Exploring mechanisms and contexts in a Peer Education Project to improve mental health literacy in schools in England: a qualitative realist evaluation

Poor adolescent mental health calls for universal prevention. The Mental Health Foundation's 'Peer Education Project' equips older students ('peer educators') to teach younger students ('peer learners') about mental health. The peer-led lessons cover defining good and bad mental health, risk and protective factors, self-care, help-seeking and looking after one another. While previous pre-post evaluations have suggested effectiveness, the mechanisms through which the intervention improves mental health literacy remain unclear. We purposively recruited seven secondary schools across England from 2020 to 2022 and collected data through five observations, 12 staff interviews and 15 student focus groups (totalling 134 students; 46 peer educators aged 14-18 years and 88 peer learners aged 11-13 years). Our realist analysis adopted retroductive logic, intertwining deductive and inductive approaches to test the initial programme theory against insights arising from the data. We developed Context-Mechanisms-Outcome configurations related to four themes: (i) modelling behaviours and forming supportive relationships, (ii) relevant and appropriate content, (iii) peer educators feeling empowered and (iV) a school culture that prioritises mental health support. Our refined programme theory highlights key mechanisms, contexts conducive to achieving the outcomes and ways to improve training, recruitment and delivery to maximise effectiveness for similar peer-led initiatives.

Changes in anxiety and depression during the COVID-19 pandemic in the European population: A meta-analysis of changes and associations with restriction policies

BACKGROUND

Early studies of common mental disorders (CMDs) during the COVID-19 pandemic mainly report increases; however, more recent findings have been mixed. Also, studies assessing the effects of restriction measures on CMDs show varied results. The aim of this meta-analysis was to assess changes in levels of CMDs from pre-/early to during the pandemic and the effects of restriction policies in the European population.

METHODS

We searched for studies assessing both pre-pandemic and peri-pandemic self-reported emotional distress and symptoms of depression or anxiety among nationally/regionally representative samples in Europe and collected microdata from those studies. Estimates of corona containment index were related to changes in CMDs using random-effects meta-regression.

RESULTS

Our search strategy resulted in findings from 15 datasets drawn from 8 European countries being included in the meta-analysis. There was no evidence of change in the prevalence of emotional distress, anxiety, or depression from before to during the pandemic; but from early pandemic periods to later periods, there were significant decreases in emotional distress and anxiety. Increased school restrictions and social distancing were associated with small increases in self-reported emotional distress.

CONCLUSIONS

Despite initial concerns of increased emotional distress and mental illness due to the COVID-19 pandemic, the results from this meta-analysis indicate that there was a decrease in emotional distress and no change in anxiety or depression in the general population in Europe. Overall, our findings support the importance of strong governance when implementing periodic and robust restriction measures to combat the spread of COVID-19.

Preliminary clinical and cost effectiveness of augmented depression therapy versus cognitive behavioural therapy for the treatment of anhedonic depression (ADepT): a single-centre, open-label, parallel-group, pilot, randomised, controlled trial

Background

Anhedonia (reduced interest/pleasure) symptoms and wellbeing deficits are core to depression and predict a poor prognosis. Current depression psychotherapies fail to target these features adequately, contributing to sub-optimal outcomes. Augmented Depression Therapy (ADepT) has been developed to target anhedonia and wellbeing. We aimed to establish clinical and economic proof of concept for ADepT and to examine feasibility of a future definitive trial comparing ADepT to Cognitive Behavioural Therapy (CBT).

Methods

In this single-centre, open-label, parallel-group, pilot randomised controlled trial, adults meeting diagnostic criteria for a current major depressive episode, scoring ≥10 on the Patient Health Questionnaire (PHQ-9) and exhibiting anhedonic features (PHQ-9 item 1 ≥ 2) were recruited primarily from high intensity Improving Access to Psychological Therapy (IAPT) service waiting lists in Devon, UK. Participants were randomised to receive 20 sessions of CBT or ADepT, using a mimimisation algorithm to balance depression severity and antidepressant use between groups. Treatment was delivered in an out-patient university-based specialist mood disorder clinic. Researcher-blinded assessments were completed at intake and six, 12, and 18 months. Co-primary outcomes were depression (PHQ-9) and wellbeing (Warwick Edinburgh Mental Wellbeing Scale) at 6 months. Primary clinical proof-of-concept analyses were intention to treat. Feasibility (including safety) and health economic analyses used complete case data. This trial is registered at the ISRCTN registry, ISRCTN85278228.

Findings

Between 3/29/2017 and 7/31/2018, 82 individuals were recruited (102% of target sample) and 41 individuals were allocated to each arm. A minimum adequate treatment dose was completed by 36/41 (88%) of CBT and 35/41 (85%) of ADepT participants. There were two serious adverse events in each arm (primarily suicide attempts; none of which were judged to be trial- or treatment-related), with no other evidence of harms. Intake and six-month primary outcome data was available for 37/41 (90%) CBT participants and 32/41 (78%) ADepT participants. Between-group effects favoured ADepT over CBT for depression (meanΔ = -1.35, 95% CI = -3.70, 1.00, d = 0.23) and wellbeing (meanΔ = 2.64, 95% CI = -1.71, 6.99, d = 0.27). At 18 months, the advantage of ADepT over CBT was preserved and ADepT had a >80% probability of cost-effectiveness.

Interpretation

These findings provide proof of concept for ADepT and warrant continuation to definitive trial.

Funding

NIHR Career Development Fellowship.

Perspectives on an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a qualitative study

BACKGROUND

A new Health and Wellbeing pathway was introduced into the Improving Access to Psychological Therapies (IAPT) service in one geographical area of the UK in 2021 to address the wider determinants of mental health problems. It comprised assisted signposting to wider services and physical health promotion. This qualitative study aimed to understand stakeholders' experiences of implementing and receiving this new support and the barriers and facilitators to its delivery.

METHODS

Forty-seven interviews were conducted, with service developers (n = 6), service deliverers (n = 12), service users (n = 22) and community and clinical partners (n = 7), as part of a larger mixed-methods evaluation. Interviews were recorded, transcribed, and analysed using reflexive thematic analysis.

RESULTS

Three themes spanned all participant groups and represented key aspects of the service: (1) identifying suitability, (2) a holistic service, and (3) moving forward. The sub-themes represent the barriers and facilitators to processes working in practice, lending insight into potential service improvements. These included strengthening the quality of communication during referral and assessment, tailoring the support and delivery mode, and increasing transparency around continued care to drive sustained benefits.

LIMITATIONS

Service users may have been selected due to their positive experiences of IAPT and were not demographically representative of the population, although participants' experiences of the service did suggest variation in our sample.

CONCLUSIONS

The Health and Wellbeing pathway was perceived as having a positive impact on mental health and could reduce the burden on therapeutic services. However, service- and individual-level barriers need to be addressed to enhance statutory and community support links, manage service users' expectations, and improve accessibility for certain groups.

Using systems thinking to understand how the South West - School Health Research Network can improve adolescent health and well-being: A qualitative process evaluation

Schools offer a valuable setting to promote good health and mental well-being amongst young people. Schools are complex systems and therefore systems interventions are needed to improve pupil health and well-being. This paper presents a qualitative process evaluation of the South West- School Health Research Network, a systems level intervention. The evaluation is based on interviews with school staff, local authorities and wider stakeholders. Given the complexity of England's educational system there is a need to intervene and monitor health at multiple levels and to ensure close partnership working to effectively improve adolescent health through schools.

Implementing a regional school health research network in england to improve adolescent health and well-being, a qualitative process evaluation

BACKGROUND

There is an increased need for prevention and early intervention surrounding young people's health and well-being. Schools offer a pivotal setting for this with evidence suggesting that focusing on health within schools improves educational attainment. One promising approach is the creation of School Health Research Networks which exist in Wales and Scotland, but are yet to be developed and evaluated in England.

METHODS

This qualitative process evaluation aimed to identify the main barriers and facilitators to implementing a pilot School Health Research Network in the South West of England (SW-SHRN). Semi-structured interviews were conducted with school staff, local authority members, and other key stakeholders. Interview data were analysed using the 7-stage framework analysis approach.

RESULTS

Four main themes were identified from the data: (1) 'Key barriers to SW-SHRN' (competing priorities of academic attainment and well-being, schools feeling overwhelmed with surveys and lack of school time and resource); (2) 'Key facilitators to SW-SHRN: providing evidence-based support to schools' (improved knowledge to facilitate change, feedback reports and benchmarking and data to inform interventions); (3) 'Effective dissemination of findings' (interpretation and implementation, embedding findings with existing evidence and policy, preferences for an online platform as well personalised communication and the importance of involving young people and families); and (4) 'Longer-term facilitators: ensuring sustainability' (keeping schools engaged, the use of repeat surveys to evaluate impact, informing school inspection frameworks and expanding reach of the network).

CONCLUSION

This study identifies several barriers to be addressed and facilitators to be enhanced in order to achieve successful implementation of School Health Research Networks in England which include providing a unique offering to schools that is not too burdensome, supporting schools to take meaningful action with their data and to work closely with existing organisations, services and providers to become meaningfully embedded in the system.

School-based peer education interventions to improve health: a global systematic review of effectiveness

INTRODUCTION

Peer education, whereby peers ('peer educators') teach their other peers ('peer learners') about aspects of health is an approach growing in popularity across school contexts, possibly due to adolescents preferring to seek help for health-related concerns from their peers rather than adults or professionals. Peer education interventions cover a wide range of health areas but their overall effectiveness remains unclear. This review aims to summarise the effectiveness of existing peer-led health interventions implemented in schools worldwide.

METHODS

Five electronic databases were searched for eligible studies in October 2020. To be included, studies must have evaluated a school-based peer education intervention designed to address the health of students aged 11-18-years-old and include quantitative outcome data to examine effectiveness. The number of interventions were summarised and the impact on improved health knowledge and reductions in health problems or risk-taking behaviours were investigated for each health area separately, the Mixed Methods Appraisal Tool was used to assess quality.

RESULTS

A total of 2125 studies were identified after the initial search and 73 articles were included in the review. The majority of papers evaluated interventions focused on sex education/HIV prevention (n = 23), promoting healthy lifestyles (n = 17) and alcohol, smoking and substance use (n = 16). Papers mainly reported peer learner outcomes (67/73, 91.8%), with only six papers (8.2%) focussing solely on peer educator outcomes and five papers (6.8%) examining both peer learner and peer educator outcomes. Of the 67 papers reporting peer learner outcomes, 35/67 (52.2%) showed evidence of effectiveness, 8/67 (11.9%) showed mixed findings and 24/67 (35.8%) found limited or no evidence of effectiveness. Of the 11 papers reporting peer educator outcomes, 4/11 (36.4%) showed evidence of effectiveness, 2/11 (18.2%) showed mixed findings and 5/11 (45.5%) showed limited or no evidence of effectiveness. Study quality varied greatly with many studies rated as poor quality, mainly due to unrepresentative samples and incomplete data.

DISCUSSION

School-based peer education interventions are implemented worldwide and span a wide range of health areas. A number of interventions appear to demonstrate evidence for effectiveness, suggesting peer education may be a promising strategy for health improvement in schools. Improvement in health-related knowledge was most common with less evidence for positive health behaviour change. In order to quantitatively synthesise the evidence and make more confident conclusions, there is a need for more robust, high-quality evaluations of peer-led interventions using standardised health knowledge and behaviour measures.

How well do Cognitive Behavioural Therapy and Behavioural Activation for depression repair anhedonia? A secondary analysis of the COBRA randomized controlled trial

A secondary analysis of the COBRA randomized controlled trial was conducted to examine how well Cognitive Behavioural Therapy (CBT) and Behavioural Activation (BA) repair anhedonia. Patients with current major depressive disorder (N = 440) were randomized to receive BA or CBT, and anhedonia and depression outcomes were measured after acute treatment (six months) and at two further follow up intervals (12 and 18 months). Anhedonia was assessed using the Snaith Hamilton Pleasure Scale (SHAPS; a measure of consummatory pleasure). Both CBT and BA led to significant improvements in anhedonia during acute treatment, with no significant difference between treatments. Participants remained above healthy population averages of anhedonia at six months, and there was no further significant improvement in anhedonia at 12-month or 18-month follow up. Greater baseline anhedonia severity predicted reduced repair of depression symptoms and fewer depression-free days across the follow-up period in both the BA and CBT arms. The extent of anhedonia repair was less marked than the extent of depression repair across both treatment arms. These findings demonstrate that CBT and BA are similarly and only partially effective in treating anhedonia. Therefore, both therapies should be further refined or novel treatments should be developed in order better to treat anhedonia.

The Peer Education Project to improve mental health literacy in secondary school students in England: a qualitative realist evaluation

BACKGROUND

Worsening of adolescent mental health and exacerbated health inequalities after the COVID-19 pandemic calls for universal preventative strategies. The Mental Health Foundation's school-based Peer Education Project seeks to improve students' mental health literacy through peer educators (aged 14-18 years) teaching peer learners (aged 11-13 years) to recognise good and bad mental health, identify risk and protective factors, and seek help accordingly. Although previous before and after quantitative assessments have found the intervention to be effective, this realist evaluation aimed to qualitatively develop the theory of change, exploring how the mechanisms played out in different contexts to achieve the desired outcomes.

METHODS

Our initial programme theory was developed following expert stakeholder consultation and reviewing the literature. We divided mechanisms into resources and reasoning to explain how the intervention components (ie, resources), experienced within specific contexts, engendered responses in the participants (ie, reasoning), to produce observable outcomes. Data collected from six purposively recruited schools in England comprised staff interviews (n=11), student focus groups (n=15), and observations (n=5). Deductive and inductive analysis was undertaken, using NVivo-informed multiple causal statements represented as context-mechanism-outcome configurations (CMOcs), to test and refine the programme theory.

FINDINGS

We created several distinct CMOcs. For example, in learners accustomed to didactic teaching methods (context), conversing with educators having similar life experience (mechanism resource) endorsed and destigmatised help-seeking behaviour (mechanism reasoning) and facilitated a realisation that seeking help was appropriate and acceptable (outcome). Other mechanisms included the following: learners perceiving the information as tailored and relevant, educators feeling empowered, and a cultural shift percolating across the school.

INTERPRETATION

Our findings show how peer education can work to improve mental health literacy, which will inform changes to the intervention to maximise its effectiveness in different operational contexts. Future research could test our theory of change in a randomised controlled trial, and examine impacts on inequalities in a more diverse sample.

FUNDING

National Institute for Health and Care Research School for Public Health Research.

Creation of a Pilot School Health Research Network in an English Education Infrastructure to Improve Adolescent Health and Well-Being: A Study Protocol

Schools play a significant role in promoting health and well-being and the reciprocal links between health and educational attainment are well-evidenced. Despite recognition of the beneficial impact of school-based health improvement programmes, significant barriers to improving health and well-being within schools remain. This study pilots a School Health Research Network in the South West of England (SW-SHRN), a systems-based health intervention bringing together schools, academic health researchers and public health and/or education teams in local authorities to share knowledge and expertise to improve the health and well-being of young people. A maximum of 20 secondary schools will be recruited to the pilot SW-SHRN. All students in Years 8 (age 12-13) and 10 (age 14-15) will be invited to complete a health and well-being questionnaire, generating a cohort of approximately 5000 adolescents. School environment questionnaires will also be completed with each school to build a regional picture of existing school health policies and programmes. Each school will be provided with a report summarising data for their students benchmarked against data for all schools in the network. Quantitative analysis will model associations between health risk behaviours and mental health outcomes and a qualitative process evaluation will explore the feasibility and sustainability of the network. This study will create adolescent health data to help provide schools and local authorities with timely and robust information on the health and well-being of their students and help them to identify areas in which public health interventions may be required. SW-SHRN will also help public health professionals focus their resources in the areas most at need.

Impact of School and Peer Connectedness on Adolescent Mental Health and Well-Being Outcomes during the COVID-19 Pandemic: A Longitudinal Panel Survey

School closures and social distancing measures during the pandemic have disrupted young people’s daily routines and social relationships. We explored patterns of change in adolescent mental health and tested the relationship between pre-pandemic levels of school and peer connectedness and changes in mental health and well-being between the first lockdown and the return to school. This is a secondary analysis of a longitudinal 3-wave panel survey. The study sample included 603 students (aged 13–14) in 17 secondary schools across south-west England. Students completed a survey pre-pandemic (October 2019), during lockdown (May 2020) and shortly after returning to school (October 2020). Multilevel models, with random effects, were conducted for anxiety, depression and well-being outcomes with school and peer connectedness as predictor variables. Symptoms of anxiety decreased from pre-pandemic to during the first UK lockdown and increased on the return to school; anxious symptoms decreased the most for students reporting feeling least connected to school pre-pandemic. Students reporting low levels of school and peer connectedness pre-pandemic experienced poorer mental health and well-being at all time points. Low school connectedness pre-pandemic was associated with a greater increase in anxious and depressive symptoms between lockdown and the return to school when compared to students with medium levels of school connectedness. No associations were found with high school connectedness or with low/high peer connectedness. For adolescents with poor school connectedness, the enforced time away from school that the pandemic caused led to reduced anxiety. Going forwards, we need to consider ways in which to promote connection with school as a way of supporting mental health and well-being.

Autism spectrum disorders as a risk factor for adolescent self-harm: a retrospective cohort study of 113,286 young people in the UK

BACKGROUND

Individuals with autism spectrum disorder (ASD) are at particularly high risk of suicide and suicide attempts. Presentation to a hospital with self-harm is one of the strongest risk factors for later suicide. We describe the use of a novel data linkage between routinely collected education data and child and adolescent mental health data to examine whether adolescents with ASD are at higher risk than the general population of presenting to emergency care with self-harm.

METHODS

A retrospective cohort study was conducted on the population aged 11-17 resident in four South London boroughs between January 2009 and March 2013, attending state secondary schools, identified in the National Pupil Database (NPD). Exposure data on ASD status were derived from the NPD. We used Cox regression to model time to first self-harm presentation to the Emergency Department (ED).

RESULTS

One thousand twenty adolescents presented to the ED with self-harm, and 763 matched to the NPD. The sample for analysis included 113,286 adolescents (2.2% with ASD). For boys only, there was an increased risk of self-harm associated with ASD (adjusted hazard ratio 2·79, 95% CI 1·40-5·57, P<0·01). Several other factors including school absence, exclusion from school and having been in foster care were also associated with a higher risk of self-harm.

CONCLUSIONS

This study provides evidence that ASD in boys, and other educational, social and clinical factors, are risk factors for emergency presentation with self-harm in adolescents. These findings are an important step in developing early recognition and prevention programmes.

A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19

People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.

“It's been up and down”—perspectives on living through COVID-19 for individuals who experience homelessness: a qualitative study

Background

The UN describes the COVID-19 pandemic as the greatest public health crisis for the current generation. However, individuals who experienced austerity, adversity, and disadvantage prior to the pandemic have been disproportionately affected with every turn the pandemic has taken, from transmission risk to vaccination take-up. One such population is individuals who experience homelessness. As the UK begins to transition to a stage of post-pandemic recovery, it is imperative to understand the perceived impact COVID-19 has had on the day-to-day lives of individuals who experience homelessness, to ensure they are not left behind and recovery planning can be better targeted to their specific needs.

Methods

Between February and May, 2021, 26 individuals (10 women and 16 men) who self-identified as experiencing homelessness within the Newcastle Gateshead area took part in telephone interviews of 20–80 min in length. Participants provided written or verbal informed consent prior to participating. Recruitment took place through existing networks, housing providers, charities, word of mouth, and snowball sampling. Analysis was co-produced with five individuals with lived experience using interpretative phenomenological analysis. NVivo release 1·5 was used to organise quotes. Ethics approval was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University's Research Ethics Committee (ref 2034/6698/2020.)

Findings

Experiences shared depicted unique stories with commonalities across the findings through five main themes: (1) surreality of day-to-day life—searching for understanding and lost autonomy; (2) an emotional rollercoaster—confronting negative emotions; (3) loneliness is my best friend—learning from being alone; (4) adversity is the only consistency—recognising past and present hardship, violence, and loss; and (5) coping with uncertainty—using drugs, mindfulness, and technology to survive.

Interpretation

The pandemic has affected the daily lives of people who experience homelessness in a variety of ways, including personal growth, no change, and regression. This study is limited by its localised recruitment in Newcastle and Gateshead in the UK; however, this local focus and involvement of individuals with lived experience has strengthened the study's implications for policy and practice in the region. Initiatives or policies developed to support post-pandemic recovery should reflect the array of impacts, while giving special recognition to loneliness, adversity, and resiliency among individuals who experience homelessness.

Funding

National Institute for Health Research School for Public Health Research.

A process evaluation of a peer education project to improve mental health literacy in secondary school students: study protocol

BACKGROUND

Emotional disorders in young people are increasing but studies have found that this age group do not always recognise the signs and symptoms of mental health problems in themselves or others. The Mental Health Foundation's school-based Peer Education Project (PEP) has the potential to improve young people's understanding of their own mental health at a critical developmental stage (early adolescence) using a peer teaching method. This study is a process evaluation to understand: the mechanisms through which PEP might improve young people's mental health literacy, any challenges with delivery, how the project can be embedded within wider school life and how it can be improved to be of most benefit to the widest number of young people. We will also validate a bespoke mental health literacy questionnaire, and test the feasibility of using it to measure outcomes in preparation for a future study evaluating effectiveness.

METHODS

All schools recruited to the study will receive the PEP intervention. The process evaluation will be informed by realist evaluation approaches to build understanding regarding key mechanisms of change and the impact of different school contexts. The evaluation will test and revise an existing intervention logic model which has been developed in partnership with the Mental Health Foundation. Process evaluation data will be collected from newly recruited schools (n = 4) as well as current PEP user schools (n = 2) including training and lesson delivery observations, staff interviews and student focus groups. Baseline and follow-up data will be collected in all newly recruited intervention schools (n = 4) from all students in Year 7/8 (who receive the PEP) and recruited peer educators in Year 12 via a self-report survey.

DISCUSSION

This study will enable us to refine the logic model underpinning the peer education project and identify areas of the intervention that can be improved. Findings will also inform the design of a future effectiveness study which will test out the extent to which PEP improves mental health literacy.

User Perspectives of Mood-Monitoring Apps Available to Young People: Qualitative Content Analysis

BACKGROUND

Mobile health apps are increasingly available and used in a clinical context to monitor young people's mood and mental health. Despite the benefits of accessibility and cost-effectiveness, consumer engagement remains a hurdle for uptake and continued use. Hundreds of mood-monitoring apps are publicly available to young people on app stores; however, few studies have examined consumer perspectives. App store reviews held on Google and Apple platforms provide a large, rich source of naturally generated, publicly available user reviews. Although commercial developers use these data to modify and improve their apps, to date, there has been very little in-depth evaluation of app store user reviews within scientific research, and our current understanding of what makes apps engaging and valuable to young people is limited.

OBJECTIVE

This study aims to gain a better understanding of what app users consider useful to encourage frequent and prolonged use of mood-monitoring apps appropriate for young people.

METHODS

A systematic approach was applied to the selection of apps and reviews. We identified mood-monitoring apps (n=53) by a combination of automated application programming interface (API) methods. We only included apps appropriate for young people based on app store age categories (apps available to those younger than 18 years). We subsequently downloaded all available user reviews via API data scraping methods and selected a representative subsample of reviews (n=1803) for manual qualitative content analysis.

RESULTS

The qualitative content analysis revealed 8 main themes: accessibility (34%), flexibility (21%), recording and representation of mood (18%), user requests (17%), reflecting on mood (16%), technical features (16%), design (13%), and health promotion (11%). A total of 6 minor themes were also identified: notification and reminders; recommendation; privacy, security, and transparency; developer; adverts; and social/community.

CONCLUSIONS

Users value mood-monitoring apps that can be personalized to their needs, have a simple and intuitive design, and allow accurate representation and review of complex and fluctuating moods. App store reviews are a valuable repository of user engagement feedback and provide a wealth of information about what users value in an app and what user needs are not being met. Users perceive mood-monitoring apps positively, but over 20% of reviews identified the need for improvement.

Informing the development of an E-platform for monitoring wellbeing in schools: involving young people in a co-design process

BACKGROUND

The use of new technologies and methodologies in young people's mental health research is needed to allow more frequent and reliable sampling. Mobile applications and e-platforms create exciting potential for the collection of large-scale cohort data, however there are various feasibility and ethical issues to consider. Consultation with young people is needed to inform the research agenda, and ensure these technologies are engaging, useful and safe. This article describes the process of Public and Patient Involvement (PPI) with a sample of young people in London, with the aim of i) informing the development of a mood-monitoring e-platform, and ii) providing feedback and advice for researchers developing web-based technologies in the mental health field.

METHODS

A total of 26 young people were consulted across four advisory group co-design sessions. All young people were students enrolled at one of the participating London based sixth form colleges, and voluntarily attended a workshop session. Audio recordings of the sessions were analysed using a thematic analysis framework.

RESULTS

We found that young people were engaged in discussions around mobile health technologies and valued the opportunity to collaborate throughout the early stages of the development process The advisory groups identified key considerations for future web-development work to encourage engagement and prolonged use, including, the promotion of trust and transparency, consideration of accessibility, provision of support, production of engaging and functional design, and acknowledgment of specific contextual influences surrounding young people's wellbeing.

CONCLUSIONS

Involving young people in the development process of e-health technologies contributes to optimising the successful adoption and prolonged usage of new methodologies. The thematic map and informant examples can be used to guide researchers interested in developing web-based technologies in the mental health field and will be directly applicable to the development of a mood-monitoring e-platform.

Routine Cognitive Behavioural Therapy for Anxiety and Depression is More Effective at Repairing Symptoms of Psychopathology than Enhancing Wellbeing

The primary focus of classic cognitive behavioural therapy (CBT) for depression and anxiety is on decreasing symptoms of psychopathology. However, there is increasing recognition that it is also important to enhance wellbeing during therapy. This study investigates the extent to which classic CBT for anxiety and depression leads to symptom relief versus wellbeing enhancement, analysing routine outcomes in patients receiving CBT in high intensity Improving Access to Psychological Therapy (IAPT) Services in the UK. At intake, there were marked symptoms of anxiety and depression (a majority of participants scoring in the severe range) and deficits in wellbeing (a majority of participants classified as languishing, relative to general population normative data). CBT was more effective at reducing symptoms of anxiety and depression than repairing wellbeing. As a result, at the end of treatment, a greater proportion of participants met recovery criteria for anxiety and depression than had moved from languishing into average or flourishing levels of wellbeing. Given the importance of wellbeing to client definitions of recovery, the present results suggest a greater emphasis should be placed on enhancing wellbeing in classic CBT.

Bringing light into darkness: A multiple baseline mixed methods case series evaluation of Augmented Depression Therapy (ADepT)

Two core features of depression are elevations in negative valence system (NVS) functioning and reductions in positive valence system (PVS) functioning. Existing psychological treatments have focused on the NVS and neglected the PVS, which may contribute to sub-optimal outcomes. The present mixed methods multiple randomised baseline case series preliminarily evaluates Augmented Depression Therapy (ADepT), a novel depression treatment targeting PVS and NVS disturbance, that aims both to reduce depression and enhance wellbeing. Eleven clinically depressed participants were recruited. Intensive time series analyses showed that 7/11 participants improved on both wellbeing and depression. Reliable and clinically significant improvement was observed for 9/11 participants on at least one of these outcomes (and also across a range of other PVS and NVS outcomes). Group level analyses showed significant pre to post change on all outcomes. Benchmarking analyses indicated these effect sizes were at least comparable (and for some PVS outcomes superior) to existing treatments. Gains were largely sustained over one-year follow-up. Qualitative interviews indicated ADepT was feasible and acceptable. These findings provide preliminary support for ADepT as a novel depression treatment. Further evaluation, directly comparing ADepT to existing treatments using randomised controlled trial designs, is now required.

Evaluating Augmented Depression Therapy (ADepT): study protocol for a pilot randomised controlled trial

BACKGROUND

While existing psychological treatments for depression are effective for many, a significant proportion of depressed individuals do not respond to current approaches and few remain well over the long-term. Anhedonia (a loss of interest or pleasure) is a core symptom of depression which predicts a poor prognosis but has been neglected by existing treatments. Augmented Depression Therapy (ADepT) has been co-designed with service users to better target anhedonia alongside other features of depression. This mixed methods pilot trial aims to establish proof of concept for ADepT and to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost-effectiveness of ADepT, compared to an evidence-based mainstream therapy (Cognitive Behavioural Therapy; CBT) in the acute treatment of depression, the prevention of subsequent depressive relapse, and the enhancement of wellbeing.

METHODS

We aim to recruit 80 depressed participants and randomise them 1:1 to receive ADepT (15 weekly acute and 5 booster sessions in following year) or CBT (20 weekly acute sessions). Clinical and health economic assessments will take place at intake and at 6-, 12-, and 18-month follow-up. Reductions in PHQ-9 depression severity and increases in WEMWBS wellbeing at 6-month assessment (when acute treatment should be completed) are the co-primary outcomes. Quantitative and qualitative process evaluation will assess mechanism of action, implementation issues, and contextual moderating factors. To evaluate proof of concept, intake-post effect sizes and the proportion of individuals showing reliable and clinically significant change on outcome measures in each arm at each follow-up will be reported. To evaluate feasibility and acceptability, we will examine recruitment, retention, treatment completion, and data completeness rates and feedback from patients and therapists about their experience of study participation and therapy. Additionally, we will establish the cost of delivery of ADepT.

DISCUSSION

We will proceed to definitive trial if any concerns about the safety, acceptability, feasibility, and proof of concept of ADepT and trial procedures can be rectified, and we recruit, retain, and collect follow-up data on at least 60% of the target sample.

TRIAL REGISTRATION

ISCRTN85278228, registered 27/03/2017.