between Sept 1, 2013, and Feb 28, 2014, we recruited 88 schools (12 391 pupils), of whom 71 schools and 6386 (51·5%) pupils were analysed (17 schools dropped out and 1308 pupils declined to participate). We allocated 18 schools (1739 [27·25%] pupils; 1690 [97·2%] completed at least one follow-up) to the substance use condition, 18 schools (1594 [25·0%] pupils; 1560 [97·9%] completed at least one follow-up) to the mental health condition, 16 schools (1497 [23·4%] pupils; 1443 [96·4%] completed at least one follow-up) to the combined condition, and 19 schools (1556 [23·4%] pupils; 1513 [97·2%] completed at least one follow-up) to the control condition. Compared with controls, the combined intervention group had increased knowledge related to alcohol and cannabis at 12, 24, and 30 months (standardised mean difference [SMD] for alcohol 0·26 [95% CI 0·14 to 0·39] and for cannabis 0·17 [0·06 to 0·28] at 30 months), increased knowledge related to mental health at 24 months (0·17 [0·08 to 0·27]), reduced growth in their odds of drinking and heavy episodic drinking at 12, 24, and 30 months (odds ratio for drinking 0·25 [95% CI 0·12 to 0·51], and for heavy episodic drinking 0·15 [0·04 to 0·58] at 30 months), and reduced increases in anxiety symptoms at 12 and 30 months (SMD -0·12 [95% CI -0·22 to -0·01] at 30 months). We found no difference in symptoms or probable diagnosis of depression. The combined intervention group also showed improvement in alcohol use outcomes compared with the substance use and mental health interventions and improvements in anxiety outcomes when compared with the mental health intervention only.

INTERPRETATION

Combined online prevention of substance use, depression, and anxiety led to increased knowledge of alcohol, cannabis, and mental health, reduced increase in the odds of any drinking and heavy episodic drinking, and reduced symptoms of anxiety over a 30-month period. These findings provide the first evidence of the effectiveness of an online universal school-based preventive intervention targeting substance use, depression, and anxiety in adolescence.

FUNDING

Australian National Health and Medical Research Council.

The interactive effects of perceived peer drinking and personality profiles on adolescent drinking: a prospective cohort study

AIMS

(1) To classify Australian adolescents according to their alcohol consumption trajectories; and (2) to assess the direct and interactive effects of perceived peer drinking (PPD) and personality on adolescent drinking.

DESIGN

Prospective cohort study comprising secondary analysis of six waves of prospective data (collected between 2014 and 2016) from the control arm of the Climate Schools Combined Study.

SETTING

Nineteen schools across three Australian states.

PARTICIPANTS

A total of 1492 socio-demographically diverse students (mean age at baseline: 13.47; 68% female; 82% born in Australia).

MEASUREMENTS

Alcohol consumption trajectories were assessed using self-reported sipping of alcohol, full standard drink consumption, binge drinking and quantity and frequency of alcohol consumption. One item assessed PPD and personality was assessed using the Substance Use Risk Profile Scale.

FINDINGS

Eight hundred and sixty-four (58%) adolescents consumed alcohol across the study period. Four drinking trajectories were identified: abstaining (n = 513; reference group); onset (n = 361; initiated after baseline); persistent (n = 531; initiated prior to baseline); and decreasing (n = 50; consumed alcohol at baseline but ceased or decreased thereafter). A significant PPD × anxiety sensitivity (AS) interaction affected probability of belonging to the onset (P < 0.001) and persistent (P = 0.003) trajectories. The effect of PPD on probability of belonging to the onset trajectory was only significant when adolescents reported low [95% confidence interval (CI) = 1.464-2.646, P < 0.001], but not high AS. The effect of PPD on probability of belonging to the persistent drinking trajectory was stronger at low (95% CI = 2.144-3.283, P < 0.001), compared with high (95% CI = 1.440-2.308, P < 0.001) AS.

CONCLUSIONS

In Australian adolescents, self-reported drinking onset and persistent drinking appear to be more strongly associated with perceived peer drinking in those with low anxiety sensitivity than those with high anxiety sensitivity.

Evaluating the Long-Term Effectiveness of School-Based Depression, Anxiety, and Substance Use Prevention Into Young Adulthood: Protocol for the Climate School Combined Study

Background

Mental health and substance use disorders are the leading causes of global disability in children and youth. Both tend to first onset or escalate in adolescence and young adulthood, calling for effective prevention during this time. The Climate Schools Combined (CSC) study was the first trial of a Web-based combined universal approach, delivered through school classes, to prevent both mental health and substance use problems in adolescence. There is also limited evidence for the cost-effectiveness of school-based prevention programs.

Objective

The aim of this protocol paper is to describe the CSC follow-up study, which aims to determine the long-term efficacy and cost-effectiveness of the CSC prevention program for depression, anxiety, and substance use (alcohol and cannabis use) up to 7 years post intervention.

Methods

A cluster randomized controlled trial (the CSC study) was conducted with 6386 participants aged approximately 13.5 years at baseline from 2014 to 2016. Participating schools were randomized to 1 of 4 conditions: (1) control (health education as usual), (2) Climate Substance Use (universal substance use prevention), (3) Climate Mental Health (universal mental health prevention), or (4) CSC (universal substance use and mental health prevention). It was hypothesized that the CSC program would be more effective than conditions (1) to (3) in reducing alcohol and cannabis use (and related harms), anxiety, and depression symptoms as well as increasing knowledge related to alcohol, cannabis, anxiety, and depression. This long-term study will invite follow-up participants to complete 3 additional Web-based assessments at approximately 5, 6, and 7 years post baseline using multiple sources of locator information already provided to the research team. The primary outcomes include alcohol and cannabis use (and related harms) and mental health symptoms. An economic evaluation of the program will also be conducted using both data linkage as well as self-report resource use and quality of life measures. Secondary outcomes include self-efficacy, social networks, peer substance use, emotion regulation, and perfectionism. Analyses will be conducted using multilevel mixed-effects models within an intention-to-treat framework.

Results

The CSC long-term follow-up study is funded from 2018 to 2022 by the Australian National Health and Medical Research Council (APP1143555). The first follow-up wave commences in August 2018, and the results are expected to be submitted for publication in 2022.

Conclusions

This is the first study to provide a long-term evaluation of combined universal substance use and mental health prevention up to 7 years post intervention. Evidence of sustained benefits into early adulthood would provide a scalable, easy-to-implement prevention strategy with the potential for widespread dissemination to reduce the considerable harms, burden of disease, injury, and social costs associated with youth substance use and mental disorders.

International Registered Report Identifier (IRRID)

PRR1-10.2196/11372

Climate schools plus: An online, combined student and parent, universal drug prevention program

Early initiation of substance use significantly increases one's risk of developing substance use dependence and mental disorders later in life. To interrupt this trajectory, effective prevention during the adolescent period is critical. Parents play a key role in preventing substance use and related harms among adolescents and parenting interventions have been identified as critical components of effective prevention programs. Despite this, there is currently no substance use prevention program targeting both students and parents that adopts online delivery to overcome barriers to implementation and sustainability. The Climate Schools Plus (CSP) program was developed to meet this need. CSP is an online substance use prevention program for students and parents, based on the effective Climate Schools prevention program for students. This paper describes the development of the parent component of CSP including a literature review and results of a large scoping survey of parents of Australian high school students (n = 242). This paper also includes results of beta-testing of the developed program with relevant experts (n = 10), and parents of Australian high school students (n = 15). The CSP parent component consists of 1) a webinar which introduces shared rule ranking, 2) online modules and 3) summaries of student lessons. The parent program targets evidence-based modifiable factors associated with a delay in the onset of adolescent substance use and/or lower levels of adolescent substance use in the future; namely, rule-setting, monitoring, and modelling. To date, this is the first combined parent-student substance use prevention program to adopt an online delivery method.

Technology-Based Interventions for Substance Use and Comorbid Disorders: An Examination of the Emerging Literature

Among individuals with substance use disorders (SUDs), comorbidity with other psychiatric disorders is common and often noted as the rule rather than the exception. Standard care that provides integrated treatment for comorbid diagnoses simultaneously has been shown to be effective. Technology-based interventions (TBIs) have the potential to provide a cost-effective platform for, and greater accessibility to, integrated treatments. For the purposes of this review, we defined TBIs as interventions in which the primary targeted aim was delivered by automated computer, Internet, or mobile system with minimal to no live therapist involvement. A search of the literature identified nine distinct TBIs for SUDs and comorbid disorders. An examination of this limited research showed promise, particularly for TBIs that address problematic alcohol use, depression, or anxiety. Additional randomized, controlled trials of TBIs for comorbid SUDs and for anxiety and depression are needed, as is future research developing TBIs that address SUDs and comorbid eating disorders and psychotic disorders. Ways of leveraging the full capabilities of what technology can offer should also be further explored.

Efficacy and outcomes of a mobile app targeting alcohol use in young people

Mobile apps provide a highly accessible way of reducing alcohol use in young people. This paper determines the 1-month efficacy and 2, 3 and 6month outcomes of the Ray's Night Out app, which aims to increase alcohol knowledge and reduce alcohol use in young people. User-experience design and agile development processes, informed by the Information-Motivation-Behavioral skills model and evidence-based motivational interviewing treatment approaches guided app development. A randomized controlled trial comparing immediate versus 1-month delayed access to the app was conducted in 197 young people (16 to 25years) who drank alcohol in the previous month. Participants were assessed at baseline, 1, 2, 3 and 6months. Alcohol knowledge, alcohol use and related harms and the severity of problematic drinking were assessed. App quality was evaluated after 1-month of app use. Participants in the immediate access group achieved a significantly greater increase in alcohol knowledge than the delayed access group at 1-month, but no differences in alcohol use or related problems were found. Both groups achieved significant reductions in the typical number of drinks on a drinking occasion over time. A reduction in maximum drinks consumed was also found at 1month. These reductions were most likely to occur in males and problem drinkers. Reductions in alcohol-related harm were also found. The app received a high mean quality (M=3.82/5, SD=0.51). The Ray app provides a youth-friendly and easily-accessible way of increasing young people's alcohol knowledge but further testing is required to determine its impact on alcohol use and related problems.

Drinking to Cope: a Latent Class Analysis of Coping Motives for Alcohol Use in a Large Cohort of Adolescents

Alcohol consumption during adolescence is widespread, although there is considerable variation in patterns of use. The aim of this study was to identify patterns of coping-motivated alcohol use in a UK birth cohort and examine individual and family characteristics associated with the resulting drinker profiles. At age 17, participants (n = 3957; 56 % female) reported their alcohol and drug use, internalising symptoms and use of alcohol to cope with a range of emotions. Socio-demographic data were collected via maternal report. Latent class analysis identified drinker subtypes based on the coping motives reported. Association between these profiles and socio-demographic characteristics and internalising disorders was examined. The vast majority (92 %) of adolescents reported alcohol consumption in the past year, and 26 % of those drank weekly or more often. Four distinct motive profiles were identified. These profiles were associated with different socio-demographic characteristics: adolescents from higher socio-economic backgrounds drank primarily for increased confidence, whereas adolescents from low socio-economic backgrounds were more likely to drink to cope with low mood. Adolescents with an anxiety or depressive disorder were six times more likely to fall within the high-risk subtype, characterised by a generalised pattern of drinking to cope with emotions across the board. Coping motives for drinking vary with individual and family factors. Adolescents from low versus high socio-economic backgrounds were characterised by distinct drinking profiles; thus, prevention messages may need to be tailored accordingly. Internalising disorders were strongly associated with a high-risk profile of coping-motivated drinking.

The Brain Games study: protocol for a randomised controlled trial of computerised cognitive training for preventing mental illness in adolescents with high-risk personality styles

INTRODUCTION

A broad range of mental disorders are now understood as aberrations of normal adolescent brain development. In both adolescents and adults, executive dysfunction has been implicated across a range of mental illnesses, and enhancing executive functioning may prove to be a useful prevention strategy for adolescents at risk for a range of psychopathology.

METHODS AND ANALYSIS

This study will consist of a double-blind, randomised controlled trial with a 12-month follow-up period. Participants will consist of 200 people aged 16-24 years who are at risk for a range of mental disorders based on personality risk factors, but have not experienced a lifetime mental illness as determined by a structured diagnostic interview. Participants will be randomly allocated to either an intervention group who complete an online cognitive training programme specifically targeting executive functioning ability or a control group who complete an online cognitive training programme that has limited executive functioning training potential. Superiority of the executive functioning training programme compared with the control training programme will be assessed at baseline, post-training and at 3-month, 6-month and 12-month follow-up. All assessments will be conducted online. The primary outcome of the study will be general psychopathology as measured by the Strengths and Difficulties Questionnaire. Secondary outcomes will include executive functioning ability, day-to-day functioning and alcohol consumption. All analyses will be undertaken using mixed-model repeated measures analysis of variance with planned contrasts.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the University of New South Wales Human Research Ethics Committee (HC15094). Results of the trial immediately post-treatment and at 12 months follow-up will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12616000127404; Pre-results.

Systematic review of universal school-based 'resilience' interventions targeting adolescent tobacco, alcohol or illicit substance use: A meta-analysis

Universal school-based interventions that address adolescent 'resilience' may represent a means of reducing adolescent substance use, however previous systematic reviews have not examined the effectiveness of such an intervention approach. A systematic review was undertaken to 1) assess whether universal school-based 'resilience' interventions are effective in reducing the prevalence of tobacco, alcohol or illicit substance use by adolescents, and 2) describe such effectiveness per intervention characteristic subgroups. Eligible studies were peer-reviewed reports (1994-2015) of randomised controlled trials including participants aged 5-18years that reported adolescent tobacco, alcohol or illicit substance use, and implemented a universal school-based 'resilience' intervention (i.e. those addressing both individual (e.g. self-esteem) and environmental (e.g. school connectedness) protective factors of resilience). Trial effects for binary outcomes were synthesised via meta-analyses and effect sizes reported as odds ratios. Subgroup (by intervention type, prevention approach, setting, intervention duration, follow-up length) and sensitivity analyses (excluding studies at high risk of bias) were conducted. Nineteen eligible studies were identified from 16,619 records (tobacco: n=15, alcohol: n=17, illicit: n=11). An overall intervention effect was found for binary measures of illicit substance use (n=10; OR: 0.78, 95%CI: 0.6-0.93, p=0.007,Tau²=0.0, I²=0%), but not tobacco or alcohol use. A similar result was found when studies assessed as high risk of bias were excluded. Overall intervention effects were evident for illicit substance use within multiple intervention characteristic subgroups, but not tobacco and alcohol. Such results support the implementation of universal school-based interventions that address 'resilience' protective factors to reduce adolescent illicit substance use, however suggest alternate approaches are required for tobacco and alcohol use. PROSPERO registration: CRD42014004906.

Long-term Results from the Empowering a Multimodal Pathway Toward Healthy Youth Program, a Multimodal School-Based Approach, Show Marked Reductions in Suicidality, Depression, and Anxiety in 6,227 Students in Grades 6-12 (Aged 11-18)

Here, we report on findings from a 15-month follow-up of a school-based program called Empowering a Multimodal Pathway Toward Healthy Youth (EMPATHY). This was primarily intended to reduce suicidal thinking in pre-teens, adolescents, and youth students aged 11-18 in middle schools (Grades 6-8) and high SCHOOLS (Grades 9-12). It also aimed to reduce depression and anxiety. The EMPATHY multimodal program consisted of repeated data collection, identification of a high-risk group, a rapid intervention for this high-risk group including offering supervised online cognitive behavioral therapy (CBT) program, a universal CBT intervention for those in Grades 6-8, a variety of interactions with trained staff ("Resiliency Coaches"), and referral to external medical and psychiatric services where appropriate. There were four time-points at which assessments were made: baseline, 3, 7, and 15 months. Here, we report cross-sectional findings over 15 months in a total of 6,227 students who were assessed at least once during the study period. Additionally, we report longitudinal findings from the 1,884 students who completed all 4 assessments. Our results found highly statistically significant decreases in suicidality rates, with the percentage of the total school population who were actively suicidal decreasing from 4.4% at baseline (n = 143 of 3,244) to 2.8% at 15 months (n = 125 of 4,496) (p < 0.001). There were also highly statistically significant reductions in depression and anxiety scores at each time-point. Thus, Mean Depression scores at baseline for the entire student population were 3.73 ± 3.87 (n = 3,244) at baseline and decreased to 3.22 ± 3.52 (n = 4,496) (p < 0.001). Since most students were not depressed, whole population changes such as this may indicate impact in many areas. In the longitudinal analysis of students who completed all four assessments, there were also highly statistically significant improvements in depression and anxiety scores at all time-points. For example, depression scores decreased from a mean of 3.43 ± 3.67 (n = 1,884) at baseline to 2.95 ± 3.53 (n = 1,884) at 15-months (p < 0.001), while the number who were actively suicidal decreased from 69 to 37. These results suggest that school-based multimodal programs, utilizing a combination of interventions, can have meaningful benefits across entire school populations.

Clinic Personnel, Facilitator, and Parent Perspectives of eHealth Familias Unidas in Primary Care

INTRODUCTION

The purpose of this qualitative study was to understand the feasibility and acceptability of implementing eHealth Familias Unidas, an Internet-based, family-based, preventive intervention for Hispanic adolescents, in primary care.

METHODS

Semistructured individual interviews with clinic personnel and facilitators (i.e., physicians, nurse practitioners, administrators, and mental health workers; n = 9) and one focus group with parents (n = 6) were audiorecorded, transcribed verbatim, and analyzed using a general inductive approach.

RESULTS

Nine major themes emerged, including recommendations to minimize disruption to clinic flow, improve collaboration and training of clinic personnel and the research team, promote the clinic as a trusted setting for improving children's behavioral health, and highlight the flexibility and convenience of the eHealth format.

DISCUSSION

This study provides feasibility and acceptability findings, along with important considerations for researchers and primary care personnel interested in collaborating to implement an eHealth preventive intervention in pediatric primary care.

Early onset mood disorders and first alcohol use in the general population

BACKGROUND

Mood disorders and alcohol use are common in the general population and often occur together. This study explored how early onset mood disorders relate to age of first alcohol use in the Australian general population.

METHODS

Discrete time survival analysis modelled the odds of first alcohol use among those with, versus without, an early onset DSM-IV mood disorders (major depression, dysthymia or bipolar disorder). Data came from the 2007 Australian National Survey of Mental Health and Wellbeing (N=8841).

RESULTS

Early onset mood disorders as an overall class were not significantly related to the odds of first alcohol use in any given year. On examining the different types of mood disorders individually early onset bipolar disorder was a significant predictor of first alcohol use. The analysis then looked at interactions with time and found that after the age of 14 years the presence of an early onset mood disorder significantly increased the odds of first alcohol use by 32%.

LIMITATIONS

Retrospective recall was used to determine age of onset data which is subject to known biases and replication is recommended in some subgroup analysis due to smaller sample sizes.

CONCLUSIONS

Mood disorders, particularly bipolar disorder, act as unique risk factors for first alcohol use in the general population and show significant interactions with developmental timing. The findings point to the potential utility of prevention programs that target alcohol use and mood disorders together from early adolescence.

Initial Findings from a Novel School-Based Program, EMPATHY, Which May Help Reduce Depression and Suicidality in Youth

We describe initial pilot findings from a novel school-based approach to reduce youth depression and suicidality, the Empowering a Multimodal Pathway Towards Healthy Youth (EMPATHY) program. Here we present the findings from the pilot cohort of 3,244 youth aged 11–18 (Grades 6-12). They were screened for depression, suicidality, anxiety, use of drugs, alcohol, or tobacco (DAT), quality-of-life, and self-esteem. Additionally, all students in Grades 7 and 8 (mean ages 12.3 and 13.3 respectively) also received an 8-session cognitive-behavioural therapy (CBT) based program designed to increase resiliency to depression. Following screening there were rapid interventions for the 125 students (3.9%) who were identified as being actively suicidal, as well as for another 378 students (11.7%) who were felt to be at higher-risk of self-harm based on a combination of scores from all the scales. The intervention consisted of an interview with the student and their family followed by offering a guided internet-based CBT program. Results from the 2,790 students who completed scales at both baseline and 12-week follow-up showed significant decreases in depression and suicidality. Importantly, there was a marked decrease in the number of students who were actively suicidal (from n=125 at baseline to n=30 at 12-weeks). Of the 503 students offered the CBT program 163 (32%) took part, and this group had significantly lower depression scores compared to those who didn’t take part. There were no improvements in self-esteem, quality-of-life, or the number of students using DAT. Only 60 students (2% of total screened) required external referral during the 24-weeks following study initiation. These results suggest that a multimodal school-based program may provide an effective and pragmatic approach to help reduce youth depression and suicidality. Further research is required to determine longer-term efficacy, reproducibility, and key program elements.