Efficacy and cost-effectiveness of two online interventions for children and adolescents at risk for depression (E.motion trial): study protocol for a randomized controlled trial within the ProHEAD consortium

Intentions and barriers to help-seeking in adolescents and young adults differing in depression severity: cross-sectional results from a school-based mental health project

BACKGROUND

Mental health problems, such as depression, have a high prevalence in young people. However, the majority of youths suffering from depression do not seek professional help. This study aimed to compare help-seeking behavior, intentions and perceived barriers between youthswith different levels of depressive symptoms.

METHODS

This cross-sectional study is part of a large-scale, multi-center project. Participants were n = 9509 youths who were recruited in German schools and completed a baseline screening questionnaire. Based on their depressive symptoms, youths were allocated to the following three subgroups: (a) without depressive symptoms, (b) with subclinical symptoms, (c) with clinical symptoms (measured by PHQ-A). Quantitative analyses compared previous help-seeking behavior, help-seeking intentions and perceived barriers (Barriers questionnaire) between these subgroups. An additional exploratory qualitative content analysis examined text answers on other perceived barriers to help-seeking.

RESULTS

Participants were mostly female (n = 5575, 58.6%) and 12 to 24 years old (M = 15.09, SD 2.37). Participants with different levels of depressive symptoms differed significantly in help-seeking behavior, intentions and perceived barriers. Specifically, participants with clinical depressive symptoms reported more previous help-seeking, but lower intentions to seek help compared to participants without symptoms (all p < 0.05). Participants with subclinical depressive symptoms reported a similar frequency of previous help-seeking, but higher intentions to seek help compared to participants without symptoms (all p < 0.05). Perception of barriers was different across subgroups: participants with clinical and subclinical depressive symptoms perceived the majority of barriers such as stigma, difficulties in accessibility, and family-related barriers as more relevant than participants without depressive symptoms. Across all subgroups, participants frequently mentioned intrapersonal reasons, a high need for autonomy, and a lack of mental health literacy as barriers to help-seeking.

CONCLUSIONS

Youths with higher levels of depressive symptoms are more reluctant to seek professional help and perceive higher barriers. This underlines the need for effective and low-threshold interventions to tackle barriers, increase help-seeking, and lower depressive symptoms in adolescents and young adults differing in depression severity.

TRIAL REGISTRATION

DRKS00014685.

A collaborative realist review of remote measurement technologies for depression in young people

Digital mental health is becoming increasingly common. This includes use of smartphones and wearables to collect data in real time during day-to-day life (remote measurement technologies, RMT). Such data could capture changes relevant to depression for use in objective screening, symptom management and relapse prevention. This approach may be particularly accessible to young people of today as the smartphone generation. However, there is limited research on how such a complex intervention would work in the real world. We conducted a collaborative realist review of RMT for depression in young people. Here we describe how, why, for whom and in what contexts RMT appear to work or not work for depression in young people and make recommendations for future research and practice. Ethical, data protection and methodological issues need to be resolved and standardized; without this, RMT may be currently best used for self-monitoring and feedback to the healthcare professional where possible, to increase emotional self-awareness, enhance the therapeutic relationship and monitor the effectiveness of other interventions.

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

Background

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

Objectives

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

Search Methods

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

Selection Criteria

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

Data Collection and Analysis

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

Main Results

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

Authors' Conclusions

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

Reasons for non-participation of children and adolescents in a large-scale school-based mental health project

Background

Non-participation in mental health studies is an under-explored but very important topic. Investigating reasons for non-participation holds promise for the planning of future study designs and recruitment strategies. This study aimed at investigating reasons for children and adolescents (C&A) not participating in a school-based mental health research project.

Methods

Data collection took place within the school-based recruitment of a large-scale multi-site project ("ProHEAD-Promoting Help-seeking using E-technology for Adolescents") in Germany. Participants were N = 534 C&A aged ≥ 12 years attending secondary schools. The present cross-sectional study analyzed anonymous survey data of C&A who themselves or whose parents, respectively, did not provide written consent to participate in the mental health research project. The questionnaire consisted of 14 items covering potential reasons for non-participation, and four free text fields. Besides descriptive statistics, free text field answers were analyzed using qualitative content analysis.

Results

Students indicated an average of M = 2.94 (SD = 1.75) reasons for their non-participation in the project. In the descriptive analysis of indicated items, the three most frequently reported reasons for non-participation included students reporting to not be concerned by the topic "mental health" (n = 290, 54.3%), not having returned the consent form to the teacher (n = 175, 32.8%), and not having time for participation (n = 149, 27.9%). In the qualitative content analysis, the most frequently assigned categories were organizational reasons (n = 216, 57.1%), general disinterest in study participation (n = 139, 36.8%), and personal attitudes toward the topic "mental health" (n = 84, 22.2%), such as not being concerned with the topic "mental health" (n = 23, 6.1%) or being too concerned with the topic "mental health" (n = 16, 4.2%).

Conclusion

The study provides unique insights into reasons for C&A and their caregivers not participating in a large federally funded mental health research project. The results suggest that in order to increase participation rates, stigma should be reduced, parents as well as teachers should be involved where possible, and the use of incentives might be helpful. The study highlights the importance of assessing reasons for non-participation, especially in online intervention studies on mental health.

The mediating role of executive function in the relationship between self-stigma and self-injury or suicidal ideation among men who have sex with men living with HIV

Background

Men who have sex with men (MSM) living with HIV suffer from psychosocial pressures and marginalization as a result of being HIV-positive and belonging to a sexual minority group, and self-injury or suicidal ideation are prevalent among this group. Studies have found that both perceived self-stigma and altered executive function is related to self-injury or suicidal ideation. However, the combined contribution of self-stigma and executive function to self-injury or suicidal ideation remains unclear, especially in MSM living with HIV. Therefore, this study is conducted to explore the mechanism of self-injury or suicidal ideation by hypothesizing that executive function plays a mediating role in the relationship between self-stigma and self-injury or suicidal ideation.

Methods

We conducted a cross-sectional survey among 448 MSM living with HIV who were recruited in the HIV clinic of a tertiary general hospital in Changsha, China, from November 2021 to February 2022. A questionnaires survey was adopted to collect sociodemographic and disease-related information and data related to executive function (including working memory, inhibition, and task monitoring), self-stigma, and self-injury or suicidal ideation. Structural equation modeling and bootstrap testing were used to investigate the potential mediating role of executive function in the relationship between self-stigma and suicidal ideation.

Results

The participants were aged 18-76 years. Those who had ever had self-injury or suicidal ideation accounted for 32.8% of the total. A higher level of self-stigma and poorer executive function were associated with more frequent self-injury or suicidal ideation (p < 0.01). The mediation model analysis showed a good fit (x ²/df = 1.07, p = 0.381). The direct effect of self-stigma on self-injury or suicidal ideation (β = 0.346, p < 0.001) and the indirect effect of self-stigma via executive function (β = 0.132, p < 0.001) were significant, with the indirect effect accounting for 27.6% of the total effect.

Conclusions

This study demonstrates that executive function mediates the relationship between self-stigma and self-injury or suicidal ideation among MSM living with HIV. It suggests that future studies targeting enhancing executive function and decreasing self-stigma may reduce self-injury or suicidal ideation among MSM living with HIV.

Moderators of pre-post changes in school-based mental health promotion: Psychological stress symptom decrease for adolescents with mental health problems, knowledge increase for all

Background

School-based mental health promotion aims to strengthen mental health and reduce stress. Results on the effectiveness of such programs are heterogeneous. This study realized a school-based mental health promotion program (StresSOS) for all students and aimed to identify moderators (mental health status, gender, grade level) of pre- to post-changes in stress symptoms and knowledge.

Methods

Participants were N = 510 adolescents (from 29 classes; 46.7% female) aged 12-18 years (M = 13.88, SD = 1.00; grade levels 7-10). They were without mental health problems (65.9%), at risk for mental health problems (21.6%), or with mental health problems (12.5%) and participated in a 90 min per week face-to-face training with 8 sessions in class at school. Demographic variables, mental health status, stress symptoms, and knowledge about stress and mental health were collected at baseline. Program acceptance, stress symptoms, and knowledge were collected post-intervention. Multilevel mixed effects models were conducted with the fixed effects time (within factor), mental health status, gender, and grade level (between factors). Random effects for students within classes were included.

Results

In the pre-post comparison, mental health status moderated the changes on psychological stress symptoms (p < 0.05). In adolescents with mental health problems the largest reduction in stress symptoms was observed between pre- and post-assessment. Gender and grade level were less relevant. For all adolescents knowledge gains were revealed (p < 0.001). Program acceptance was moderated by mental health status and grade level (p < 0.01). Mentally healthy adolescents and within the group of adolescents at-risk or with mental health problems, especially younger students (7th/8th grade), rated program acceptance higher.

Conclusion

Psychological stress symptoms decreased among adolescents with mental health problems and not among adolescents at risk for or without mental health problems. Mental health-related knowledge increased for all adolescents. The results add to knowledge on school-based mental health intervention research and practice. Its implications for different prevention strategies (universal, selective or a combination of both) are discussed.

Days with and without self-injurious thoughts and behaviors: Impact of childhood maltreatment on adolescent online social networking

INTRODUCTION

Among adolescents, an increasing rate of interpersonal interactions occurs online. Previous research has shown that interpersonal context exerts a robust impact on suicidal thoughts or behaviors, yet little attention has focused on examining the content of online interactions surrounding self-injurious thoughts or behaviors. As such, the present study sought to compare online social networking behaviors among adolescents on days with and without experiencing self-injurious thoughts or behaviors, as influenced by childhood maltreatment history.

METHOD

Adolescents aged 13-18 hospitalized for self-injurious thoughts or behaviors were recruited as part of an ongoing longitudinal study. A subsample (N = 22) of adolescents provided data from their online social networking platforms (i.e., text messages, Facebook, Instagram, and Twitter). Using a mixed-methods approach, online social networking data on days of experiencing self-injurious thoughts or behaviors and days of not experiencing self-injurious thoughts or behaviors were compared.

RESULTS

Results indicate the frequency and content of online social networking messaging do not change by day of self-injurious thoughts or behaviors or history of childhood maltreatment. However, childhood maltreatment predicts received conflictual messages as well as sent symptomatic messages on days of experiencing self-injurious thoughts or behaviors.

CONCLUSIONS

Childhood maltreatment may play a role in the content of adolescent online behaviors, particularly on days when they experience self-injurious thoughts or behaviors. Implications for intervention are discussed.

Effectiveness and Implementation Outcome Measures of Mental Health Curriculum Intervention Using Social Media to Improve the Mental Health Literacy of Adolescents

Purpose

Globally, adolescent mental health problems reportedly manifest more severely in individuals with lower mental health literacy. Mental health curriculum interventions using social media have been associated with positive implementation outcomes. This study aimed to investigate whether such an intervention significantly improves adolescent mental health literacy and is associated with positive implementation outcome measures.

Methods

This study employed a quasi-experimental design, comparing the before-and-after difference between the intervention group (n₁=77) and the control group (n₁=76). A mental health literacy module was delivered using social media. Data were collected using validated questionnaires. Effect size and difference-in-differences model calculations (and associated 95% confidence intervals, CI) were conducted alongside other descriptive analyses.

Results

The estimated intervention effect size and difference-in-differences estimates were greater than zero. The effect was greater in the intervention than in the control group (p<0.05) despite sex and age differences. The effect size estimate provided by Cohen’s d and Hedges’ g values was medium-to-large (d/g=0.429–0.767, p<0.05). The difference-in-differences reflected a significant effect (DID=0.348, CI: 0.154–0.542, p<0.001) in increasing mental health literacy despite differences associated with sex, age, and school grade. The intervention program was acceptable, appropriate, feasible, and satisfactory, and more than 80% of participants said they agree to completely agree with these implementation outcomes. Resources and personal and family-related factors were among the perceived influencing factors determining the effectiveness and implementation outcome measures.

Conclusion

The intervention program effectively improved the mental health literacy of adolescents. It has been highlighted that social media interventions for mental health promotion could be practical and scalable; however, there is a need to take into account socio-demographic differences and barriers to inclusion/compliance.

More Depressive Symptoms, Alcohol and Drug Consumption: Increase in Mental Health Symptoms Among University Students After One Year of the COVID-19 Pandemic

Background: As the majority of studies examining mental health during the pandemic are cross-sectional, little is known about the changes in mental health during the pandemic, especially in university students. Most studies indicate a worsening of mental health conditions. This study aimed to evaluate the mental health status of German university students during the third wave of the pandemic in 2021 and to compare the results to a sample of a congruent cross-sectional study from 2020. Methods: Two cross-sectional and anonymous online surveys among university students were conducted (first survey: July-August 2020, N = 3,382; second survey: March-April 2021, N = 5,642). Mental health status was assessed with standardized measures (depressive symptoms, alcohol and drug consumption, and eating disorder symptoms), and social and emotional aspects of the COVID-19 pandemic were assessed. In addition to descriptive statistics and group comparisons of the two survey samples from 2020 and 2021, respectively, risk and protective factors related to mental health were analyzed. Results: There were significant differences in severities of depressive symptoms and alcohol and drug consumption between the two online surveys from 2020 and 2021. Findings suggest an increase in the severity of depressive symptoms as well as alcohol and drug consumption. Significantly more respondents reported suicidal ideation in the survey from 2021. Lower self-efficacy, less social support and lower resilience as well as higher perceived stress and more loneliness were reported by the participants of the survey from 2021 compared to 2020. Regarding factors predicting mental health symptoms, being female was a positive predictor for hazardous alcohol use and anorexia nervosa in comparison to men. Further, younger age, being diverse, higher perceived stress and loneliness were positive predictors for all mental health outcomes. Conclusion: This study reveals an increase in severities of depressive symptoms, including suicidal ideation, drug and alcohol consumption among students. Being diverse, younger age, higher perceived stress and loneliness were mutual risk factors for higher depressive and eating disorder symptoms as well as alcohol consumption. Universities and health care policy should recognize and address mental health issues of young adults during ongoing times of crisis and invest in easy-to-access interventions.

A Systematic Review on TeleMental Health in Youth Mental Health: Focus on Anxiety, Depression and Obsessive-Compulsive Disorder

Background and Objectives: The Internet is widely used and disseminated amongst youngsters and many web-based applications may serve to improve mental health care access, particularly in remote and distant sites or in settings where there is a shortage of mental health practitioners. However, in recent years, specific digital psychiatry interventions have been developed and implemented for special populations such as children and adolescents. Materials and Methods: Hereby, we describe the current state-of-the-art in the field of TMH application for young mental health, focusing on recent studies concerning anxiety, obsessive-compulsive disorder and affective disorders. Results: After screening and selection process, a total of 56 studies focusing on TMH applied to youth depression (n = 29), to only youth anxiety (n = 12) or mixed youth anxiety/depression (n = 7) and youth OCD (n = 8) were selected and retrieved. Conclusions: Telemental Health (TMH; i.e., the use of telecommunications and information technology to provide access to mental health assessment, diagnosis, intervention, consultation, supervision across distance) may offer an effective and efficacious tool to overcome many of the barriers encountering in the delivery of young mental health care.

Further Evidence that Subsyndromal Manifestations of Depression in Childhood Predict the Subsequent Development of Major Depression: A Replication Study in a 10 Year Longitudinally Assessed Sample

BACKGROUND

We have previously shown that subsyndromal scores on the Child Behavior Checklist (CBCL)-Anxiety/Depression (Anx/Dep) scale at baseline predicted the subsequent development of Major Depressive Disorder (MDD) in youth with ADHD. The present study aimed to replicate these findings in a separate, long-term, longitudinal sample of children at high- and low- risk for depression.

METHODS

219 children of parents with and without depression and/or anxiety, ages 2-25, were stratified into 3 groups: 1) children with familial risk for depression (by presence of parental MDD) plus subsyndromal scores on the CBCL-Anx/Dep scale, 2) children with familial risk for depression without subsyndromal scores, and 3) children with neither familial risk for depression nor subsyndromal scores. Subjects were reassessed at both 5 and 10 year follow-ups.

RESULTS

Children with both subsyndromal scores on the CBCL-Anx/Dep plus a familial risk for depression were at greater risk for developing MDD at the 10 year follow-up when compared with all other groups. Those with familial risk but no subsyndromal scores had an intermediate risk that was greater than the controls, who had the lowest risk.

LIMITATIONS

The recruitment of the study included families with parental panic disorder, so the sample likely included more families with anxiety disorders than the general population.

CONCLUSIONS

Our results showed that subsyndromal scores of the CBCL-Anx/Dep scale increased the risk for the subsequent development of MDD, particularly in children at high risk for depression. These results confirm the CBCL-Anx/Dep scale's utility in identifying children at high risk for developing MDD.

Promoting Help-seeking using E-technology for ADolescents with mental health problems: study protocol for a randomized controlled trial within the ProHEAD Consortium

BACKGROUND

The highest incidence and prevalence of mental health problems across the lifespan as well as the first onset of most long-term mental health conditions are reported for youths between 14 and 25 years of age. At the same time, only 25% of adolescents with mental health problems receive professional treatment. One explanation for poor treatment access in youths is their low help-seeking behavior. Barriers that can keep children and adolescents (C&A) from seeking professional help include a lack of perceived need, structural barriers, or stigma. Interventions based on e-technology might present an effective approach, overcoming these barriers by reducing stigma and providing low-threshold access with enhanced reach, ultimately facilitating help-seeking for mental health problems among youths.

METHODS

The study is designed as a multi-center, randomized controlled trial. In total, an estimated number of n = 1,500 C&A with mental health problems, drawn from a school-based sample of n = 15,000 pupils attending school grades 6 to 13 (≥ 12 years of age), recruited in five regions of Germany, will be randomized either to an intervention (ProHEAD online) or a control condition. C&A in the intervention group will receive online access to tailored information and individual advice on where to seek professional help for their specific needs close to their place of living, case reports of and interaction with peers, as well as the opportunity for online and telephone counseling. C&A in the control intervention will receive a recommendation to seek help and online information on where to find professional help. All participants will be asked to complete questionnaires concerning their help-seeking behavior at baseline, during the intervention (monitoring), and also at a 1 and 2 year follow-up. The primary endpoint is the number of C&A seeking conventional face-to-face professional help in the real-world setting within 1 year after their initial screening.

DISCUSSION

The trial will investigate if an Internet-based intervention can increase professional help-seeking in C&A with mental health problems. With its randomized controlled design and large-scale school-based sampling, the study aims to overcome the shortages of previous research. The intervention has the potential to narrow the treatment gap in C&A and to ultimately improve the mental health care system.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014685 . Registered on 7 July, 2018.

Efficacy and cost-effectiveness of Internet-based selective eating disorder prevention: study protocol for a randomized controlled trial within the ProHEAD Consortium

BACKGROUND

The development of efficacious, cost-effective, and widely accessible programs for the prevention of eating disorders (EDs) is crucial in order to reduce the ED-related burden of illness. Programs using dissonance-based and cognitive behavioral approaches are most effective for the selective prevention of ED. Internet-based delivery is assumed to maximize the reach and impact of preventive efforts. However, the current evidence for Internet-based ED prevention is limited. The present trial evaluates the efficacy and cost-effectiveness of two new interventions (based on dissonance theory and principles of cognitive behavioral therapy (CBT)) that are implemented as add-ons to the existing Internet-based ED prevention program ProYouth.

METHODS

The trial is one of five sub-projects of the German multicenter consortium ProHEAD. It is a three-arm, parallel, randomized controlled superiority trial. Participants will be randomized to (1) the online program ProYouth (active control condition) or (2) ProYouth plus a structured dissonance-based module or (3) ProYouth plus a CBT-based chat group intervention. As part of ProHEAD, a representative school-based sample of N = 15,000 students (≥ 12 years) will be screened for mental health problems. N = 309 participants at risk for ED (assessed with the Weight Concerns Scale (WCS) and the Short Evaluation of Eating Disorders (SEED)) will be included in the present trial. Online assessments will be conducted at baseline, at end of intervention (6 weeks), at 6 months follow-up, and - as part of ProHEAD - at 12 and 24 months follow-up. The primary outcome is ED-related impairment (assessed with the Child version of the Eating Disorder Examination-Questionnaire (ChEDE-Q)) at the end of the intervention. Secondary outcomes include ED-related symptomatology at follow-up, ED-related stigma, ED-related help-seeking, and acceptance of and compliance with the interventions. For the health economic evaluation data on costs of the interventions, healthcare utilization and health-related quality of life will be assessed.

DISCUSSION

This is the first study augmenting a flexible prevention approach such as ProYouth with structured evidence-based modules in order to overcome some of the key limitations in the current practice of ED prevention.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS00014679 . Registered on 25 April 2018.

Effectiveness of a web-based screening and brief intervention with weekly text-message-initiated individualised prompts for reducing risky alcohol use among teenagers: study protocol of a randomised controlled trial within the ProHEAD consortium

BACKGROUND

Early and excessive alcohol use is a significant threat to healthy development. Evidence supports the effectiveness of electronic alcohol interventions for young drinkers. However, effects are typically small and studies targeting under 18-year-olds are scarce. This trial is the first to evaluate the effectiveness of a single-session, brief, motivational, web-based intervention (ProWISE) plus weekly text-message-initiated individualised prompts (TIPs) in reducing alcohol consumption and alcohol-related harm among children and adolescents aged ≥ 12 years. TIPs are designed to decrease risky alcohol use by reaching youth in the contexts of their everyday lives and by providing individualised feedback on drinking intentions, actual drinking and succession in achieving personal goals for low-risk drinking or abstinence.

METHODS/DESIGN

The trial is part of the multicentre consortium ProHEAD testing e-interventions for mental health problems in children and adolescents. Participants in grades 6-13 aged ≥ 12 years will be recruited in schools which participate in ProHEAD (target N = 15,000). Main criterion for inclusion in the ProWISE-TIP trial is a positive screening for at-risk alcohol use in the CRAFFT-d questionnaire (target n = 1076). In a multicentre, four-arm, randomised controlled design the following groups will be compared: (A) web-based intervention plus TIPs for 12 weeks; (B) web-based intervention plus text-message-initiated assessment of alcohol consumption for 12 weeks; (C) web-based intervention only; and (D) alcohol-related psychoeducation. TIPs will be delivered shortly before and after high-risk situations for excessive alcohol use and will be tailored to age, gender, drinking motives and alcohol consumption. Study participants will be followed up at three, six and nine months in the ProWISE-TIP trial and at one and two years in the ProHEAD consortium. Primary outcome is alcohol use in the past 30 days at nine months after enrolment. Secondary outcomes are alcohol-related problems, co-occurring substance use, health service utilisation, mental health problems and quality of life.

DISCUSSION

Trial results will generate important evidence on how to enhance effectiveness of single-session, web-based alcohol interventions for youth. The ProWISE-TIP intervention, if effective, can be used as a stand-alone alcohol intervention or as an add-on to school-based or community-based alcohol prevention programs.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014606 Registered on 20 April 2018.

School-based mental health promotion in children and adolescents with StresSOS using online or face-to-face interventions: study protocol for a randomized controlled trial within the ProHEAD Consortium

BACKGROUND

Schools are an ideal setting in which to promote health. However, empirical data on the effectiveness of school-based mental health promotion programs are rare, and research on universal Internet-based prevention in schools is almost non-existent. Following the life skills approach, stress management training is an important component of health promotion. Mental health literacy is also associated with mental health status, and it facilitates formal help-seeking by children and adolescents (C&A). The main objectives of this study are (1) the development and evaluation of an Internet-based version of a universal school-based health promotion program called StresSOS and (2) demonstrating non-inferiority of the online setting compared to the face-to-face setting. StresSOS aims to improve stress management and mental health literacy in C&A.

METHODS/DESIGN

A school-based sample of 15,000 C&A (grades 6-13 and older than 12 years) will be recruited in five regions of Germany within the ProHEAD Consortium. Those with a screening result at baseline indicating no mental health problems will be invited to participate in a randomized controlled trial comparing StresSOS online to an active online control condition (Study A). In addition, 420 adolescents recruited as a separate school-based sample will participate in the StresSOS face-to-face intervention. Participants in both intervention groups (online or face-to-face) will receive the same eight treatment modules to allow for the comparison of both methods of delivery (Study B). The primary outcome is the number of C&A with symptoms of mental health problems at a 12 months follow-up. Secondary outcomes are related to stress/coping (i.e., knowledge, symptoms of stress, coping resources), mental health literacy (knowledge and attitudes toward mental disorders and help-seeking), program usage patterns, cost-effectiveness, and acceptability of the intervention.

DISCUSSION

This study represents the first adequately powered non-inferiority trial in the area of school-based mental health promotion. If online StresSOS proves efficacious and non-inferior to face-to-face delivery, this offers great potential for health promotion in youths, both in and outside the school environment.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014693 . Registered on 14 May 2018.