A Novel Multimodal Digital Service (Moderated Online Social Therapy+) for Help-Seeking Young People Experiencing Mental Ill-Health: Pilot Evaluation Within a National Youth E-Mental Health Service

A scoping review of effective health practices for the treatment of birth trauma

BACKGROUND

There is currently no consensus on the most effective health practices to manage or reduce the effects of birth trauma (BT) and childbirth-related posttraumatic stress disorder (CB-PTSD).

AIM

The aim was to map the current literature on effective health practices for BT/CB-PTSD, identify key elements (the what, when and how) important for effective health practices, and highlight gaps in maternity care.

METHODS

A systematic search was conducted across key nursing, allied, and medical databases (MEDLINE, Scopus, PubMed) for key terms related to (1) birth trauma and (2) intervention. Only peer-reviewed, English-language papers published since 2000 were included to ensure the relevance and timeliness of the findings. Following PRISMA-ScR guidelines, 6,347 articles were identified through databases/registers and citation searching. After removing 1,342 duplicates, 5,005 were screened by title and abstract. A further 4,544 were excluded, leaving 461 for full-text screening. Afterf excluding another 433, 28 papers met inclusion for this review.

FINDINGS

The first session delivered early (within the first 72 h of birth) by a clinician (midwife/psychologist/counsellor) significantly reduced BT/CB-PTSD in the short-term. Both trauma-focused and non-trauma-focused were supported at this stage, provided they were structured. If intervention is delayed (weeks to months post-birth), a trauma-focused, multi-session approach is recommended.

DISCUSSION

Early, structured interventions should be considered routine care for women with BT/CB-PTSD, with more intensive, structured, trauma-focused approach for persistent symptoms. The potential role of digital mental health tools is promising, particularly for women in low-resource settings, but requires further research to evaluate feasibility, acceptability, and sustainability.

Digital Mental Health Interventions for Young People Aged 16-25 Years: Scoping Review

BACKGROUND

Digital mental health interventions for young people offer a promising avenue for promoting mental well-being and addressing mental health issues in this population.

OBJECTIVE

This scoping review aims to explore the range of digital mental health interventions available for young people aged 16-25 years, with a particular focus on digital tool types, modalities, delivery formats, target populations, and study retention rates.

METHODS

The scoping review was conducted in 6 databases (PubMed, Web of Science, Scopus, MEDLINE, Cochrane Library, and PsychInfo). Studies were included if they were published from 2019 to 2024 in English, reported on a population of young people aged 16-25 years, and included validated mental health or well-being outcome measures. All types of digital interventions from promotion and prevention to treatment of mental health were included.

RESULTS

After screening 13,306 articles, 145 articles were included in the final review. The findings reveal a diverse landscape of studies, equally focusing on the prevention and promotion of mental health and the treatment of mental ill health, most commonly using cognitive behavioral therapy (63/145, 43.4%). The most common digital tools were apps (51/135, 37.8%), web-based resources (45/135, 33.3%), and websites (19/135, 14.1%). The results highlight the over emphasis on convenience sampling (140/145, 96.6%), with participants mainly recruited from universities or colleges, and a lack of representation from marginalized groups, including lesbian, gay, bisexual, transgender, and queer youth; those from socioeconomically deprived backgrounds; and those who are neurodivergent. Moreover, the focus on anxiety and depression leaves other mental health conditions underrepresented. Retention rates ranged from 16% to 100% and averaged 66% across all studies.

CONCLUSIONS

There is a need for more research on mental health promotion and prevention measures among those aged younger than 25 years as young people are at increased risk of mental health issues. This includes exploring different intervention approaches and modalities beyond cognitive behavioral therapy and ensuring inclusivity in study populations. Standardizing intervention durations and incorporating long-term follow-up data could provide valuable insights into the efficacy and effectiveness of digital interventions. Future studies should aim for greater inclusivity, ensuring representation from marginalized groups to address the diverse mental health needs of young people effectively. By adopting these approaches, digital mental health interventions can become more accessible, engaging, and impactful for young people worldwide.

Application of a Sociotechnical Framework to Uncover Factors That Influence Effective User Engagement With Digital Mental Health Tools in Clinical Care Contexts: Scoping Review

BACKGROUND

Digital health tools such as mobile apps and patient portals continue to be embedded in clinical care pathways to enhance mental health care delivery and achieve the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. However, a key issue that has greatly hindered the value of these tools is the suboptimal user engagement by patients and families. With only a small fraction of users staying engaged over time, there is a great need to better understand the factors that influence user engagement with digital mental health tools in clinical care settings.

OBJECTIVE

This review aims to identify the factors relevant to user engagement with digital mental health tools in clinical care settings using a sociotechnical approach.

METHODS

A scoping review methodology was used to identify the relevant factors from the literature. Five academic databases (MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO) were searched to identify pertinent articles using key terms related to user engagement, mental health, and digital health tools. The abstracts were screened independently by 2 reviewers, and data were extracted using a standardized data extraction form. Articles were included if the digital mental health tool had at least 1 patient-facing component and 1 clinician-facing component, and at least one of the objectives of the article was to examine user engagement with the tool. An established sociotechnical framework developed by Sittig and Singh was used to inform the mapping and analysis of the factors.

RESULTS

The database search identified 136 articles for inclusion in the analysis. Of these 136 articles, 84 (61.8%) were published in the last 5 years, 47 (34.6%) were from the United States, and 23 (16.9%) were from the United Kingdom. With regard to examining user engagement, the majority of the articles (95/136, 69.9%) used a qualitative approach to understand engagement. From these articles, 26 factors were identified across 7 categories of the established sociotechnical framework. These ranged from technology-focused factors (eg, the modality of the tool) and the clinical environment (eg, alignment with clinical workflows) to system-level issues (eg, reimbursement for physician use of the digital tool with patients).

CONCLUSIONS

On the basis of the factors identified in this review, we have uncovered how the tool, individuals, the clinical environment, and the health system may influence user engagement with digital mental health tools for clinical care. Future work should focus on validating and identifying a core set of essential factors for user engagement with digital mental health tools in clinical care environments. Moreover, exploring strategies for improving user engagement through these factors would be useful for health care leaders and clinicians interested in using digital health tools in care.

Developing Digital Mental Health Tools With Culturally Diverse Parents and Young People: Qualitative User-Centered Design Study

BACKGROUND

Approximately 39% of young people (aged 16-24 y) experience mental ill health, but only 23% seek professional help. Early intervention is essential for reducing the impacts of mental illness, but young people, particularly those from culturally diverse communities, report experiencing shame and stigma, which can deter them from engaging with face-to-face services. Digital mental health (DMH) tools promise to increase access, but there is a lack of literature exploring the suitability of DMH tools for culturally diverse populations.

OBJECTIVE

The project was conducted in partnership with a large-scale national DMH organization that promotes evidence-based early intervention, treatment, and support of mental health in young people and their families. The organization wanted to develop a self-directed web-based platform for parents and young people that integrates psychological assessments and intervention pathways via a web-based "check-in" tool. Our project explored the views of culturally diverse parents and young people on the opportunities and barriers to engagement with a web-based DMH screening tool.

METHODS

We conducted a 2-phase qualitative study aiming to identify potential issues faced by culturally diverse communities when engaging with DMH tools designed for the Australian public. We worked with 18 culturally diverse participants (parents: n=8, 44%; young people: n=10, 56%) in a series of design-led workshops drawing on methods from speculative design and user experience to understand the opportunities and barriers that organizations might face when implementing population-level DMH tools with culturally diverse communities. NVivo was used to conduct thematic analyses of the audio-recorded and transcribed workshop data.

RESULTS

Five themes were constructed from the workshops: (1) trust in the use and application of a DMH tool, (2) data management and sharing, (3) sociocultural influences on mental health, (4) generational differences in mental health and digital literacy, and (5) stigma and culturally based discrimination in mental health support.

CONCLUSIONS

The emergent themes have important considerations for researchers wishing to develop more inclusive DMH tools. The study found that healthy parent-child relationships will increase engagement in mental health support for young persons from culturally diverse backgrounds. Barriers to engagement with DMH tools included culturally based discrimination, the influence of culture on mental health support, and the potential impact of a diagnostic label on help seeking. The study's findings suggest a need for culturally safe psychoeducation for culturally diverse end users that fosters self-determination with tailored resources. They also highlight important key challenges when working with culturally diverse populations.

Online Safety When Considering Self-Harm and Suicide-Related Content: Qualitative Focus Group Study With Young People, Policy Makers, and Social Media Industry Professionals

BACKGROUND

Young people are disproportionately impacted by self-harm and suicide, and concerns exist regarding the role of social media and exposure to unsafe content. Governments and social media companies have taken various approaches to address online safety for young people when it comes to self-harm and suicide; however, little is known about whether key stakeholders believe current approaches are fit-for-purpose.

OBJECTIVE

From the perspective of young people, policy makers and professionals who work within the social media industry, this study aimed to explore (1) the perceived challenges and views regarding young people communicating on social media about self-harm and suicide, and (2) what more social media companies and governments could be doing to address these issues and keep young people safe online.

METHODS

This qualitative study involved 6 focus groups with Australian young people aged 12-25 years (n=7), Australian policy makers (n=14), and professionals from the global social media industry (n=7). Framework analysis was used to summarize and chart the data for each stakeholder group.

RESULTS

In total, 3 primary themes and six subthemes are presented: (1) challenges and concerns, including the reasons for, and challenges related to, online communication about self-harm and suicide as well as reasoning with a deterministic narrative of harm; (2) roles and responsibilities regarding online safety and suicide prevention, including who is responsible and where responsibility starts and stops, as well as the need for better collaborations; and (3) future approaches and potential solutions, acknowledging the limitations of current safety tools and policies, and calling for innovation and new ideas.

CONCLUSIONS

Our findings highlight tensions surrounding roles and responsibilities in ensuring youth online safety and offer perspectives on how social media companies can support young people discussing self-harm and suicide online. They also support the importance of cross-industry collaborations and consideration of social media in future suicide prevention solutions intended to support young people.

A national evaluation of a multi-modal, blended, digital intervention integrated within Australian youth mental health services

BACKGROUND

Youth mental health (YMH) services have been established internationally to provide timely, age-appropriate, mental health treatment and improve long-term outcomes. However, YMH services face challenges including long waiting times, limited continuity of care, and time-bound support. To bridge this gap, MOST was developed as a scalable, blended, multi-modal digital platform integrating real-time and asynchronous clinician-delivered counselling; interactive psychotherapeutic content; vocational support; peer support, and a youth-focused online community. The implementation of MOST within Australian YMH services has been publicly funded.

OBJECTIVE

The primary aim of this study was to evaluate the real-world engagement, outcomes, and experience of MOST during the first 32 months of implementation.

METHOD

Young people from participating YMH services were referred into MOST. Engagement metrics were derived from platform usage. Symptom and satisfaction measures were collected at baseline, 6, and 12 (primary endpoint) weeks. Effect sizes were calculated for the primary outcomes of depression and anxiety and secondary outcomes of psychological distress and wellbeing.

RESULTS

Five thousand seven hundred and two young people from 262 clinics signed up and used MOST at least once. Young people had an average of 19 login sessions totalling 129 min over the first 12 weeks of use, with 71.7% using MOST for at least 14 days, 40.1% for 12 weeks, and 18.8% for 24 weeks. There was a statistically significant, moderate improvement in depression and anxiety at 12 weeks as measured by the PHQ4 across all users irrespective of treatment stage (d = 0.41, 95% CI 0.35-0.46). Satisfaction levels were high, with 93% recommending MOST to a friend. One thousand one hundred and eighteen young people provided written feedback, of which 68% was positive and 31% suggested improvement.

CONCLUSIONS

MOST is a highly promising blended digital intervention with potential to address the limitations and enhance the impact of YMH services.

Using a co-design approach to develop a Preventative Online Mental Health Program for Youth (POMHPY): a quality improvement project

BACKGROUND

During the COVID-19 pandemic, youth in Ontario, Canada experienced a steep rise in mental health concerns. Preventative intervention programs can address the psychological impact of the pandemic on youth and build resiliency. Co-design approaches to developing such programs actively involve young people, resulting in solutions tailored to their unique needs. The current paper details the co-design approach to creating a Preventative Online Mental Health Program for Youth (POMHPY)-a virtually delivered program designed for Ontario youth ages 12 to 25 that promotes mental, physical, and social wellbeing.

METHODS

The Participatory Action Research (PAR) framework guided the development of the initiative. Literature reviews were conducted to identify existing evidence-based programs targeting youth. Youth perspectives were primarily gathered via the Youth Advisory Group, comprising a Youth Resilience Coordinator and a Youth Engagement Lead, who contributed to a literature review, surveys, focus groups, and program assets. Community insights were gathered through Community Reference Group (CRG) meetings, which engaged participants from local and provincial organizations, as well as individuals either directly representing or affiliated at arm's length with youth.

RESULTS

A review of the current literature highlighted the importance of regular physical activity, social connectedness, good sleep hygiene, and healthy family relationships to emotional wellbeing. Survey findings informed program session length, duration, delivery, and activities. Focus groups expanded on the survey findings and provided an in-depth understanding of youth preferences for program delivery. CRG meetings captured community insights on program refinements to better meet the needs of youth. As such, the development of POMHPY was a collaborative effort among researchers, youth, and community partners.

CONCLUSIONS

The findings highlight the value of co-design and PAR-informed approaches in developing youth-targeted online wellbeing programs, providing actionable insights for iterative improvements and future pilot testing. The resulting 6-week program, led by youth facilitators, will focus on teaching mental, social, and physical wellness strategies and skills through various evidence-based, interactive activities.

The Necessity and Acceptability of Text Message Therapy to Peripartum Mothers

Objective: This study delineated the unmet mental health needs of peripartum mothers with symptoms of depression, ascertained their willingness to engage in psychotherapy via text message, and identified potential determinants of that willingness (e.g., demographics, preferred communication methods) to inform improvement to service delivery. Method: This was a cross-sectional national survey of 897 adults who had given birth in the previous 24 months, had at least one lifetime symptom of depression, had internet access, and could read English. Univariate analysis was followed by multivariable Firth's logistic regression. Results: Peripartum participants with at least one symptom of depression wanted mental health care the most within 2 years of giving birth (64.4%) and had less access to mental health care during pregnancy and postpartum (35.1% and 38.1%, compared with 23.9%). Fifty-three percent of participants were willing to engage in psychotherapy via text message. Determinants of willingness to engage in text message therapy for all periods (pregnancy, postpartum, and not peripartum) included wanting mental health treatment but not having access and previous experience with psychotherapy via text message. During pregnancy and not peripartum, more depressive symptoms were associated with willingness to engage in psychotherapy via text message. Conclusion: The peripartum period is an especially high-risk time for mothers to experience depressive symptoms. In general, most wanted therapy but were unable to access it. Most participants were willing to engage in text message therapy.

A mindfulness-based, cognitive, social, digital relapse-prevention intervention for youth with depression in Australia: study protocol for a randomised controlled trial of Rebound

INTRODUCTION

Major depressive disorder (MDD) causes significant disease burden and functional impairment during adolescence and young adulthood. While most young people recover from their first episode, around two-thirds will experience one or more relapses, which can become more severe and treatment-resistant with each episode. To address relapse in MDD, we developed a moderated online social therapy platform (titled Rebound) that integrates: (i) peer-to-peer social networking; (ii) tailored third-wave therapeutic content targeting mindfulness, self-compassion and rumination; and (iii) three types of human support (clinicians, peer workers, career consultants), informed by self-determination theory. The aim of this trial is to determine whether, in addition to treatment as usual (TAU), Rebound, an 18-month complex digital intervention, is superior to 18 months of enhanced TAU in preventing relapse and managing depressive symptoms.

METHODS AND ANALYSIS

This study is a rater-masked randomised controlled trial. The treatment conditions include Rebound plus TAU or enhanced TAU alone. We aim to recruit 255 young people with at least one episode of MDD, aged 14-27 years. The study includes monthly assessment points over 18 months. The study includes a 48-month recruitment period and an 18-month treatment phase. The primary outcome is depressive relapse at 18 months, as measured by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Research Version (SCID-5-RV). Secondary outcomes include the severity of depressive symptoms, time to relapse, time to remission, remission status, severity of anxiety symptoms, study and employment outcomes and cost-effectiveness. We will also examine four therapeutic mechanisms (mindfulness, self-compassion skills, social support and reduced rumination) to understand the 'how and why' of the intervention effects.

ETHICS AND DISSEMINATION

Melbourne Health Human Research Ethics Committee (HREC/42967/MH-2018) provided ethics approval for this study. Findings will be made available through scientific journals and forums and to the public via social media and the Orygen website.

TRIAL REGISTRATION NUMBER

ANZCTR, ACTRN12619001412123.

Gamification in eHealth for Chronic Disease Self-Management in Youth: A Systematic Review

This systematic review primarily aims to provide a summary of the game mechanics implemented in eHealth tools supporting young people's self-management of their chronic diseases. This review secondarily investigates the rationale for implementing game mechanics and the effects of these tools. A systematic search was conducted in Embase, Medline, PsycINFO, and Web of Science, from inception until August 30, 2022. Studies were eligible if focus was on the utilization of gamification in eHealth self-management interventions for young people (age = 10-25 years) with chronic diseases. Primary quantitative, qualitative, and mixed-method studies written in English were included. We identified 34 eHealth tools, of which 20 (59%) were gamified tools and 14 (41%) were serious games. We found that 55 unique game mechanics were implemented. The most commonly used were rewards (50%), score (44%), creative control (41%), and social interaction (32%). In comparison with gamified tools, the number and diversity of game mechanics applied were higher in serious games. For most tools (85%), a general rationale was provided for utilizing gamification, which often was to promote engaging experiences. A rationale for using specific game mechanics was less commonly provided (only for 45% of the game mechanics). The limited availability of experimental research precludes to test the effectiveness of using gamification in eHealth to support self-management in young people with chronic diseases. In this study, we highlight the importance of reporting the rationale for utilizing specific game mechanics in eHealth tools to ensure a proper alignment with evidence-based practice and the need of conducting experimental research. PROSPERO: CRD42021293037.

A Novel Blended Transdiagnostic Intervention (eOrygen) for Youth Psychosis and Borderline Personality Disorder: Uncontrolled Single-Group Pilot Study

BACKGROUND

Integrating innovative digital mental health interventions within specialist services is a promising strategy to address the shortcomings of both face-to-face and web-based mental health services. However, despite young people's preferences and calls for integration of these services, current mental health services rarely offer blended models of care.

OBJECTIVE

This pilot study tested an integrated digital and face-to-face transdiagnostic intervention (eOrygen) as a blended model of care for youth psychosis and borderline personality disorder. The primary aim was to evaluate the feasibility, acceptability, and safety of eOrygen. The secondary aim was to assess pre-post changes in key clinical and psychosocial outcomes. An exploratory aim was to explore the barriers and facilitators identified by young people and clinicians in implementing a blended model of care into practice.

METHODS

A total of 33 young people (aged 15-25 years) and 18 clinicians were recruited over 4 months from two youth mental health services in Melbourne, Victoria, Australia: (1) the Early Psychosis Prevention and Intervention Centre, an early intervention service for first-episode psychosis; and (2) the Helping Young People Early Clinic, an early intervention service for borderline personality disorder. The feasibility, acceptability, and safety of eOrygen were evaluated via an uncontrolled single-group study. Repeated measures 2-tailed t tests assessed changes in clinical and psychosocial outcomes between before and after the intervention (3 months). Eight semistructured qualitative interviews were conducted with the young people, and 3 focus groups, attended by 15 (83%) of the 18 clinicians, were conducted after the intervention.

RESULTS

eOrygen was found to be feasible, acceptable, and safe. Feasibility was established owing to a low refusal rate of 25% (15/59) and by exceeding our goal of young people recruited to the study per clinician. Acceptability was established because 93% (22/24) of the young people reported that they would recommend eOrygen to others, and safety was established because no adverse events or unlawful entries were recorded and there were no worsening of clinical and social outcome measures. Interviews with the young people identified facilitators to engagement such as peer support and personalized therapy content, as well as barriers such as low motivation, social anxiety, and privacy concerns. The clinician focus groups identified evidence-based content as an implementation facilitator, whereas a lack of familiarity with the platform was identified as a barrier owing to clinicians' competing priorities, such as concerns related to risk and handling acute presentations, as well as the challenge of being understaffed.

CONCLUSIONS

eOrygen as a blended transdiagnostic intervention has the potential to increase therapeutic continuity, engagement, alliance, and intensity. Future research will need to establish the effectiveness of blended models of care for young people with complex mental health conditions and determine how to optimize the implementation of such models into specialized services.

The Urgent Need for an Evidence-Based Digital Mental Health Practice Model of Care for Youth

Australian providers of mental health services and support for young people include private and public allied health providers, government initiatives (eg, headspace), nongovernment organizations (eg, Kids Helpline), general practitioners (GPs), and the hospital system. Over 20 years of research has established that many young people prefer to seek mental health support online; however, clear client pathways within and between online and offline mental health services are currently lacking. The authors propose a Digital Mental Health Practice model of care for youth to assist with digital mental health service mapping. The proposed model offers accessible pathways for a client to engage with digital mental health services, provides clear navigation to access support for individual needs, and facilitates a seamless connection with offline mental health services using a transferable electronic health records system. This future-looking model also includes emerging technologies, such as artificial intelligence and the metaverse, which must be accounted for as potential tools to be leveraged for digital therapies and support systems. The urgent need for a user-centered Digital Mental Health Practice model of care for youth in Australia is discussed, highlighting the shortcomings of traditional and existing online triage models evident during the COVID-19 pandemic, and the complex challenges that must be overcome, such as the integration of diverse mental health care providers and establishment of a robust electronic health records system. Potential benefits of such a model include reduced pressure on emergency rooms, improved identification of immediate needs, enhanced referral practices, and the establishment of a cost-efficient national digital mental health care model with global applicability. The authors conclude by stressing the consequences of inaction, warning that delays may lead to more complex challenges as new technologies emerge and exacerbate the long-term negative consequences of poor mental health management on the economic and biopsychosocial well-being of young Australians.

The Cost-Effectiveness of a Novel Online Social Therapy to Maintain Treatment Effects From First-Episode Psychosis Services: Results From the Horyzons Randomized Controlled Trial

BACKGROUND

Digital interventions have potential applications in promoting long-term recovery and improving outcomes in first-episode psychosis (FEP). This study aimed to evaluate the cost-effectiveness of Horyzons, a novel online social therapy to support young people aged 16-27 years following discharge from FEP services, compared with treatment as usual (TAU) from a healthcare sector and a societal perspective.

STUDY DESIGN

A cost-effectiveness analysis (CEA), based on the change in social functioning, and a cost-utility analysis (CUA) using quality-adjusted life years were undertaken alongside a randomized controlled trial. Intervention costs were determined from study records; resources used by patients were collected from a resource-use questionnaire and administrative data. Mean costs and outcomes were compared at 18 months and incremental cost-effectiveness ratios were calculated. Uncertainty analysis using bootstrapping and sensitivity analyses was conducted.

STUDY RESULTS

The sample included 170 participants: Horyzons intervention group (n = 86) and TAU (n = 84). Total costs were significantly lower in the Horyzons group compared with TAU from both the healthcare sector (-AU$4789.59; P < .001) and the societal perspective (-AU$5131.14; P < .001). In the CEA, Horyzons was dominant, meaning it was less costly and resulted in better social functioning. In the CUA, the Horyzons intervention resulted in fewer costs but also yielded fewer QALYs. However, group differences in outcomes were not statistically significant. When young people engaged more with the platform, costs were shown to decrease and outcomes improved.

CONCLUSIONS

The Horyzons intervention offers a cost-effective approach for improving social functioning in young people with FEP after discharge from early intervention services.

Effective elements of eHealth interventions for mental health and well-being in children and adolescents: A systematic review

Background

Mental health problems among children and adolescents increased in recent years, while mental health services are overburdened with long waiting lists. eHealth interventions, that is, interventions delivered digitally via apps or websites, offer a promising approach to prevent and efficiently treat emerging mental health problems in youth. Over the past years, rapid technological progress has led to diverse eHealth interventions for youth mental health. However, a structured overview of effective eHealth elements and mechanisms through which interventions aim to improve mental health is lacking. The aim of this pre-registered systematic review is to identify elements of eHealth interventions that improve mental health and well-being in children and adolescents aged 10-25 from both clinical and general populations.

Methods

This systematic review conducted in April 2023 in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines identified 108 studies and 103 distinct interventions between 2011-2023. The overall sample size was 33,435 participants (30.7% male, mean age = 18.4 years, SD = 2.5). Most studies (64.8%) were randomized controlled trials (RCTs) to test the interventions. The remaining studies utilized a pre-post or group-comparison design (non-RCTs).

Results

The interventions were heterogeneous in design, method of delivery, target group and outcome measures. Overall, 77.7% of the studies showed a positive significant association between eHealth intervention and mental health or well-being. Elements that were often related to improved mental health and well-being were cognitive behavioural therapy (CBT) or self-monitoring as therapeutic principles, blended approaches combining eHealth with traditional therapy, peer/parental involvement and technological gamification elements, such as rewards.

Conclusions

Elements of youth eHealth interventions that appear to positively impact mental health or well-being are (a) CBT-based, (b) self-monitoring (c) blended interventions, (d) peer or parental involvement or (e) gamification. Future directions for the development and implementation of eHealth interventions for youth are discussed.

Digital mental health intervention for schizophrenia spectrum and psychotic disorders: Protocol for a pragmatic feasibility study of Horyzons-Canada

Background

Schizophrenia spectrum and other psychotic disorders (SSPD) are among the most debilitating of all mental disorders. While the evidence for psychosocial interventions such as cognitive behavioral therapy and peer support has significantly improved, access to these services remains limited. This paper describes a protocol for a pragmatic feasibility study of a digital mental health intervention (HoryzonsCa) that provides access to evidence-based psychosocial interventions, social networking, and clinical and peer support services through a secured, web-based platform for adults diagnosed with SSPD.

Objective

The objectives are: (1) Adapt and translate HoryzonsCa for implementation in English and French; (2) Develop an implementation and training strategy; (3) Assess the acceptability, safety, and demand of HoryzonsCa; (4) Assess clinical outcomes and perceived impacts; (5) Examine the experiences and process of adapting and implementing HoryzonsCa; (6) Explore the role of sociocultural and demographic factors on HoryzonsCa outcomes and implementation.

Methods

This feasibility study will use a single-group, pre-post, mixed-methods (QUAN-QUAL convergent) research design, with assessments at baseline and 12 weeks. The study aims to recruit 100 individuals (ages 18-50) diagnosed with SSPD from two healthcare settings in Canada. Data collection includes interview-based psychometric measures, self-reports, focus groups, and interviews with participants. The study will also collect qualitative data from moderators and the research team, and will be conducted entirely remotely.

Conclusions

This study has been prospectively registered and is underway. It will provide timely information on the feasibility and potential impacts of using digital mental health services for individuals with chronic mental health conditions.

Trial Registration

ISRCTN12561259; https://doi.org/10.1186/ISRCTN12561259 (250/max 250 words).

A systematic scoping review of peer support interventions in integrated primary youth mental health care

Peer support, defined as the social and emotional support offered and received by individuals with a shared experience of mental health difficulties, is gaining popularity in youth mental health settings. This systematic scoping review aimed to collate and synthesise the evidence on key aspects of peer support interventions within integrated youth services and educational settings. Specifically, it synthesised evidence on the (1) assessed mental health outcomes in peer support interventions, (2) key characteristics and associated roles of peer support workers (PSWs) and (3) barriers and facilitators to implementation. A search of peer reviewed articles from January 2005 to June 2022 across five electronic databases (PsychINFO, Pubmed, Scopus, ERIC and CINAHL) was conducted. A total of 15 studies retrieved in the search met the inclusion criteria and were included in the review. This review supports previous research indicating that peer support has potential for improving recovery related outcomes. While a variety of interventions and PSW roles were reported, studies could be strengthened by providing more in-depth information on intervention content. Examples of barriers to implementation included staff concerns around confidentiality of peer support relationships as well as PSWs' confidence in their roles. Facilitators included positive support from staff members and role clarity.

Phone-Based Text Therapy for Youth Mental Health: Rapid Review

BACKGROUND

Mental illness has become a prevalent issue impacting adolescents worldwide. Many barriers, including stigma and poor health literacy, prevent this population group from accessing reliable mental health care services. Synchronous text-therapy counseling is an underused therapeutic approach in combating adolescent mental illness. Phone-based text therapy is uniquely placed to offer personalized counseling to adolescents through a familiar and engaging treatment modality.

OBJECTIVE

This rapid review aims to understand the clinical effectiveness, usability, and accessibility of phone-based text therapy for youth mental health.

METHODS

Cochrane CENTRAL, Embase, PubMed, and PsycINFO were used to search for suitable literature. Five groups of keywords were used: those related to (1) "therapy," (2) "text," (3) "phone," (4) "youth," and (5) "mental health." Eligibility criteria were formed through the PICO (Population, Intervention, Control, and Outcome) framework. Studies were included if a synchronous phone-based text therapy intervention was used in an adolescent population, with an age range of 12-24 years. Only literature available in full-text, English, and a peer-reviewed journal was considered. Furthermore, a date limit of 5 years was set to reflect the recent development of digital interventions for mental health. Pertinent information from each study was tabulated, and a narrative synthesis was used to assess, describe, and organize the included studies comprehensively and concisely.

RESULTS

Of the 771 studies dual screened, 7 studies were included in this rapid review. Most of the exclusions occurred due to the use of the wrong intervention, such as asynchronous messaging. The selected studies had a low risk of bias and were suitable for the review. All interventional trials demonstrated reductions in mental health symptoms, primarily depression and anxiety. Most studies displayed high usability among participants, while data were unclear regarding accessibility.

CONCLUSIONS

This review reveals the high potential of phone-based text therapy as an intervention for adolescents experiencing mental illness. We hope that this review promotes further refinement of text-based phone therapies and encourages future research on this subject matter.

The Effects of a Digital, Transdiagnostic, Clinically and Peer-Moderated Treatment Platform for Young People With Emerging Mental Health Complaints: Repeated Measures Within-Subjects Study

BACKGROUND

To address the growing prevalence of youth mental health problems, early intervention is crucial to minimize individual, societal, and economic impacts. Indicative prevention aims to target emerging mental health complaints before the onset of a full-blown disorder. When intervening at this early stage, individuals are more responsive to treatment, resulting in cost-effective outcomes. The Moderated Online Social Therapy platform, which was successfully implemented and proven effective in Australia, is a digital, peer- and clinically moderated treatment platform designed for young people. The Netherlands was the first country outside Australia to implement this platform, under the name Engage Young People Early (ENYOY). It has the potential to reduce the likelihood of young people developing serious mental health disorders.

OBJECTIVE

This study aims to investigate the effects on young people using the ENYOY-platform in relation to psychological distress, psychosocial functioning, and positive health parameters.

METHODS

Dutch-speaking young people with emerging mental health complaints (N=131) participated in the ENYOY-platform for 6 months in a repeated measures within-subjects study. Psychological distress, psychosocial functioning, and positive health parameters were assessed at baseline and 3, 6, and 12 months. Repeated measures ANOVA was conducted and adjusted for age, sex, therapy, and community activity. The Reliable Change Index and Clinically Significant Index were computed to compare the baseline with the 6- and 12-month measurements. The missing data rate was 22.54% and the dropout rate 62.6% (82/131).

RESULTS

The primary analysis (77/131, 58.8%) showed that psychological distress decreased and psychosocial functioning improved over time with large effect sizes (P<.001 in both cases; ηp2=0.239 and 0.318, respectively) independent of age (P=.76 for psychological distress and P=.48 for psychosocial functioning), sex (P=.24 and P=.88, respectively), therapy activity (P=.49 and P=.80, respectively), or community activity (P=.59 and P=.48, respectively). Similarly, secondary analyses (51/131, 38.9%) showed significant effects of time on the quality of life, well-being, and meaningfulness positive health parameters (P<.05; ηp2=0.062, 0.140, and 0.121, respectively). Improvements in all outcome measures were found between baseline and 3 and 6 months (P≤.001-.01; d=0.23-0.62) and sustained at follow-up (P=.18-.97; d=0.01-0.16). The Reliable Change Index indicated psychological distress improvements in 38% (39/102) of cases, no change in 54.9% (56/102) of cases, and worsening in 5.9% (6/102) of cases. Regarding psychosocial functioning, the percentages were 50% (51/102), 43.1% (44/102), and 6.9% (7/102), respectively. The Clinically Significant Index demonstrated clinically significant changes in 75.5% (77/102) of cases for distress and 89.2% (91/102) for functioning.

CONCLUSIONS

This trial demonstrated that the ENYOY-platform holds promise as a transdiagnostic intervention for addressing emerging mental health complaints among young people in the Netherlands and laid the groundwork for further clinical research. It would be of great relevance to expand the population on and service delivery of the platform.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-021-03315-x.

Developing a Theory of Change for a Digital Youth Mental Health Service (Moderated Online Social Therapy): Mixed Methods Knowledge Synthesis Study

BACKGROUND

Common challenges in the youth mental health system include low access, poor uptake, poor adherence, and limited overall effectiveness. Digital technologies offer promise, yet challenges in real-world integration and uptake persist. Moderated Online Social Therapy (MOST) aims to overcome these problems by integrating a comprehensive digital platform into existing youth mental health services. Theory of change (ToC) frameworks can help articulate how and why complex interventions work and what conditions are required for success.

OBJECTIVE

The objective of this study is to create a ToC for MOST to explain how it works, why it works, who benefits and how, and what conditions are required for its success.

METHODS

We used a multimethod approach to construct a ToC for MOST. The synthesis aimed to assess the real-world impact of MOST, a digital platform designed to enhance face-to-face youth mental health services, and to guide its iterative refinement. Data were gathered from 2 completed and 4 ongoing randomized controlled trials, 11 pilot studies, and over 1000 co-design sessions using MOST. Additionally, published qualitative findings from diverse clinical contexts and a review of related digital mental health literature were included. The study culminated in an updated ToC framework informed by expert feedback. The final ToC was produced in both narrative and table form and captured components common in program logic and ToC frameworks.

RESULTS

The MOST ToC captured several assumptions about digital mental health adoption, including factors such as the readiness of young people and service providers to embrace digital platforms. External considerations included high service demand and a potential lack of infrastructure to support integration. Young people and service providers face several challenges and pain points MOST seeks to address, such as limited accessibility, high demand, poor engagement, and a lack of personalized support. Self-determination theory, transdiagnostic psychological treatment approaches, and evidence-based implementation theories and their associated mechanisms are drawn upon to frame the intervention components that make up the platform. Platform usage data are captured and linked to short-, medium-, and long-term intended outcomes, such as reductions in mental health symptoms, improvements in functioning and quality of life, reductions in hospital visits, and reduced overall mental health care costs.

CONCLUSIONS

The MOST ToC serves as a strategic framework for refining MOST over time. The creation of the ToC helped guide the development of therapeutic content personalization, user engagement enhancement, and clinician adoption through specialized implementation frameworks. While powerful, the ToC approach has its limitations, such as a lack of standardized methodology and the amount of resourcing required for its development. Nonetheless, it provides an invaluable roadmap for iterative development, evaluation, and scaling of MOST and offers a replicable model for other digital health interventions aiming for targeted, evidence-based impact.

Implementing Technologies to Enhance Coordinated Specialty Care Framework: Implementation Outcomes From a Development and Usability Study

BACKGROUND

Coordinated specialty care (CSC) has demonstrated efficacy in improving outcomes in individuals at clinical high risk for psychosis and individuals with first-episode psychosis. Given the limitations of scalability and staffing needs, the augmentation of services using digital mental health interventions (DMHIs) may be explored to help support CSC service delivery.

OBJECTIVE

In this study, we aimed to understand the methods to implement and support technology in routine CSC and offered insights from a quality improvement study assessing the implementation outcomes of DMHIs in CSC.

METHODS

Patients and clinicians including psychiatrists, therapists, and supported education and employment specialists from a clinical-high-risk-for-psychosis clinic (Center for Early Detection Assessment and Response to Risk [CEDAR]) and a first-episode-psychosis clinic (Advancing Services for Psychosis Integration and Recovery [ASPIRE]) participated in a quality improvement project exploring the feasibility of DMHIs following the Access, Alignment, Connection, Care, and Scalability framework to implement mindLAMP, a flexible and evidenced-based DMHI. Digital navigators were used at each site to assist clinicians and patients in implementing mindLAMP. To explore the differences in implementation outcomes associated with the app format, a menu-style format was delivered at CEDAR, and a modular approach was used at ASPIRE. Qualitative baseline and follow-up data were collected to assess the specific implementation outcomes.

RESULTS

In total, 5 patients (ASPIRE: n=3, 60%; CEDAR: n=2, 40%) were included: 3 (60%) White individuals, 2 (40%) male and 2 (40%) female patients, and 1 (20%) transgender man, with a mean age of 19.6 (SD 2.05) years. Implementation outcome data revealed that patients and clinicians demonstrated high accessibility, acceptability, interest, and belief in the sustainability of DMHIs. Clinicians and patients presented a wide range of interest in unique use cases of DMHI in CSC and expressed variable feasibility and appropriateness associated with nuanced barriers and needs. In addition, the results suggest that adoption, penetration, feasibility, and appropriateness outcomes were moderate and might continue to be explored and targeted.

CONCLUSIONS

Implementation outcomes from this project suggest the need for a patient- and clinician-centered approach that is guided by digital navigators and provides versatility, autonomy, and structure. Leveraging these insights has the potential to build on growing research regarding the need for versatility, autonomy, digital navigator support, and structured applications. We anticipate that by continuing to research and improve implementation barriers impeding the adoption and penetration of DMHIs in CSC, accessibility and uptake of DMHIs will improve, therefore connecting patients to the demonstrated benefits of technology-augmented care.

Understanding What Drives Long-term Engagement in Digital Mental Health Interventions: Secondary Causal Analysis of the Relationship Between Social Networking and Therapy Engagement

BACKGROUND

Low engagement rates with digital mental health interventions are a major challenge in the field. Multicomponent digital interventions aim to improve engagement by adding components such as social networks. Although social networks may be engaging, they may not be sufficient to improve clinical outcomes or lead users to engage with key therapeutic components. Therefore, we need to understand what components drive engagement with digital mental health interventions overall and what drives engagement with key therapeutic components.

OBJECTIVE

Horyzons was an 18-month digital mental health intervention for young people recovering from first-episode psychosis, incorporating therapeutic content and a private social network. However, it is unclear whether use of the social network leads to subsequent use of therapeutic content or vice versa. This study aimed to determine the causal relationship between the social networking and therapeutic components of Horyzons.

METHODS

Participants comprised 82 young people (16-27 years) recovering from first-episode psychosis. Multiple convergent cross mapping was used to test causality, as a secondary analysis of the Horyzons intervention. Multiple convergent cross mapping tested the direction of the relationship between each pair of social and therapeutic system usage variables on Horyzons, using longitudinal usage data.

RESULTS

Results indicated that the social networking aspects of Horyzons were most engaging. Posting on the social network drove engagement with all therapeutic components (r=0.06-0.36). Reacting to social network posts drove engagement with all therapeutic components (r=0.39-0.65). Commenting on social network posts drove engagement with most therapeutic components (r=0.11-0.18). Liking social network posts drove engagement with most therapeutic components (r=0.09-0.17). However, starting a therapy pathway led to commenting on social network posts (r=0.05) and liking social network posts (r=0.06), and completing a therapy action led to commenting on social network posts (r=0.14) and liking social network posts (r=0.15).

CONCLUSIONS

The online social network was a key driver of long-term engagement with the Horyzons intervention and fostered engagement with key therapeutic components and ingredients of the intervention. Online social networks can be further leveraged to engage young people with therapeutic content to ensure treatment effects are maintained and to create virtuous cycles between all intervention components to maintain engagement.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614000009617; https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12614000009617.

Experiences of a Digital Mental Health Intervention from the Perspectives of Young People Recovering from First-Episode Psychosis: A Focus Group Study

Horyzons is a digital health intervention designed to support recovery in young people receiving specialized early intervention services for first-episode psychosis (FEP). Horyzons was developed in Australia and adapted for implementation in Canada based on input from clinicians and patients (Horyzons-Canada Phase 1) and subsequently pilot-tested with 20 young people with FEP (Horyzons-Canada Phase 2).

OBJECTIVE

To understand the experiences of young adults with FEP who participated in the pilot study based on focus group data.

METHODS

Among the twenty individuals that accessed the intervention, nine participated across four focus groups. Three team members were involved in data management and analysis, informed by a thematic analysis approach. A coding framework was created by adapting the Phase 1 framework to current study objectives, then revised iteratively by applying it to the current data. Once the coding framework was finalized, it was systematically applied to the entire dataset.

RESULTS

Four themes were identified: (1) Perceiving Horyzons-Canada as helpful for recovery; (2) Appreciating core intervention components (i.e., peer networking; therapeutic content; moderation) and ease of use; (3) Being unaware of its features; and (4) Expressing concerns, suggestions, and future directions.

CONCLUSIONS

Horyzons-Canada was well received, with participants wanting it to grow in scale, accessibility, and functionality.

Integrating digital interventions with clinical practice in youth mental health services

OBJECTIVE

Integrating digital technologies with clinical practice promises to improve access and enhance care in the context of high service demand and constrained capacity.

METHOD

We outline the emerging research in the integration of digital tools in clinical care, known as blended care, and provide case examples of mental health technology platforms currently in use, summarise findings regarding novel technologies such as virtual reality, and outline real-world implementation challenges and potential solutions.

RESULTS

Recent evidence shows that blended care approaches are clinically effective and improve service efficiency. Youth-specific technologies such as moderated online social therapy (MOST) are achieving a range of positive clinical and functional outcomes, while emerging technologies like virtual reality have strong evidence in anxiety disorder, and accumulating evidence in psychotic conditions. Implementation science frameworks show promise in helping overcome the common challenges faced in real-world adoption and ongoing use.

CONCLUSION

The integrated, blended use of digital mental health technologies with face-to-face clinical care has the potential to improve care quality for young people while helping overcome the growing challenges faced by youth mental health service providers.

Digital health innovation to prevent relapse and support recovery in young people with first-episode psychosis: A pilot study of Horyzons-Canada

Digital health innovations may help to improve access to psychosocial therapy and peer support; however, the existence of evidence-based digital health interventions for individuals recovering from a first-episode psychosis (FEP) remains limited. This study aims to investigate the feasibility, acceptability, safety, and pre-post outcomes of Horyzons-Canada (HoryzonsCa), a Canadian adaptation of a digital mental health intervention consisting of psychosocial interventions, online social networking, and clinical and peer support moderation. Using a convergent mixed-methods research design, we recruited participants from a specialized early intervention clinic for FEP in Montreal, Canada. Twenty-three participants (mean age = 26.8) completed baseline assessments, and 20 completed follow-up assessments after 8 weeks of intervention access. Most participants provided positive feedback on general experience (85%, 17/20) and the utility of Horyzons for identifying their strengths (70%, 14/20). Almost all perceived the platform as easy to use (95%, 19/20) and felt safe using it (90%, 18/20). There were no adverse events related to the intervention. Participants used HoryzonsCa to learn about their illness and how to get better (65%, 13/20), receive support (60%, 12/20), and access social networking (35%, 7/20) and peer support (30%, 6/20). Regarding adoption, 65% (13/20) logged in at least 4 times over 8 weeks. There was a nonsignificant increase in social functioning and no deterioration on the Clinical Global Impression Scale. Overall, HoryzonsCa was feasible to implement and perceived as safe and acceptable. More research is needed with larger sample sizes and using in-depth qualitative methods to better understand the implementation and impact of HoryzonsCa.

A randomized controlled trial of moderated online social therapy for family carers of first-episode psychosis patients in a specialist treatment setting

BACKGROUND

Family members, who provide the majority of informal care during the recovery period from first-episode psychosis (FEP), experience high levels of psychological distress. However, there is a lack of effective and accessible interventions for FEP carers.

OBJECTIVE

To determine the effectiveness of an online intervention ("Altitudes") in relation to the primary outcome of FEP-carer stress at 6 months follow-up.

METHODS

We conducted a cluster randomized controlled trial in which FEP carers were randomized to Altitudes combined with specialized treatment as usual (STAU) or STAU alone. In addition to questionnaires, we included multiple waves of intensive ecological momentary assessment (EMA) to measure carer stress and family outcomes in 164 carers of young (15-27 years) FEP patients.

RESULTS

Both groups improved over time on stress and a range of secondary outcomes, including mental health symptoms, self-efficacy, and expressed emotion with no group by time interactions. At 12 months there were significantly fewer visits to emergency departments by FEP patients in the Altitudes group (p = 0.022). Modelling of multiple EMA waves revealed that more time spent by carers with FEP patients predicted greater worry, expressed emotion, and adaptive coping.

CONCLUSIONS

Engagement and usability findings for Altitudes were positive. Further refinements to our online carer interventions may be needed to engage carers in purposeful skill development for improved management of stress and communication with the young person compared with existing specialist family interventions.

TRIAL REGISTRATION

ACTRN12616000968471.

Moderated digital social therapy for young people with emerging mental health problems: A user-centered mixed-method design and usability study

Introduction

Over 25% of Dutch young people are psychologically unhealthy. Individual and societal consequences that follow from having mental health complaints at this age are substantial. Young people need care which is often unavailable. ENgage YOung people earlY (ENYOY) is a moderated digital social therapy-platform that aims to help youngsters with emerging mental health complaints. Comprehensive research is being conducted into the effects and to optimize and implement the ENYOY-platform throughout the Netherlands. The aim of this study is to explore the usability and user experience of the ENYOY-platform.

Methods

A user-centered mixed-method design was chosen. 26 young people aged 16-25 with emerging mental health complaints participated. Semi-structured interviews were conducted to explore usability, user-friendliness, impact, accessibility, inclusivity, and connection (Phase 1). Phase 2 assessed usability problems using the concurrent and retrospective Think Aloud-method. User experience and perceived helpfulness were assessed using a 10-point rating scale and semi-structured interviews (Phase 3). The Health Information Technology Usability Evaluation Scale (Health-ITUES; Phase 1) and System Usability Scale (SUS; Phase 2 and 3) were administered. Qualitative data was analyzed using thematic analysis. Task completion rate and time were tracked and usability problems were categorized using the Nielsen's rating scale (Phase 2).

Results

Adequate to high usability was found (Phase 1 Health-ITUES 4.0(0.34); Phase 2 SUS 69,5(13,70); Phase 3 SUS 71,6(5,63)). Findings from Phase 1 (N = 10) indicated that users viewed ENYOY as a user-friendly, safe, accessible, and inclusive initiative which helped them reduce their mental health complaints and improve quality of life. Phase 2 (N = 10) uncovered 18 usability problems of which 5 of major severity (e.g. troubles accessing the platform). Findings from Phase 3 (N = 6) suggested that users perceived the coaching calls the most helpful [9(0.71)] followed by the therapy content [6.25(1.41)]. Users liked the social networking aspect but rated it least helpful [6(2.1)] due to inactivity.

Conclusion

The ENYOY-platform has been found to have adequate to high usability and positive user experiences were reported. All findings will be transferred to the developmental team to improve the platform. Other evaluation methods and paring these with quantitative outcomes could provide additional insight in future research.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Introducing an implementation framework for augmenting care with digital technology for early psychosis patients: theory and motivation

BACKGROUND

Treatment programs for early-course psychosis are evidence-based interventions that provide specialty care to improve outcomes in patients. Digital technologies offer the potential to augment services and meet the growing demand for care.

AIMS

We introduce a framework to guide the assessment of site readiness for technology and their ability to successfully introduce, implement, and sustain digital technology use. While broader in use that early course psychosis, we focus on this use case to introduce the theory and clinical application.

METHODS

Adapting the replicating effective programs framework, we present an early psychosis focused model. Considering the unique opportunities and challenges of these programs, we present a five-stage evaluation framework. Informed by our clinical experience and recent literature, we present tools and examples to help programs plan and execute successful technology implementation.

RESULTS

The AACCS framework is comprised of five stages: (1) Access (e.g. identifying access to and comfort with technology), (2) Align (e.g. understanding aspects technology can augment), (3) Connect (e.g. customizing technology to stakeholder needs), (4) Care (e.g. implementing technology into treatment), and (5) Sustain (e.g. creating sustainable services). Site visits revealed patients have access to digital tools and are open to implementation into care, while staff prefers digital skills training.

CONCLUSIONS

This framework assists programs in identifying clinical targets to be augmented with technology, stages of implementation, and recommendations for sustaining meaningful technology use.

Social media-based interventions for adolescent and young adult mental health: A scoping review

Background

Mental health conditions are common among adolescents and young adults, yet few receive adequate mental health treatment. Many young people seek support and information online through social media, and report preferences for digital interventions. Thus, digital interventions deployed through social media have promise to reach a population not yet engaged in treatment, and at risk of worsening symptoms.

Objective

In this scoping review, we aimed to identify and review empirical research on social media-based interventions aimed at improving adolescent and young adult mental health. A secondary objective was to identify the features and functionalities of platforms described as social media.

Methods

Adhering to the PRISMA-ScR guidelines for scoping reviews, the search was conducted in PubMed MEDLINE; Embase Central Register of Controlled Trials (Wiley); PsycINFO (Ebsco); Scopus; Web of Science; IEEE Xplore; ACM Digital Library; and ClinicalTrials.gov from inception until November 2021. Studies were included if they involved adolescents or young adults (10-26 years of age) that meet clinical, or subclinical, levels of a mental health condition and include a pre- and post-assessment of mental health outcomes.

Results

Among the 18,380 references identified, 15 met full inclusion criteria and were published between 2017 and 2021-this included four randomized controlled trials, seven non-randomized pre-post trials, and four were experimental or quasi-experimental designs. Just five studies were delivered through an existing social media site (Facebook or Pixtori), with the remainder focused on purpose-built networks. Three studies involved adolescents or young adults who self-reported a mental health condition, seven involved young people diagnosed with a mental health condition by a clinician or who scored above a clinical threshold on valid clinical measure, three involved college students without a mental health inclusion criterion, and two studies focused on young people with a cancer diagnosis.

Conclusions

The review highlights innovations in the delivery of mental health interventions, provides preliminary evidence of the ability of social media interventions to improve mental health outcomes, and underscores the need for, and merit of, future work in this area. We discuss opportunities and challenges for future research, including the potential to leveragei existing peer networks, the use of just-in-time interventions, and scaling interventions to meet need.

The role of digital tools in providing youth mental health: results from an international multi-center study

Since the traditional mental health system showed significant limitations in the early identification, diagnosis and treatment of the current new youth psychopathological trajectories, by substantially failing in targeting the needs of the current young generation, there is the demand to redesign and digitally adapt youth mental health care and systems. Indeed, the level of digital literacy and the level of digital competency and knowledge in the field of digital psychiatry is still under-investigated among mental health professionals, particularly in youth mental health. Therefore, we aimed at: (a) carrying out a post-hoc analysis of an international multi-centre study, to investigate the opinions of mental health professionals regarding the feasibility, efficacy and clinical experience in delivering digital mental health interventions (DMHIs) in youths; (b) providing a comprehensive overview on the integrated digitally-based youth mental health care models and innovations. Mental health professionals declared the lack of a formal training in digital psychiatry, particularly in youth mental health. Subjects who received a formal theoretical/practical training on DMHIs displayed a statistical trend towards a positive feasibility of digital psychiatry in youth mental health (p = 0.053) and a perceived increased efficacy of digital psychiatry in youths (p = 0.051). Respondents with higher Digital Psychiatry Opinion (DPO) scores reported a positive perceived feasibility of DMHIs in youths (p < 0.041) and are more prone to deliver DMHIs to young people (p < 0.001). Respondents with higher knowledge scores (KS) declared that DMHIs are more effective in youth mental health (p < 0.001). Overall, the digitalisation indeed allowed young people to keep in touch with a mental health professional, facilitating a more dynamic and fluid mental health care access and monitoring, generally preferred and considered more feasible by post-Millennial youngsters. Accordingly, our findings demonstrated that mental health professionals are more prone to offer DMHIs in youth mental health, particularly whether previously trained and knowledgeable on the topic.

Online Group Counseling for Young People Through a Customized Social Networking Platform: Phase 2 of Kids Helpline Circles

There is a growing need for high-quality evidence to support the efficacy of online counseling and peer support via social networking sites (SNSs) as an intervention to reduce mental health symptoms in young people. This article presents Phase 2 of Kids Helpline (KHL) Circles, which used mixed methods to assess the acceptability, safety, user experience, and mental health benefits of a purpose-built, counselor-facilitated SNS. Young people aged 13-25 years (n = 552) were recruited to participate in one of six 8-week "Circles." Of those, 154 participants completed study surveys at three timepoints (baseline, midpoint, endpoint). Significant reductions in depression, anxiety, stress, and general distress symptoms were reported at the midpoint of the intervention, with further significant reductions in depression and stress symptoms by the endpoint. More than half said that their mental health improved as a direct result of KHL Circles, and most felt less mental health stigma and would be more willing to seek help for mental health issues in the future. These results contribute to increasing the evidence base for SNS interventions to reduce mental health symptoms. Adjustments are necessary for the ongoing evolution of this service to ensure it is user-centered and scientifically rigorous.

Online interventions for cannabis use among adolescents and young adults: Systematic review and meta-analysis

BACKGROUND

Young people present high rates of cannabis use, abuse, and dependence. The United Nations estimates that roughly 3.8% of the global population aged 15-64 years used cannabis at least once in 2017. Cannabis use in young people may impair cognitive skills, interfere with learning, impact relationships, and lead to long term behavioural and psychological consequences. Online cannabis interventions (OCI) are increasingly popular, but their dissemination is not often supported by empirical evidence.

AIM

To systematically compile and analyse the effectiveness of OCI for the reduction of cannabis use among adolescents and young adults (AYA).

METHODS

Pooled effect sizes of cannabis use between treatment and control groups were estimated. For each comparison, Hedge's g was calculated using a random effects model.

RESULTS

The search strategy yielded 4531 articles. Of those, a total of 411 articles were retrieved for detailed evaluation resulting in 17 eligible studies (n = 3525). Analyses revealed that online interventions did not significantly reduce cannabis consumption (Hedge's g = -0.061, 95% CI [-0.363] to [-0.242], p = .695) and high heterogeneity was noted (Q = 191.290). More recent studies using structured interventions, daily feedback, AYA centred designs, and peer support, specifically targeting CU seemed to have positive effects to address CU in this population.

CONCLUSIONS

The lack of positive outcomes suggests that more specific and targeted interventions may be necessary to promote cannabis-related behavioural change among young people. These targeted interventions may include structured CU modules, daily feedback, peer support for increased adherence, user-centred design procedures, and input from key stakeholders such as families and service providers.

Usability, Feasibility, and Effect of a Biocueing Intervention in Addition to a Moderated Digital Social Therapy-Platform in Young People With Emerging Mental Health Problems: A Mixed-Method Approach

Introduction

To optimize treatment, it is of utmost importance to take into account the myriad of biological, social, and psychological changes that young people go through during adolescence which make them more vulnerable for developing mental health problems. Biocueing, a non-invasive method to transform physiological parameters into an observable signal, could strengthen stress- and emotion regulation by cueing physiologically unusual values in daily life. The aim of this study is to investigate the usability, feasibility, and exploratory effect of biocueing in addition to ENgage YOung people earlY (ENYOY), a moderated digital social therapy-platform, in young people with emerging mental health complaints.

Methods

A user-centered mixed-method design was used. A focus group was conducted to optimize the ENYOY-platform and biocueing intervention. Biocueing was operationalized by a smartwatch and the Sense-IT app. A within-subjects design was used; 10 days for all participants 'biofeedback off' (control), followed by 10 days 'biofeedback on' (experimental). Emotional awareness and perceived stress were measured using ecological momentary assessment. Eight individuals participated. User-friendliness, usability, and acceptance were assessed using a qualitative design.

Results

Findings from the focus group resulted in several adaptations of the biocueing intervention to the ENYOY-platform and vice versa. The average measurement compliance rate was 78.8%. Level-one findings showed different individual effects on perceived stress and emotional awareness. Level-two analyses showed no overall effects on perceived stress (B = -0.020, p = 0.562) and overall positive effects on emotional awareness (B = 0.030, p = 0.048) with small effect sizes (Improvement Rate Difference = 0.05-0.35). The intervention was found to be acceptable and showed moderate usability. Participants indicated they experienced improvements in reflection on feelings and changes in behavior, such as pausing and evaluating the situation.

Conclusion

These preliminary results show that biocueing could be a promising addition to digital treatment platforms and help young people become more emotionally aware. Improvements should be made regarding the usability and acceptability of the smartwatch, as well as more extensive integration of the biocueing intervention with a digital treatment platform. It would be relevant to gain a better understanding of which individuals would benefit most from an additional biocueing intervention.

Characterizing Use of a Multicomponent Digital Intervention to Predict Treatment Outcomes in First-Episode Psychosis: Cluster Analysis

BACKGROUND

Multicomponent digital interventions offer the potential for tailored and flexible interventions that aim to address high attrition rates and increase engagement, an area of concern in digital mental health. However, increased flexibility in use makes it difficult to determine which components lead to improved treatment outcomes.

OBJECTIVE

This study aims to identify user profiles on Horyzons, an 18-month digital relapse prevention intervention for first-episode psychosis that incorporates therapeutic content and social networking, along with clinical, vocational, and peer support, and to examine the predictive value of these user profiles for treatment outcomes. A secondary objective is to compare each user profile with young people receiving treatment as usual (TAU).

METHODS

Participants comprised 82 young people (aged 16-27 years) with access to Horyzons and 84 receiving TAU, recovering from first-episode psychosis. In addition, 6-month use data from the therapy and social networking components of Horyzons were used as features for K-means clustering for joint trajectories to identify user profiles. Social functioning, psychotic symptoms, depression, and anxiety were assessed at baseline and 6-month follow-up. General linear mixed models were used to examine the predictive value of user profiles for treatment outcomes and between each user profile with TAU.

RESULTS

A total of 3 user profiles were identified based on the following system use metrics: low use, maintained use of social components, and maintained use of both therapy and social components. The maintained therapy and social group showed improvements in social functioning (F_2,51=3.58; P=.04), negative symptoms (F_2,51=4.45; P=.02), and overall psychiatric symptom severity (F_2,50=3.23; P=.048) compared with the other user profiles. This group also showed improvements in social functioning (F_1,62=4.68; P=.03), negative symptoms (F_1,62=14.61; P<.001), and overall psychiatric symptom severity (F_1,63=5.66; P=.02) compared with the TAU group. Conversely, the maintained social group showed increases in anxiety compared with the TAU group (F_1,57=7.65; P=.008). No differences were found between the low use group and the TAU group on treatment outcomes.

CONCLUSIONS

Continued engagement with both therapy and social components might be key in achieving long-term recovery. Maintained social use and low use outcomes were broadly comparable with TAU, emphasizing the importance of maintaining engagement for improved treatment outcomes. Although the social network may be a key ingredient to increase sustained engagement, as users engaged with this more consistently, it should be leveraged as a tool to engage young people with therapeutic content to bring about social and clinical benefits.

Gaming My Way to Recovery: A Systematic Scoping Review of Digital Game Interventions for Young People's Mental Health Treatment and Promotion

Nearly all young people use the internet daily. Many youth with mental health concerns, especially since the Covid-19 pandemic, are using this route to seek help, whether through digital mental health treatment, illness prevention tools, or supports for mental wellbeing. Videogames also have wide appeal among young people, including those who receive mental health services. This review identifies the literature on videogame interventions for young people, ages 12-29, and maps the data on game use by those with mental health and substance use problems, focusing on evidence for the capacity of games to support treatment in youth mental health services; how stakeholders are involved in developing or evaluating games; and any potential harms and ethical remedies identified. A systematic scoping review methodology was used to identify and assess relevant studies. A search of multiple databases identified a total of 8,733 articles. They were screened, and 49 studies testing 32 digital games retained. An adapted stepped care model, including four levels, or steps, based on illness manifestation and severity, was used as a conceptual framework for organizing target populations, mental health conditions and corresponding digital games, and study results. The 49 selected studies included: 10 studies (20.4%) on mental health promotion/prevention or education for undiagnosed youth (Step 0: 7 games); 6 studies (12.2%) on at-risk groups or suspected mental problems (Step 1: 5 games); 24 studies (49.0%) on mild to moderate mental conditions (Steps 2-3: 16 games); and 9 studies (18.4%) focused on severe and complex mental conditions (Step 4: 7 games). Two interventions were played by youth at more than one level of illness severity: the SPARX game (Steps 1, 2-3, 4) and Dojo (Steps 2-3 and 4), bringing the total game count to 35 with these repetitions. Findings support the potential integration of digital games in youth services based on study outcomes, user satisfaction, relatively high program retention rates and the potential usefulness of most games for mental health treatment or promotion/prevention. Most studies included stakeholder feedback, and involvement ratings were very high for seven games. Potential harms were not addressed in this body of research. This review provides an important initial repository and evaluation of videogames for use in clinical settings concerned with youth mental health.

Young people's experience of online therapy for first-episode psychosis: A qualitative study

OBJECTIVES

This study aimed to understand how young people with first-episode psychosis experienced online therapy on a Moderated Online Social Therapy (MOST) platform known as Horyzons.

METHODS

Semi-structured in-depth qualitative interviews were conducted with 12 young people who had previously participated in Horyzons, a randomized controlled trial (RCT) of a long-term digital intervention for first-episode psychosis. Interviews were analysed using a phenomenological approach.

RESULTS

This study found that the online therapy experience for first-episode psychosis was idiosyncratic, taking on different meaning for different users. The relatively fixed therapeutic content led to experiences that included on-demand help-seeking, positive distraction, revision, generalization and translation, and normalization. We also found that although the experience of online therapy was motivating to some, it was overwhelming for others.

CONCLUSIONS

The self-directed and flexible nature of the Horyzons online therapy gave some young people a sense of welcomed control over their mental health journey, and others felt overwhelmed by the high level of choice. Feeling overwhelmed by the level of choice appeared to interrupt their engagement with the platform, and thus their overall ability to use the intervention meaningfully. We also found that on-demand help-seeking and positive distraction were two functions unique to young people through online therapy and may have been related to the significant reduction in the number of overall presentations by young people to emergency departments and a non-significant trend for lower hospitalizations due to psychosis in the intervention group of the Horyzons RCT.

PRACTITIONER POINTS

Young people used online therapy for on-demand support to help deal with distress. Young people used online therapy to distract themselves from distress in a positive way. Some young people valued the flexibility of online therapy, which increased their motivation to engage with it. Some young people were overwhelmed by the amount of choice available to them via online therapy, which decreased their motivation to engage.

Human-Computer Interaction in Digital Mental Health

Human-computer interaction (HCI) has contributed to the design and development of some efficient, user-friendly, cost-effective, and adaptable digital mental health solutions. But HCI has not been well-combined into technological developments resulting in quality and safety concerns. Digital platforms and artificial intelligence (AI) have a good potential to improve prediction, identification, coordination, and treatment by mental health care and suicide prevention services. AI is driving web-based and smartphone apps; mostly it is used for self-help and guided cognitive behavioral therapy (CBT) for anxiety and depression. Interactive AI may help real-time screening and treatment in outdated, strained or lacking mental healthcare systems. The barriers for using AI in mental healthcare include accessibility, efficacy, reliability, usability, safety, security, ethics, suitable education and training, and socio-cultural adaptability. Apps, real-time machine learning algorithms, immersive technologies, and digital phenotyping are notable prospects. Generally, there is a need for faster and better human factors in combination with machine interaction and automation, higher levels of effectiveness evaluation and the application of blended, hybrid or stepped care in an adjunct approach. HCI modeling may assist in the design and development of usable applications, and to effectively recognize, acknowledge, and address the inequities of mental health care and suicide prevention and assist in the digital therapeutic alliance.

The psychological effects of COVID-19 spread in young Canadian adults

BACKGROUND AND AIM

The novel coronavirus disease 2019 (COVID-19) not only threatens physical health but also psychological well-being. As a result of the pandemic, increased mental health burdens have been recorded in young adults around the world. We sought to understand the association of stressors related to the COVID-19 pandemic with symptoms of psychological and emotional distress in young Canadian adults.

METHOD

Questionnaire respondents were asked about the extent to which they were personally impacted by COVID-19, and symptoms related to depression, anxiety, post-traumatic disorder, and emotional distress.

RESULTS

Of 84 respondents, most identified as female (74%; 62/84). Overall, 61% (51/84) reported experiencing symptoms of psychological distress related to depression, anxiety, or post-traumatic stress disorder (PTSD); specifically, 43% (36/84) reported anxiety-related symptoms, 33% (28/84) reported depression-related symptoms, and 6% (5/84) reported PTSD-related symptoms. Individuals with family in settings high risk for COVID-19 infection and individuals who received government aid with a reduction in income were 4.30-fold and 2.80-fold more likely, respectively, to experience symptoms of psychological distress (95% CI 1.31-14.14; p = .013 and 95% CI 1.08-7.25; p = .038, respectively). Visits to social media daily to hourly for COVID-19 related news resulted in a 3.24-fold increase in the likelihood of experiencing depression-related symptoms (95% CI 1.26-8.35; p = .020).

CONCLUSION

We demonstrate a necessity to focus on alleviating the mental health burdens and contributing stressors within young Canadian adults. Though the mental health burdens are currently exacerbated by the effects of the COVID-19 pandemic, they may persist after the pandemic ends if left unaddressed.

Designing and scaling up integrated youth mental health care

Mental ill-health represents the main threat to the health, survival and future potential of young people around the world. There are indications that this is a rising tide of vulnerability and need for care, a trend that has been augmented by the COVID-19 pandemic. It represents a global public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent reform and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to benefit, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be addressed? Since the start of the century, a range of co-designed youth mental health strategies and innovations have emerged. These range from digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted according to the availability of resources, workforce, cultural factors and health financing patterns. The fulcrum of this progress is the advent of broad-spectrum, integrated primary youth mental health care services. They represent a blueprint and beach-head for an overdue global system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of fundamental principles and design features. These include establishing an accessible, "soft entry" youth primary care platform with digital support, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people with genuine and substantial mental health needs, that they are benefiting from them, and that both these young people and their families are highly satisfied with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned to this transitional age range (from approximately 12 to 25 years). The rising tide of mental ill-health in young people globally demands that this focus be elevated to a top priority in global health.

Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review

BACKGROUND

Ongoing primary care during adolescence is recommended by best practice guidelines for adolescents and young adults (AYAs; ages 12-25) with chronic conditions. A synthesis of the evidence on the roles of Primary Care Physicians (PCPs) and benefits of primary care is needed to support existing guidelines.

METHODS

We used Arksey and O'Malley's scoping review framework, and searched databases (MEDLINE, EMBASE, PsychINFO, CINAHL) for studies that (i) were published in English between 2004 and 2019, (ii) focused on AYAs with a chronic condition(s) who had received specialist pediatric services, and (iii) included relevant findings about PCPs. An extraction tool was developed to organize data items across studies (eg, study design, participant demographics, outcomes).

RESULTS

Findings from 58 studies were synthesized; 29 (50%) studies focused exclusively on AYAs with chronic health conditions (eg, diabetes, cancer), while 19 (33%) focused exclusively on AYAs with mental health conditions. Roles of PCPs included managing medications, "non-complex" mental health conditions, referrals, and care coordination, etc. Frequency of PCP involvement varied by AYAs; however, female, non-Black, and older AYAs, and those with severe/complex conditions appeared more likely to visit a PCP. Positive outcomes were reported for shared-care models targeting various conditions (eg, cancer, concussion, mental health).

CONCLUSION

Our findings drew attention to the importance of effective collaboration among multi-disciplinary specialists, PCPs, and AYAs for overcoming multiple barriers to optimal transitional care. Highlighting the need for further study of the implementation of shared care models to design strategies for care delivery during transitions to adult care.

The youth online training and employment system: Study protocol for a randomized controlled trial of an online vocational intervention for young people with mental ill health

AIM

People diagnosed with mental disorders experience higher rates of unemployment than those without. Career adaptability, defined as the ability to respond flexibly and make informed career decisions in work and throughout career transitions, is becoming increasingly important as the nature of work changes rapidly. Early vocational intervention may ameliorate poor education and employment outcomes experienced by young people with mental ill-health and promote transferable skills and adaptability. Online-based career support allows for ongoing access throughout different career stages. The current study combines mental health-informed digital career and peer motivation, to create a Youth Online Training and Employment System (YOTES) that supports young people with mental ill-health obtain and remain in education or employment.

METHODS

This study is an unblinded randomized controlled trial for young people with mental ill-health, aged 16-25, who are seeking vocational support. Participants will be randomized to receive either YOTES, a moderated, online intervention with vocational, social, and peer motivation, or a control intervention, the headspace Digital Work and Study Service. Both groups will have access to in-person career support if seeking employment. The primary outcome will be career adaptability compared between the YOTES and control groups at 6-months post baseline. Secondary outcomes include number of hours worked in the past 7 days, hope, career confidence, psychological distress and health economic outcomes at 6- and 12-months post baseline.

CONCLUSION

Results will demonstrate whether an online career intervention moderated by career practitioners with peer motivation can result in improved career adaptability in young people with mental ill-health.

Interventions to address loneliness and social isolation in young people: A systematic review of the evidence on acceptability and effectiveness

INTRODUCTION

Loneliness is prevalent and associated with negative health outcomes in young people. Our understanding of how it can be best addressed is limited. This systematic review aims to assess the acceptability and effectiveness of interventions to reduce and prevent loneliness and social isolation in young people.

METHODS

Six bibliographic databases were searched; references of included studies were screened for relevant literature. A pre-defined framework was used for data extraction. Quality appraisal was performed using the Mixed Method Appraisal Tool. Data were synthesised narratively.

RESULTS

9,358 unique references were identified; 28 publications from 16 interventions met the inclusion criteria. The majority of interventions were high intensity, individual or small group interventions, often targeted at specific 'at risk' populations. While 14 interventions were associated with a statistically significant reduction in loneliness or social isolation, the heterogeneous measures of loneliness, small sample sizes, short periods of follow-up and high attrition rates limit evidence on effectiveness. Interventions implemented in more general populations of young people appeared more acceptable than those in specific 'at risk' populations.

CONCLUSION

High intensity interventions are unlikely to be feasible at a population level. Further work is required to develop and evaluate theoretically-informed loneliness interventions for young people that reach wider audiences.

Learning About the Current State of Digital Mental Health Interventions for Canadian Youth to Inform Future Decision-Making: Mixed Methods Study

Background

The COVID-19 pandemic has increased the demand for youth mental health services in Canada as disruptions to clinical care continue to persist due to the risk of transmission and exposure to the virus. Digital mental health interventions, including web-based resources and mobile apps, have provided opportunities to support youth mental health remotely across Canada. There is a need to better understand how these digital interventions are being selected, recommended, and used in various regions across Canada.

Objective

A national jurisdictional scan was completed to (1) determine what web-based programs, apps, and websites are promoted and licensed in Canada for youth mental health; (2) identify criteria and decision-making processes that Canadian jurisdictions use to select web-based programs, apps, and websites for youth mental health; and (3) identify upcoming trends, innovations, and digital mental health possibilities that are emerging in the youth sector.

Methods

The aims of the jurisdictional scan were addressed through a review of related academic and grey literature; stakeholder interviews, including individuals involved in various areas of the youth mental health sector; and a social media review of pertinent Twitter content.

Results

A total of 66 web-based resources and apps were identified for use by youth in Canada. 16 stakeholder interviews were completed and included discussions with researchers, clinicians, youth organizations, and others involved in digital interventions for youth mental health. These discussions identified a limited use of frameworks used to guide decision-making processes when selecting digital interventions. Many clinicians agreed on a similar set of eligibility requirements for youth mental health apps and digital resources, such as the evidence base and cultural relevance of the intervention. Stakeholders also identified upcoming trends and innovations in the youth digital mental health space, including artificial intelligence, digital phenotyping, and personalized therapy. Over 4 weeks, 2184 tweets were reviewed to identify and compare global and national trends and innovations involving digital mental health and youth. Key trends included the promotion of regional chat services as well as the effects of the COVID-19 pandemic on youth mental health and access to care.

Conclusions

As organizations begin to plan for the delivery of mental health care following the pandemic, there are concerns about the sustainability of these digital mental health interventions as well as a need for services to be more informed by the experiences and preferences of youth.

The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality

As the COVID-19 pandemic has largely increased the utilization of telehealth, mobile mental health technologies - such as smartphone apps, vir-tual reality, chatbots, and social media - have also gained attention. These digital health technologies offer the potential of accessible and scalable interventions that can augment traditional care. In this paper, we provide a comprehensive update on the overall field of digital psychiatry, covering three areas. First, we outline the relevance of recent technological advances to mental health research and care, by detailing how smartphones, social media, artificial intelligence and virtual reality present new opportunities for "digital phenotyping" and remote intervention. Second, we review the current evidence for the use of these new technological approaches across different mental health contexts, covering their emerging efficacy in self-management of psychological well-being and early intervention, along with more nascent research supporting their use in clinical management of long-term psychiatric conditions - including major depression; anxiety, bipolar and psychotic disorders; and eating and substance use disorders - as well as in child and adolescent mental health care. Third, we discuss the most pressing challenges and opportunities towards real-world implementation, using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to explain how the innovations themselves, the recipients of these innovations, and the context surrounding innovations all must be considered to facilitate their adoption and use in mental health care systems. We conclude that the new technological capabilities of smartphones, artificial intelligence, social media and virtual reality are already changing mental health care in unforeseen and exciting ways, each accompanied by an early but promising evidence base. We point out that further efforts towards strengthening implementation are needed, and detail the key issues at the patient, provider and policy levels which must now be addressed for digital health technologies to truly improve mental health research and treatment in the future.

W. M. J, Alvarez-Jimenez M, Nieman DH. ENgage YOung people earlY (ENYOY): a mixed-method study design for a digital transdiagnostic clinical - and peer- moderated treatment platform for youth with beginning mental health complaints in the Netherlands

BACKGROUND

The onset of mental disorders typically occurs between the ages of 12 and 25, and the burden of mental health problems is the most consequential for this group. Indicated prevention interventions to target individuals with subclinical symptoms to prevent the transition to clinical levels of disorders, even leading to suicide, have shown to be effective. However, the threshold to seek help appears to be high. Digital interventions could offer a solution, especially during the Covid-19 pandemic. This implementation study will investigate the digital indicated prevention intervention ENgage YOung people Early (ENYOY), the Dutch version of the original Moderated Online Social Therapy Platform (MOST+) from Australia. In addition, the relationship between stress biomarkers, symptoms and outcome measures of youth using the platform will be investigated in this study.

METHODS

The MOST+ platform will be adapted, translated and developed for the situation in the Netherlands in collaboration with a Youth Panel. A prospective cohort of 125 young people (16-25 years) with beginning mental health complaints will be on the platform and followed for a year, of which 10 participants will have an additional smart watch and 10 participants will be asked to provide feedback about the platform. Data will be collected at baseline and after 3, 6 and 12 months. Outcome measures are Psychological Distress assessed with the Kessler Psychological Distress Scale (K10), Social and occupational functioning (measures by the SOFAS), positive mental health indicators measured by the Positive Health Instrument, stress biomarkers with a smart-watch, website journeys of visitors, and feedback of youth about the platform. It will be a mixed-method study design, containing qualitative and quantitative measures.

DISCUSSION

This trial will specifically address young people with emerging mental health complaints, and offers a new approach for treatment in the Netherlands. Considering the waiting lists in (child and adolescent)-psychiatry and the increase in suicides among youth, early low-threshold and non-stigmatizing help to support young people with emerging psychiatric symptoms is of crucial importance. Moreover, this project aims to bridge the gap between child and adolescent and adult psychiatry.

TRIAL REGISTRATION

Netherlands Trial Register ID NL8966 , retrospectively registered on the 19th of October 2020.

The Horyzons project: a randomized controlled trial of a novel online social therapy to maintain treatment effects from specialist first-episode psychosis services

This study aimed to determine whether, following two years of specialized support for first-episode psychosis, the addition of a new digital intervention (Horyzons) to treatment as usual (TAU) for 18 months was more effective than 18 months of TAU alone. We conducted a single-blind randomized controlled trial. Participants were people with first-episode psychosis (N=170), aged 16-27 years, in clinical remission and nearing discharge from a specialized service. They were randomly assigned (1:1) to receive Horyzons plus TAU (N=86) or TAU alone (N=84) between October 2013 and January 2017. Horyzons is a novel, comprehensive digital platform merging: peer-to-peer social networking; theory-driven and evidence-informed therapeutic interventions targeting social functioning, vocational recovery and relapse prevention; expert clinician and vocational support; and peer support and moderation. TAU involved transfer to primary or tertiary community mental health services. The primary outcome was social functioning at 18 months as measured by the Personal and Social Performance Scale (PSP). Forty-seven participants (55.5%) in the Horyzons plus TAU group logged on for at least 6 months, and 40 (47.0%) for at least 9 months. Social functioning remained high and stable in both groups from baseline to 18-month follow-up, with no evidence of significant between-group differences (PSP mean difference: -0.29, 95% CI: -4.20 to 3.63, p=0.77). Participants in the Horyzons group had a 5.5 times greater increase in their odds to find employment or enroll in education compared with those in TAU (odds ratio, OR=5.55, 95% CI: 1.09-28.23, p=0.04), with evidence of a dose-response effect. Moreover, participants in TAU were twice as likely to visit emergency services compared to those in the Horyzons group (39% vs. 19%; OR=0.31, 95% CI: 0.11-0.86, p=0.03, number needed to treat, NNT=5). There was a non-significant trend for lower hospitalizations due to psychosis in the Horyzons group vs. TAU (13% vs. 27%; OR=0.36, 95% CI: 0.11-1.08, p=0.07, NNT=7). So, although we did not find a significant effect of Horyzons on social functioning compared with TAU, the intervention was effective in improving vocational or educational attainment, a core component of social recovery, and in reducing usage of hospital emergency services, a key aim of specialized first-episode psychosis services. Horyzons holds significant promise as an engaging and sustainable intervention to provide effective vocational and relapse prevention support for young people with first-episode psychosis beyond specialist services.

Online Indicated Preventive Mental Health Interventions for Youth: A Scoping Review

Objective: Between the ages of 12 and 25 the onset of mental disorders typically occurs, and the burden of mental health problems is greatest for this group. Indicated preventive interventions to target individuals with subclinical symptoms to prevent the transition to clinical levels of disorders have gained considerable traction. However, the threshold to seek help appears to be high even when help is needed. Online interventions could offer a solution, especially during the COVID-19 pandemic. This scoping review will present an overview of the recent research of indicated online preventive interventions for youth (12-25 years) experiencing the early stages of mental health complaints with the aim of identifying the nature and extent of the research evidence. Methods: The 5-stage framework by Arksey and O'Malley was used. Academic literature published from 2013 onwards in printed or electronic format was included from Scopus, PsychINFO, and Ovid MEDLINE(R) ALL. Results: The search yielded 11,122 results, with the final selection resulting in inclusion of 30 articles for this review. In total, the articles included 4,950 participants. 26.7% of the selected articles focused on youth between 12 and 25 years. Of the articles 60% did not screen for, nor exclude participants with clinical levels of symptoms. Most studies used a common evidence-based therapy for the disorder-category targeted. More than half of the online interventions included some form of human support. Adherence levels ranged between 27.9 and 98%. The results indicate general effectiveness, usability and acceptability of online indicated preventive interventions. The most commonly used approach was CBT (n = 12 studies). Studies varied in their size, rigor of study, effectiveness and outcome measures. Online interventions with a combination of clinical and peer moderation (n = 3 studies) appear to result in the most stable and highest effect sizes. Conclusion: Online indicated preventive mental health interventions for youth with emerging mental health issues show promise in reducing various mental health complaints, and increasing positive mental health indicators such as well-being and resilience. Additionally, high levels of usability and acceptability were found. However, the included studies show important methodological shortcomings. Also, the research has mainly focused on specific diagnostic categories, meaning there is a lack of transdiagnostic approaches. Finally, clear definitions of- as well as instruments to measure- emerging or subclinical mental health symptoms in youth remain are missing.