Web-Based Decision Aid to Assist Help-Seeking Choices for Young People Who Self-Harm: Outcomes From a Randomized Controlled Feasibility Trial

Determinants of unmet needs for mental health services amongst adolescents in Shiraz, Iran: a cross-sectional study

Background

Mental disorders are increasingly prevalent among adolescents without appropriate response. There are a variety of reasons for unmet mental health needs, including attitudinal and structural barriers. Accordingly, we investigated perceived mental health needs, using mental health services, and their barriers in adolescents.

Method

This cross-sectional study was conducted in 2022 in Shiraz, Iran. Demographic characteristics, the Adolescent Unmet Needs Checklist, and the Young Schema Questionnaire were administered to 348 adolescents aged 13-19 years. Adolescents were classified as having no needs, fully met needs, partially met needs, or wholly unmet needs. Logistic regression analysis was used to determine factors associated with perceived unmet need and refer participants to healthcare centers.

Results

193 (55.5%) adolescents reported perceived need for mental healthcare out of whom, 21.6% reported fully and 21.6% partially unmet needs. Noticeably, only 12.4% of needy participants reported met need. "Reluctance to seek mental healthcare" and "asked but not receiving help" were common barriers to using the services.

Conclusion

The present study reveals unmet mental healthcare needs as a significant public health concern among the adolescents. To address this significant concern, reorientation of primary care, removing economic barriers from mental healthcare services, and improving health literacy in the community are recommended.

A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques

Reviews around interventions to improve shared decision making (SDM) for child and youth mental health have produced inconclusive findings on what approaches increase participation. Importantly, the previous reviews did not explore the use of theory, as well as mechanisms of change (intervention functions) and active units of change (behaviour change techniques). The aim of this review was to explore these factors and ascertain how, if at all, these contribute to SDM. Five databases were searched up until April 2020. Studies met inclusion criteria if they were: (a) an intervention to facilitate SDM; (b) aimed at children, adolescence, or young people aged up to 25, with a mental health difficulty, or their parents/guardians; and (c) included a control group. Data were extracted on patient characteristics, study design, intervention, theoretical background, intervention functions, behaviour change techniques, and SDM. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Eight different interventions met inclusion criteria. The role of theory to increase SDM remains unclear. Specific intervention functions, such as 'education' on SDM and treatment options and 'environmental restructuring' using decision aids, are being used in SDM interventions, as well as 'training' for clinicians. Similarly, behaviour change techniques linked to these, such as 'adding objects to the environment', 'discussing pros/cons', and clinicians engaging in 'behavioural practice/rehearsal'. However, as most studies scored low on the quality assessment criteria, as well as a small number of studies included and a low number of behaviour change techniques utilised, links between behaviour change techniques, intervention functions and increased participation remain tentative. Intervention developers and clinicians may wish to consider specific intervention functions and behaviour change techniques to facilitate SDM.

Developing a Mobile App for Young Adults with Nonsuicidal Self-Injury: A Prototype Feedback Study

Nonsuicidal self-injury (NSSI) affects approximately 13% of young adults. Though evidence-based treatments for NSSI exist, most young adults do not receive treatment. Digital interventions can provide access to evidence-based treatments for NSSI at scale. Further, preliminary research suggests the acceptability, feasibility, and potential efficacy of digital interventions for NSSI. To date, however, there are few publicly available digital interventions developed specifically for young adults who engage in NSSI. The aim of this study was to solicit young adults' impressions of early app prototypes to identify ways of improving interactive features and content needs. Building on a prior interview study which explored young adults' self-management of NSSI and their use of technology in self-management, this study involved three waves of iterative app prototype feedback sessions with 10 young adults with past month NSSI. In general, participants responded favorably and provided feedback to augment the app to better meet their needs, including adding new features and functionality as well as increasing opportunities for personalization. We discuss two key design challenges related to the roles of tracking and temporality in digital interventions for NSSI, and then frame design considerations related to these challenges within the lived informatics model.

Web-based support services to help prevent suicide in young people and students: A mixed-methods, user-informed review of characteristics and effective elements

The online world may provide an alternative means to engage young people and students with suicidal feelings, who are typically reluctant to seek help. We aimed to map, characterise and obtain user evaluation of current online suicide support for this group in order to assess the usefulness of current provision and how it may be improved. We conducted a mixed-methods study, comprised of an internet search, content analysis of site features and qualitative interviews with site users: 9 young people and 4 general practitioners. Data collection took place in 2019 and 2020 in the UK. Young people participants were recruited through the well-being networks of a large University in South-West England and via a national young person's mental health app. General practitioners were recruited locally through professional networks. We identified a wide range of easily accessible online support, including examples of interactive services, such as live chat and text messaging, but a lack of support that is both suicide-specific and young adult-specific, and an absence of online suicide or mental health crisis support services tailored specifically for students. Qualitative data showed that clarity, brevity and immediacy are the most important facets of engaging crisis help for young people, and that young people may prefer to use text-based rather than verbal forms of communication when seeking help. Few services provided access to active peer support, outside of lived-experience stories, which were evaluated as both valuable and potentially harmful. There is a need to further develop tailored suicide specific online crisis support for young people and students, which is able to 'speak to' their age-specific needs and preferences. While lived experience may provide a valuable means of supporting young audiences, caution is required since this may have unintended negative consequences and further research is needed to understand the safe framing of such material.

How Technologies Can Support Self-Injury Self-Management: Perspectives of Young Adults With Lived Experience of Nonsuicidal Self-Injury

Background

There is growing interest in the design of digital interventions to improve conditions for young people who engage in high-risk behaviors, like nonsuicidal self-injury (NSSI). However, few studies have focused on how young people self-manage NSSI, or their existing, and historic, use of technologies to support their goals related to NSSI behavior change. Such an understanding has the potential to inform the design of digital interventions that meet this population's unique needs.

Objectives

This study aims to (a) understand the self-management practices of young adults who engage in NSSI, (b) explore how they currently use technologies for self-injury self-management, and (c) identify the ways they can envision an app-based technology supporting their self-management.

Methods and Materials

Twenty young adults (aged 18-24) with lived experience of NSSI, and who were not currently enrolled in therapy, were recruited from online venues. Participants completed baseline measures to assess mental health and NSSI characteristics, followed by a virtual 1-h semi-structured interview where they were invited to share their experience of self-management, their goals, and their thoughts on supportive technology. Interview scripts were transcribed and analyzed via thematic analysis.

Results

Themes and sub-themes are organized under two broad domain areas: (1) How young adults self-manage NSSI thoughts and behaviors and (2) Opportunities and challenges for digital interventions to assist young adults in their recovery process. We found that young adults had varied experiences with, and goals related to, NSSI. Participants reported a lack of effective strategies to reduce NSSI urges and a desire for an app-based technology to track patterns and deliver personalized suggestions for self-management. Participants reported existing use of technologies as part of self-management, as well as early information and support seeking for NSSI online.

Conclusions

This study contributes a greater understanding of young people's experiences with self-injury, their self-management practices, and their desire to engage with technology. Our findings highlight the need for design flexibility in developing digital interventions that support individual goals, unique presentations of NSSI, and needs at different phases of recovery. Implications for the design of highly personalized and relevant digital interventions to address NSSI are discussed.

Use of a Mobile Peer Support App Among Young People With Nonsuicidal Self-injury: Small-scale Randomized Controlled Trial

BACKGROUND

Nonsuicidal self-injury (NSSI) is a widespread behavior among adolescents and young adults. Although many individuals who self-injure do not seek treatment, there is evidence for web-based help-seeking through web-based communities and mobile peer support networks. However, few studies have rigorously tested the efficacy of such platforms on outcomes relevant for NSSI recovery.

OBJECTIVE

The aim of this small-scale preregistered randomized controlled trial is to provide preliminary insight into the shorter- and longer-term efficacy of the use of a peer support app, TalkLife, in reducing NSSI frequency and urges and increasing readiness to change. In addition, we explore contact with informal support, interest in therapy, and attitudes toward professional help-seeking.

METHODS

Individuals aged 16-25 years with current (within 3 months) and chronic (>6 episodes in the past year) NSSI history were eligible to participate in this study. After baseline assessments, the intervention group was instructed to use the app actively (eg, post or comment at least three times per week) and the control group received weekly psychoeducational materials through email, for 8 weeks. Follow-up was assessed at 1 month and 2 months. Linear mixed modeling was used to evaluate condition and time point effects for the primary outcomes of NSSI frequency and urges, readiness to change, contact with informal support, interest in therapy, and attitudes toward professional help-seeking.

RESULTS

A total of 131 participants were included in the analysis. We evidenced a significant effect of condition on NSSI frequency such that the participants using the peer support app self-injured less over the course of the study (mean 1.30, SE 0.18) than those in the control condition (mean 1.62, SE 0.18; P=.02; η2=0.02). We also evidenced a significant condition effect of readiness to change such that the treatment participants reported greater confidence in their ability to change their NSSI behavior (mean 6.28, SE 0.41) than the control participants (mean 5.67, SE 0.41; P=.04; η2=0.02). No significant differences were observed for contact with informal support, interest in therapy, or attitudes toward professional help-seeking.

CONCLUSIONS

Use of the peer support app was related to reduced NSSI frequency and greater confidence in one's ability to change NSSI behavior over the course of the study period, but no effects on NSSI urges, contact with informal support, interest in therapy, or attitudes toward professional help-seeking were observed. The findings provide preliminary support for considering the use of mobile peer support apps as a supplement to NSSI intervention and point to the need for larger-scale trials.

TRIAL REGISTRATION

Open Science Foundation; https://osf.io/3uay9.

Development of decision aid on health help-seeking for medical students

BACKGROUND

Rates of mental health problems are increasing among medical students, who have added pressures compared with non-medical students. Medical student populations exhibit low rates of help-seeking and often struggle with disclosing health conditions due to the barriers experienced and concerns over negative repercussions.

AIMS

This study aimed to create and test the feasibility and potential efficacy of an online decision aid (DA) tool that provides medical students with resources for disclosing and help-seeking for their health concerns.

METHODS

The research used mixed methods, comprising two rounds of testing, the first used the Think-Aloud method to identify modifications needed, and both of which measured feasibility and assessed decision making outcomes pre and post use of the DA utilizing O'Connor's Decisional Conflict Scale (DCS) (2010) and Stage of Decision Making (SDM) (2003) measures.

RESULTS

Results showed good feasibility of the DA. The mean DCS total score decreased from 32 to 16.75, (Wilcoxon signed-rank tests Z = -3.06, P < 0.05). There was no significant change in the SDM.

CONCLUSIONS

The results suggest that the DA may reduce decisional conflict, improving their certainty and confidence in decision making, but had no immediate impact on their SDM, consistent with some other DAs. Further longitudinal research would be beneficial.

Management of a High-Performing Mental Health Recovery Research Group

A personal perspective is given on the processes involved in managing and sustaining a high-performing mental health recovery research group. The broader context of scholarship in the United Kingdom is outlined, in which academic productivity is commodified specifically in relation to peer-reviewed journal papers. Four leadership choices in developing a high-performing research group are discussed: optimal group size; sharing the workload; maintaining a programmatic focus; and performance expectations. Approaches to maximising innovation are identified, including emotional and intellectual engagement of team members, working with diverse stakeholders and convening communities of practice. We use a highly managed approach to publications from inception to acceptance, which is described in detail. The use of these approaches is illustrated in relation to the Recovery Research Team which was formed in 2009. Specific recovery-related issues covered include demonstrating the ability to develop a significant recovery research portfolio (our four current large [>UK£2 m] studies relate to recovery narratives, global mental health peer support work, digital interventions and Recovery Colleges); the positive implications of actively recruiting researchers with mental health lived experience; how performance issues are managed; our approach to involving lived experience co-authors in papers; and our decision to conduct mixed-methods rather than solely qualitative studies.

Interventions for self-harm in children and adolescents

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents.

OBJECTIVES

To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments.

AUTHORS' CONCLUSIONS

Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.

Examining the Relationship Between the Use of a Mobile Peer-Support App and Self-Injury Outcomes: Longitudinal Mixed Methods Study

BACKGROUND

Many individuals who self-injure seek support and information through online communities and mobile peer-support apps. Although researchers have identified risks and benefits of participation, empirical work linking participation in these web-based spaces to self-injury behaviors and thoughts is limited.

OBJECTIVE

This study aims to investigate the relationship between behavioral and linguistic traces on a mobile peer support app and self-injury outcomes.

METHODS

Natural use data and web-based surveys (N=697) assessing self-injury outcomes were collected from 268 users (aged 13-38 years; median 19; 149/268, 55.6% female) of a mobile peer-support app for 4 months. Participants were identified as having posted self-injury content using an internal classifier. Natural log data was used to predict self-injury outcomes in a series of multilevel logistic and linear regressions.

RESULTS

Greater engagement on a mobile peer-support app was associated with a decreased likelihood of self-injury thoughts (odds ratio [OR] 0.25, 95% CI 0.09-0.73) and fewer intentions to self-injure (b=-0.37, SE 0.09), whereas posting triggering content was associated with an increased likelihood of engaging in behaviors (OR 5.37, 95% CI 1.25-23.05) and having self-injury thoughts (OR 17.87, 95% CI 1.64-194.15). Moreover, viewing triggering content was related to both a greater ability to resist (b=1.39, SE 0.66) and a greater intention to self-injure (b=1.50, SE 0.06).

CONCLUSIONS

To our knowledge, this is the first study to connect naturally occurring log data to survey data assessing self-injury outcomes over time. This work provides empirical support for the relationship between participation in online forums and self-injury outcomes, and it articulates mechanisms contributing to this relationship.

What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review

BACKGROUND

Increasing rates of mental health problems among adolescents are of concern. Teens who are most in need of mental health attention are reluctant to seek help. A better understanding of the help-seeking in this population is needed to overcome this gap.

METHODS

Five databases were searched to identify the principal barriers, facilitators and interventions targeting help-seeking for common mental health problems in adolescents aged 10-19 years. The search was performed in June 2018 and updated in April 2019. Two independent screening processes were made using the eligibility criteria. Quality assessment of each study was performed, and findings summarised using a narrative synthesis.

RESULTS

Ninety studies meet the inclusion criteria for this review for barrier and facilitators (n = 54) and interventions (n = 36). Stigma and negative beliefs towards mental health services and professionals were the most cited barriers. Facilitators included previous positive experience with health services and mental health literacy. Most interventions were based on psychoeducation, which focused on general mental health knowledge, suicide and self-harm, stigma and depression. Other types of interventions included the use of multimedia and online tools, peer training and outreach initiatives. Overall, the quality of studies was low to medium and there was no general agreement regarding help-seeking definition and measurements.

CONCLUSION

Most of the interventions took place in an educational setting however, it is important to consider adolescents outside the educational system. Encouraging help-seeking should come with the increased availability of mental health support for all adolescents in need, but this is still a major challenge for Child and Adolescent Mental Health Services. There is also a need to develop shared definitions, theoretical frameworks and higher methodological standards in research regarding help-seeking behaviours in adolescents. This will allow more consistency and generalisability of findings, improving the development of help-seeking interventions and ensuring timely access to mental health treatments.