Reducing suicidal thoughts in the Australian general population through web-based self-help: study protocol for a randomized controlled trial

BACKGROUND: Suicidal thoughts are common in the general population, causing significant disability. However, a substantial number of people struggling with suicidality do not access appropriate services. Online self-help may help overcome barriers to help-seeking. This study aims to examine the effectiveness of an online self-help program targeted at reducing suicidal thoughts compared with an attention-matched control condition in the Australian adult population. This trial is based on a Dutch self-help program, which was found to be effective in reducing suicidal thoughts. METHODS/DESIGN: A total of 570 community-dwelling adults (18 to 65 years old) with suicidal thoughts will be recruited via various media and randomly assigned to the 6-week online program aimed at reducing suicidal thoughts or a 6-week attention-matched control program. Primary outcome measure is the severity of suicidal thoughts. Secondary outcome measures include suicide plans, capacity to cope with suicidal thoughts, reasons for living, symptoms of depression, hopelessness, anxiety/worry, rumination, panic, perceived burdensomeness and thwarted belongingness, acquired capability, alcohol consumption, insomnia, and various cost-effectiveness measures. DISCUSSION: Although the original Dutch trial found web-based self-help to be effective in reducing suicidal thoughts, randomized controlled trials (RCT) of online programs for suicidal thoughts are rare. The present study extends previous research by running the first English language RCT of this sort. As a result of the original study, the current RCT includes refinements to the design, including greater levels of participant anonymity and longer follow-up periods. Limitations of this trial include the potential for high drop-out and the inability to ascertain whether any suicides occur during the study.This study is supported by a grant from the National Health and Medical Research Council (NHMRC) Australia (GNT1046317) and forms part of research conducted by the NHMRC Centre for Research Excellence in Suicide Prevention (CRESP) (GNT1042580). AC is supported by NHMRC Early Career Fellowship 1013199. PB is supported by NHMRC Early Career Fellowship 1035262. HC is supported by NHMRC Fellowship 1056964

Technology-based interventions for mental health in tertiary students: Systematic review

BACKGROUND: Mental disorders are responsible for a high level of disability burden in students attending university. However, many universities have limited resources available to support student mental health. Technology-based interventions may be highly relevant to university populations. Previous reviews have targeted substance use and eating disorders in tertiary students. However, the effectiveness of technology-based interventions for other mental disorders and related issues has not been reviewed. OBJECTIVE: To systematically review published randomized trials of technology-based interventions evaluated in a university setting for disorders other than substance use and eating disorders. METHODS: The PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials databases were searched using keywords, phrases, and MeSH terms. Retrieved abstracts (n=1618) were double screened and coded. Included studies met the following criteria: (1) the study was a randomized trial or a randomized controlled trial, (2) the sample was composed of students attending a tertiary institution, (3) the intervention was delivered by or accessed using a technological device or process, (4) the age range of the sample was between 18 and 25 years, and (5) the intervention was designed to improve, reduce, or change symptoms relating to a mental disorder.RESULTS: A total of 27 studies met inclusion criteria for the present review. Most of the studies (24/27, 89%) employed interventions targeting anxiety symptoms or disorders or stress, although almost one-third (7/24, 29%) targeted both depression and anxiety. There were a total of 51 technology-based interventions employed across the 27 studies. Overall, approximately half (24/51, 47%) were associated with at least 1 significant positive outcome compared with the control at postintervention. However, 29% (15/51) failed to find a significant effect. Effect sizes were calculated for the 18 of 51 interventions that provided sufficient data. Median effect size was 0.54 (range -0.07 to 3.04) for 8 interventions targeting depression and anxiety symptoms and 0.84 (range -0.07 to 2.66) for 10 interventions targeting anxiety symptoms and disorders. Internet-based technology (typically involving cognitive behavioral therapy) was the most commonly employed medium, being employed in 16 of 27 studies and approximately half of the 51 technology-based interventions (25/51, 49%). Distal and universal preventive interventions were the most common type of intervention. Some methodological problems were evident in the studies, with randomization methods either inadequate or inadequately described, few studies specifying a primary outcome, and most of the studies failing to undertake or report appropriate intent-to-treat analyses. CONCLUSIONS: The findings of this review indicate that although technological interventions targeting certain mental health and related problems offer promise for students in university settings, more high quality trials that fully report randomization methods, outcome data, and data analysis methods are needed

A review of web-based support systems for students in higher education

Abstract Background Recent evidence suggests that there is an increasing need for accessible and anonymous services to support higher education (HE) students suffering from psychological and/or academic difficulties. Such difficulties can lead to several negative outcomes, including poor academic performance, sub-optimal mental health, reduced study satisfaction, and dropout from study. Currently, universities in the UK lack financial resources and the on-campus mental health services traditionally offered to students are increasingly economically unsustainable. Compounded by the perceived stigma of using such services, mental health providers have been driven to address the escalating needs of students through online services. Methods In this paper, we review online support systems identified through a literature search and a manual search of references in the identified papers. Further systems were identified through web searches, and systems still in development were identified by consultation with researchers in the field. We accessed systems online to extract relevant information, regarding the main difficulties addressed by the systems, the psychological techniques used and any relevant research evidence to support their effectiveness. Conclusion A large number of web-based support systems have been developed to support mental health and wellbeing, although few specifically target HE students. Further research is necessary to establish the effectiveness of such interventions in providing a cost-effective alternative to face-to-face therapy, particularly in certain settings such as HE institutions

A cluster randomised effectiveness-implementation trial of an intervention to increase the adoption of PAX Good Behaviour Game, a mental health prevention program, in Australian primary schools: Study protocol

Introduction: Implementation of evidence-based programs in school settings can be challenging, undermining the benefits these programs deliver for children. The primary aim of this study is to assess whether an enhanced implementation intervention increases adoption of the PAX Good Behaviour Game in New South Wales (NSW) primary schools in Australia. A secondary outcome is to investigate the impact of the PAX Good Behaviour Game on children's mental health in the Australian context. Methods and analysis: The study uses a cluster randomised hybrid type 3 effectiveness-implementation design and will involve 40 NSW primary schools. Randomisation will occur at the school level. All NSW primary schools trained in the PAX Good Behaviour Game are eligible for participation. The intervention is a multicomponent implementation strategy that has been iteratively co-designed by our research team and local stakeholders. Intervention schools will have access to eight implementation support strategies in addition to the training received as usual delivery to build knowledge and skills. Research staff will assess implementation and effectiveness outcomes using self-report online surveys with teachers and support staff at baseline, 6-weeks, 6-months and 12-months follow up. Semi-structured interviews with teachers and support staff will be used to examine which implementation strategies worked for whom and under what conditions. Discussion: If successful, this study will highlight effective strategies schools or education departments can use internationally to improve their translation of evidence-based programs into routine practices. This will lead to better outcomes for children and young people

An experimental study exploring the impact of vignette gender on the quality of university students’ mental health first aid for peers with symptoms of depression

Background University students have high rates of depression, and friends are often the most commonly-used source of support for emotional distress in this population. This study aimed to explore students’ ability to provide effective support for their peers with depressive symptoms and the factors influencing the quality of their mental health first aid (MHFA) skills, including students’ gender, course of study, and gender of student experiencing depression. Methods Via an online survey, students at two British universities (N = 483) were quasi-randomly allocated to view a video vignette of either a male or female student depicting symptoms of depression. An open-ended question probed MHFA actions they would take to help the vignette character, which were rated using a standardised scoring scheme based on MHFA guidelines. Results Students reported low MHFA scores (mean 2.89, out of possible 12). The most commonly reported action was provision of support and information, but only eight (1.6 %) students stated an intention to assess risk of harm. Those studying clinically non-relevant degrees with limited mental health content reported poorer MHFA (p = <0.001) and were less confident about their ability to support a friend with depression (p = 0.04). There was no main effect of vignette gender, but within the group of students on non-relevant courses the male vignette received significantly poorer MHFA than the female vignette (p = 0.02). A significant three-way interaction found that male participants studying non-relevant degrees who viewed a male vignette had poorer MHFA compared to females studying non-relevant degrees who viewed the female vignette (p = 0.005). Conclusions Most students lack the necessary MHFA skills to support friends suffering from symptoms of depression, or to help them get appropriate support and prevent risk of harm. Students on courses which do not include mental health related content are particularly ill-equipped to support male students, with male students receiving the poorest quality MHFA from fellow male students on these courses. MHFA training has the potential to improve outcomes for students with depression, and could have a valuable role in reducing the excess risk of harm seen in male students

Co-design and Development of Implementation Strategies: Enhancing the PAX Good Behaviour Game in Australian Schools

Effective implementation strategies are important for take-up of programs in schools. However, to date, few implementation strategies have been co-designed with teachers and support staff (including principals) in Australia. The aim of this study was to iteratively co-design multiple implementation strategies to enhance the delivery of mental health prevention program, PAX Good Behaviour Game, in New South Wales primary schools. The secondary aim was to evaluate the acceptability of the implementation strategies from the perspective of school staff. Twenty-nine educational staff (including principals) informed the co-design of the implementation strategies across three phases. Phase 1 involved a rapid review of the literature and stakeholder meetings to agree upon potential evidence-based strategies. Phase 2 involved focus group discussions with educational staff to co-design implementation strategies. Phase 3 involved semi-structured interviews with school staff to assess strategy acceptability after implementation at 6-months post-baseline. Data were analysed using deductive, framework analysis. The final co-designed intervention included nine implementation strategies accessible through a toolkit delivered to the school’s leadership team. These strategies were deemed acceptable in school settings that experienced periods of both face-to-face and remote learning due to the changing COVID-19 situation in 2021. This paper contributes to the implementation literature by transparently reporting how educational staff-informed implementation strategies were iteratively co-designed. This will provide a roadmap for other researchers to co-design implementation strategies to further support the delivery of evidence-based prevention programs in schools

The Future Proofing Study: Design, methods and baseline characteristics of a prospective cohort study of the mental health of Australian adolescents

Objectives: The Future Proofing Study (FPS) was established to examine factors associated with the onset and course of mental health conditions during adolescence. This paper describes the design, methods, and baseline characteristics of the FPS cohort. Methods: The FPS is an Australian school-based prospective cohort study with an embedded cluster-randomized controlled trial examining the effects of digital prevention programs on mental health. Data sources include self-report questionnaires, cognitive functioning, linkage to health and education records, and smartphone sensor data. Participants are assessed annually for 5 years. Results: The baseline cohort (N = 6388, M = 13.9 years) is broadly representative of the Australian adolescent population. The clinical profile of participants is comparable to other population estimates. Overall, 15.1% of the cohort met the clinical threshold for depression, 18.6% for anxiety, 31.6% for psychological distress, and 4.9% for suicidal ideation. These rates were significantly higher in adolescents who identified as female, gender diverse, sexuality diverse, or Aboriginal and/or Torres Strait Islander (all ps < 0.05). Conclusions: This paper provides current and comprehensive data about the status of adolescent mental health in Australia. The FPS cohort is expected to provide significant insights into the risk, protective, and mediating factors associated with development of mental health conditions during adolescence

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

Background: Anxiety, depressive and substance use disorders account for three quarters of the disability attributed to mental disorders and frequently co-occur. While programs for the prevention and reduction of symptoms associated with (i) substance use and (ii) mental health disorders exist, research is yet to determine if a combined approach is more effective. This paper describes the study protocol of a cluster randomised controlled trial to evaluate the effectiveness of the CLIMATE Schools Combined intervention, a universal approach to preventing substance use and mental health problems among adolescents. Methods/design: Participants will consist of approximately 8400 students aged 13 to 14-years-old from 84 secondary schools in New South Wales, Western Australia and Queensland, Australia. The schools will be cluster randomised to one of four groups; (i) CLIMATE Schools Combined intervention; (ii) CLIMATE Schools - Substance Use; (iii) CLIMATE Schools - Mental Health, or (iv) Control (Health and Physical Education as usual). The primary outcomes of the trial will be the uptake and harmful use of alcohol and other drugs, mental health symptomatology and anxiety, depression and substance use knowledge. Secondary outcomes include substance use related harms, self-efficacy to resist peer pressure, general disability, and truancy. The link between personality and substance use will also be examined.Discussion: Compared to students who receive the universal CLIMATE Schools - Substance Use, or CLIMATE Schools - Mental Health or the Control condition (who received usual Health and Physical Education), we expect students who receive the CLIMATE Schools Combined intervention to show greater delays to the initiation of substance use, reductions in substance use and mental health symptoms, and increased substance use and mental health knowledge

Trial for the Prevention of Depression (TriPoD) in final-year secondary students: study protocol for a cluster randomised controlled trial

Background: Evidence suggests that current treatments cannot fully alleviate the burden of disease associated with depression but that prevention approaches offer a promising opportunity to further reduce this burden. Adolescence is a critical period in the development of mental illness, and final school examinations are a significant and nearly universal stressor that may act as a trigger for mental health difficulties such as depression. The aim of the present trial is to investigate the impact of SPARX-R, an online, gamified intervention based on cognitive behavioural principles, on the prevention of depression in secondary school students before their final examinations. Methods/Design: Government, independent and Catholic secondary schools in New South Wales, Australia, will be recruited to participate in the trial. All students enrolled in their final year of high school (year 12) in participating schools will be invited to participate. To account for possible attrition, the target sample size was set at 1600 participants across 30 schools. Participating schools will be cluster randomised at the school level to receive either SPARX-R or lifeSTYLE, an attention-controlled placebo comparator. The control intervention is an online program aimed at maintaining a healthy lifestyle. The primary outcome will be symptoms of depression, and secondary outcomes will include symptoms of anxiety, suicidal ideation and behaviours, stigma and academic performance. Additional measures of cost-effectiveness, as well as process variables (e.g., adherence, acceptability) and potential predictors of response to treatment, will be collected. Consenting parents will be invited to complete measures regarding their own mental health and expectations for their child. Assessments will be conducted pre- and post-intervention and at 6- and 18-month follow-up. Primary analyses will compare changes in levels of depressive symptomatology for the intervention group relative to the attention control condition using mixed-effects model repeated-measures analyses to account for clustering within schools. Discussion: This is the first trial of a universal depression prevention intervention delivered to school students in advance of a specific, significant stressor. If found to be effective, this program may offer schools a new approach to preparing students for their final year of schooling. Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12614000316606 . Registered 25 March 2014.Yael Perry, Alison L. Calear, Andrew Mackinnon, Philip J. Batterham, Julio Licinio, Catherine King, Noel Thomsen, Jan Scott, Tara Donker, Sally Merry, Theresa Fleming, Karolina Stasiak, Aliza Werner-Seidler, and Helen Christense

Using participatory design methodologies to co-design and culturally adapt the Spanish version of the Mental Health eClinic: Qualitative study

Background: The Mental Health eClinic (MHeC) aims to deliver best-practice clinical services to young people experiencing mental health problems by making clinical care accessible, affordable, and available to young people whenever and wherever they need it most. The original MHeC consists of home page with a visible triage system for those requiring urgent help; a online physical and mental health self-report assessment; a results dashboard; a booking and videoconferencing system; and the generation of a personalized well-being plan. Populations who do not speak English and reside in English-speaking countries are less likely to receive mental health care. In Australia, international students have been identified as disadvantaged compared with their peers; have weaker social support networks; and have higher rates of psychological distress. This scenario is acquiring significant relevance as Spanish-speaking migration is rapidly growing in Australia, and the mental health services for culturally and linguistically diverse populations are limited. Having a Spanish version (MHeC-S) of the Mental Health eClinic would greatly benefit these students. Objective: We used participatory design methodologies with users (young people aged 16-30 years, supportive others, and health professionals) to (1) conduct workshops with users to co-design and culturally adapt the MHeC; (2) inform the development of the MHeC-S alpha prototype; (3) test the usability of the MHeC-S alpha prototype; (4) translate, culturally adapt, and face-validate the MHeC-S self-report assessment; and (5) collect information to inform its beta prototype. Methods: A research and development cycle included several participatory design phases: co-design workshops; knowledge translation; language translation and cultural adaptation; and rapid prototyping and user testing of the MHeC-S alpha prototype. Results: We held 2 co-design workshops with 17 users (10 young people, 7 health professionals). A total of 15 participated in the one-on-one user testing sessions (7 young people, 5 health professionals, 3 supportive others). We collected 225 source documents, and thematic analysis resulted in 5 main themes (help-seeking barriers, technology platform, functionality, content, and user interface). A random sample of 106 source documents analyzed by 2 independent raters revealed almost perfect agreement for functionality (kappa=.86; P\u3c.001) and content (kappa=.92; P\u3c.001) and substantial agreement for the user interface (kappa=.785; P\u3c.001). In this random sample, no annotations were coded for help-seeking barriers or the technology platform. Language was identified as the main barrier to getting medical or psychological services, and smartphones were the most-used device to access the internet. Acceptability was adequate for the prototype’s 5 main elements: home page and triage system, self-report assessment, dashboard of results, booking and video visit system, and personalized well-being plan. The data also revealed gaps in the alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities. Spanish-language apps and e-tools, as well as online mental health information, were lacking. Conclusions: Through a research and development process, we co-designed and culturally adapted, developed and user tested, and evaluated the MHeC-S. By translating and culturally adapting the MHeC to Spanish, we aimed to increase accessibility and availability of e-mental health care in the developing world, and assist vulnerable populations that have migrated to English-speaking countries