Self-Guided Mental Health Apps Targeting Racial and Ethnic Minority Groups: Scoping Review

BACKGROUND

The use of mental health apps (MHAs) is increasing rapidly. However, little is known about the use of MHAs by racial and ethnic minority groups.

OBJECTIVE

In this review, we aimed to examine the acceptability and effectiveness of MHAs among racial and ethnic minority groups, describe the purposes of using MHAs, identify the barriers to MHA use in racial and ethnic minority groups, and identify the gaps in the literature.

METHODS

A systematic search was conducted on August 25, 2023, using Web of Science, Embase, PsycINFO, PsycArticles, PsycExtra, and MEDLINE. Articles were quality appraised using the Mixed Methods Appraisal Tool, and data were extracted and summarized to form a narrative synthesis.

RESULTS

A total of 15 studies met the inclusion criteria. Studies were primarily conducted in the United States, and the MHAs designed for racial and ethnic minority groups included ¡Aptívate!, iBobbly, AIMhi- Y, BRAVE, Build Your Own Theme Song, Mindful You, Sanadak, and 12 more MHAs used in 1 study. The MHAs were predominantly informed by cognitive behavioral therapy and focused on reducing depressive symptoms. MHAs were considered acceptable for racial and ethnic minority groups; however, engagement rates dropped over time. Only 2 studies quantitatively reported the effectiveness of MHAs among racial and ethnic minority groups. Barriers to use included the repetitiveness of the MHAs, stigma, lack of personalization, and technical issues.

CONCLUSIONS

Considering the growing interest in MHAs, the available evidence for MHAs for racial and ethnic minority groups appears limited. Although the acceptability seems consistent, more research is needed to support the effectiveness of MHAs. Future research should also prioritize studies to explore the specific needs of racial and ethnic minority groups if MHAs are to be successfully adopted.

An App to Support Fathers' Mental Health and Well-Being: User-Centered Development Study

BACKGROUND

Numerous studies describe the popularity and usefulness of parenting programs. In particular, parenting programs are generally viewed as effective for supporting parents' mental well-being during key transition periods. However, the evidence base for fathers is limited owing to their lack of involvement in parenting programs and scarcity of tailored support.

OBJECTIVE

This paper aimed to describe the co-design process for a universal digital intervention for fathers (fatherli) and the outline of a logic model with its expected outcomes.

METHODS

Following established guidelines for co-designing and developing complex interventions, we conducted a nonsystematic review of the available literature to gather key information, developed market surveys to assess fathers' needs and interests, consulted with key stakeholders to obtain expert opinions, and engaged in a rapid iterative prototyping process with app developers. Each step was summarized, and the information was collated and integrated to inform a logic model and the features of the resulting intervention.

RESULTS

The steps in the co-design process confirmed a need for and interest in a digital intervention for fathers. In response to this finding, fatherli was developed, consisting of 5 key features: a discussion forum for anyone to post information about various topics (the forum), a socializing platform for fathers to create and engage with others in small groups about topics or points of shared interest (dad hub), a tool for fathers to find other fathers with shared interests or within the same geographic location (dad finder), a resource for fathers to access up-to-date information about topics that interest them (dad wiki), and a portal to book sessions with coaches who specialize in different topics (dad coaching space). The evidence-based logic model proposes that if fatherli is successfully implemented, important outcomes such as increased parental efficacy and mental health help-seeking behaviors may be observed.

CONCLUSIONS

We documented the co-design and development process of fatherli, which confirmed that it is possible to use input from end users and experts, integrated with theory and research evidence, to create suitable digital well-being interventions for fathers. In general, the key findings suggest that an app that facilitates connection, communication, and psychoeducation may appeal to fathers. Further studies will now focus on acceptability, feasibility, and effectiveness. Feedback gathered during pilot-testing will inform any further developments in the app to increase its applicability to fathers and its usability.

Prevalence of mental health and behaviour problems among adolescents in the English-speaking Caribbean: systematic review and meta-analysis

Objective

Children and young people (CYP) from low-and-middle-income and developing countries are at risk of poor mental health and wellbeing. Yet these regions are generally under-resourced in terms of mental health services. As a first step to inform service planning and delivery in the English-speaking Caribbean we pooled the available evidence to estimate the prevalence of common mental health problems.

Methods

A comprehensive search of CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, LILACS, and Web of Science databases, supplemented by grey literature searches was performed until January 2022. Studies conducted in the English-speaking Caribbean that reported prevalence estimates of mental health symptomology or diagnoses in CYP were included. The Freeman-Tukey transformation was applied to calculate the weighted summary prevalence under a random-effects model. Subgroup analyses were also performed to observe emerging patterns in the data. Studies were quality assessed using the Joanna Briggs Institute Prevalence Critical Appraisal Checklist and the GRADE approach. The study protocol was registered with PROSPERO, CRD42021283161.

Results

33 publications from 28 studies representing 65,034 adolescents from 14 countries met the eligibility criteria. Prevalence estimates ranged from 0.8 to 71.9% with most subgroup estimates between 20 and 30%. The overall pooled prevalence of mental health problems was 23.5% (95% CI 0.175-0.302; I2 = 99.7%). There was limited evidence of significant variation in prevalence estimates among subgroups. The quality of the body of evidence was judged as moderate.

Conclusion

It is estimated that between 1 in 4 and 1 in 5 adolescents in the English-speaking Caribbean experience symptoms of mental health problems. These findings highlight the importance of sensitisation, screening, and provision of appropriate services. Ongoing research identifying risk factors and validating outcome measures is also needed to inform evidence-based practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-023-00037-2.

Mental health and wellbeing of further and higher education students returning to face-to-face learning after Covid-19 restrictions

AIM

This study aimed to examine the mental health and wellbeing of further and higher education students and the associating factors after returning to face-to-face (in-person) learning after Covid-19 restrictions.

METHODS

A cross-sectional study informed by student consultations was conducted using a survey design. Mental health and wellbeing were assessed using self-report items on the Depression, Anxiety and Stress Scale (DASS-21) and the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS). Descriptive statistics and stepwise multiple linear regression analyses were conducted on data collected between December 2021 and June 2022.

RESULTS

N = 1160 students participated; 69.6% between 16 and 25 years, 67.9% studying in the UK, 66.5% studying away from home, 60.2% identified as she/her, 59.8% studying at the undergraduate degree level, 42.5% belonging to non-White ethnic backgrounds, 29.6% identifying as having additional needs and 22.8% as sexual minority. Moderate anxiety (M = 13.67, SD = 9.92) and depression (M = 17.04, SD = 11.56) scores were mainly reported. Wellbeing scores (M = 20.31, SD = 3.93) were lower than the estimate for the pre-pandemic general population. Gender expression, sexuality, age, ethnicity, having additional needs, and level and location of study was associated with mental health or wellbeing. Individual coping styles, levels of self-efficacy and physical activity were also associated with mental health or wellbeing.

CONCLUSIONS

Many students returning to further and higher education after Covid-19 restrictions experienced reduced mental health and wellbeing, and some students were at greater risk. Providing student-centred interventions focusing on self-efficacy, coping styles and physical activity may help improve the mental health and wellbeing of students.

Factors associated with children and young people's mental health in the English-speaking Caribbean region: Systematic review and narrative synthesis

BACKGROUND

Studies conducted in regions consisting of low and middle income and developing countries often report high prevalence of mental health problems among children and young people (CYP). To identify some of the contributing factors we examined the available evidence from research in one such setting.

METHODS

Multiple academic databases and grey literature sources were searched until January 2022. We then identified primary research focusing on CYP's mental health in the English-speaking Caribbean region. Data was extracted and summarized to form a narrative synthesis of the factors associated with CYP's mental health. The synthesis was then organised according to the social-ecological model. The Joanna Briggs Institute's critical appraisal tools were used to examine the quality of the reviewed evidence. The study protocol was registered with PROSPERO, CRD42021283161.

RESULTS

From 9684 records, 83 publications representing CYP ages 3 to 24 years from 13 countries met our inclusion criteria. The evidence was varied in quality, quantity and consistency for 21 factors associated with CYP's mental health. Adverse events and negative peer to peer and sibling relationships were consistently associated with mental health problems, while helpful coping strategies were associated with better mental health. There were mixed findings for age, sex/gender, race/ethnicity, academic level, comorbidity, positive affect, health risks behaviours, religion/prayer, parent history, parent to parent and parent to child relationships, school/employment, geography and social status. There was also some limited evidence for associations between sexuality, screen time and policies/procedures and CYP's mental health. At least 40% of the evidence contributing to each of the factors was judged as high quality.

CONCLUSION

Individual, relationship, community and societal factors may influence CYP's mental health outcomes in the English-speaking Caribbean. Knowledge of these factors is useful to inform early identification and early interventions. More research is needed to explore inconsistent findings and understudied areas.

A preliminary evaluation of Kids Matter: A community-based parenting intervention

Parents living in deprived communities are more likely to report lower parental self-efficacy and wellbeing. Poor parental wellbeing and self-efficacy are known risk factors in the development of a range of health and behavioural problems in childhood, adolescence and adulthood. Parenting interventions are key to prevent adverse outcomes in children, however, the mechanisms by which parents learn to understand and support their children are still not well understood. This study evaluated the acceptability of Kids Matter, a parenting intervention targeting parents who are struggling with financial adversity. Secondarily, the relationship between parental wellbeing and and self-efficacy was examined. The present is a retrospective, consecutive case series design study, comparing routinely collected data at pre-intervention, post-intervention, and at 3-month follow-up. Descriptive frequencies were drawn to explore parents' impressions of the programme. Multivariate analysis of variance and regression modelling were used to evaluate associations between parental wellbeing and self-efficacy at different time points. Parents found the programme enjoyable and useful. The intervention led to significant improvements in parental wellbeing and self-efficacy. Improvements in parental wellbeing were significantly associated with improvements in self-efficacy. This study provides evidence of the acceptability and effectiveness of Kids Matter.

Determination of Markers of Successful Implementation of Mental Health Apps for Young People: Systematic Review

Background

Smartphone apps have the potential to address some of the current issues facing service provision for young people’s mental health by improving the scalability of evidence-based mental health interventions. However, very few apps have been successfully implemented, and consensus on implementation measurement is lacking.

Objective

This review aims to determine the proportion of evidence-based mental health and well-being apps that have been successfully adopted and sustained in real-world settings. A secondary aim is to establish if key implementation determinants such as coproduction, acceptability, feasibility, appropriateness, and engagement contribute toward successful implementation and longevity.

Methods

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, an electronic search of 5 databases in 2021 yielded 18,660 results. After full-text screening, 34 articles met the full eligibility criteria, providing data on 29 smartphone apps studied with individuals aged 15 to 25 years.

Results

Of 34 studies, only 10 (29%) studies were identified that were evaluating the effectiveness of 8 existing, commercially available mental health apps, and the remaining 24 (71%) studies reported the development and evaluation of 21 newly developed apps, of which 43% (9/21) were available, commercially or otherwise (eg, in mental health services), at the time of enquiry. Most studies addressed some implementation components including adoption, acceptability, appropriateness, feasibility, and engagement. Factors including high cost, funding constraints, and lengthy research processes impeded implementation.

Conclusions

Without addressing common implementation drivers, there is considerable redundancy in the translation of mobile mental health research findings into practice. Studies should embed implementation strategies from the outset of the planned research, build collaborations with partners already working in the field (academic and commercial) to capitalize on existing interventions and platforms, and modify and evaluate them for local contexts or target problems and populations.

Trial Registration

PROSPERO CRD42021224365; https://tinyurl.com/4umpn85f

Associations between child mental health, carer worry and help-seeking

Carers may not always express child mental health concerns to health professionals. Therefore, identifying factors delaying help-seeking is important. The aim of this study was to examine the relationship between carer affect and help-seeking. In a secondary analysis of data collected from school-aged children (N = 1,857, mean age = 9.85 years, 51% female), we used logistic regression to examine the associations between carer worry, help-seeking and child mental health. Regarding worry, higher levels of emotional problems (OR = 1.42, 95% CI = 1.33-1.52), conduct problems (OR = 1.24, 95% CI = 1.12, 1.36), peer problems (OR = 1.17, 95% CI = 1.05-1.27) or functional impairment (OR = 1.37, 95% CI = 1.2-.56) were associated with higher levels of carer worry. Regarding help-seeking, higher levels of functional impairment were associated with higher levels of help-seeking (OR = 1.51, 95% CI = 1.09-2.11). After controlling for mental health problems, carers who reported being worried about their child's mental health were less likely than other carers to seek help (OR = 0.13, 95% CI = 0.05-0.35). Knowledge of these factors may inform early interventions. Alongside implications for future research and practice, limitations of the study are discussed.

Children and young people's mental health in the English-speaking Caribbean: a scoping review and evidence map

Internationally, there is a wealth of research suggesting that many children and young people experience mental health problems. However, the evidence from low- and middle-income countries and developing nations is generally limited. This scoping review aimed to add to the body of evidence by providing an overview of the available research literature on children and young people's (CYP's) mental health in the English-speaking Caribbean region. Seven key online academic databases and grey literature sources were searched until January 2021. Records were screened against predefined criteria and suitable articles retrieved. Relevant information was then charted and summarized. All stages of the review were informed by expert consultations. Ninety-six articles from 7901 records met the inclusion criteria. Most of the studies were conducted in Jamaica, Trinidad and Tobago and Barbados while fewer studies reported findings from St Lucia, The Bahamas and St Kitts and Nevis. Research funding was not frequently reported, and participants were predominantly recruited in education settings. There was a substantial focus on depressive symptoms and behaviour problems. Little or no research was available for younger children (< 12), complex clinical cases or commonly under-represented groups. Four unique interventions were identified of which one intervention showed no significant impact on CYP. Among the commonly used outcome measures only the Jamaican Youth Checklist (teacher-reported), Beck Depression Inventory-II, Brief Screen for Depression, Trinidad and Tobago Youth Survey and Minnesota Multiphasic Personality Inventory had evidence for psychometric validity within this population. We discuss future directions, implications and recommendations for research, practice, policy and training.

Patient and Public Involvement in Youth Mental Health Research: Protocol for a Systematic Review of Practices and Impact

Various health settings have advocated for involving patients and members of the public (PPI) in research as a means to increase quality and relevance of the produced knowledge. However, youth PPI has been an understudied area. This protocol paper describes a new project that aims to summarize what is known about PPI with young people in mental health research. In line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses Statement guidelines we will identify and appraise suitable articles and extract and synthesize relevant information including at least two reviewers at each stage of the process. Results will be presented in two systematic reviews that will describe (a) how youth PPI has been conducted (Review1) and (b) what impact youth PPI had on the subsequent research and on stakeholders (Review2). To our knowledge, this is the first set of reviews that uses a critical appraisal tool, which is co-developed with children and young people. Findings from this project will provide valuable insights and set out the key steps to adopting adequate PPI methods when involving children and young people in mental health research.

Mobile Apps That Promote Emotion Regulation, Positive Mental Health, and Well-being in the General Population: Systematic Review and Meta-analysis

BACKGROUND

Among the general public, there appears to be a growing need and interest in receiving digital mental health and well-being support. In response to this, mental health apps (MHapps) are becoming available for monitoring, managing, and promoting positive mental health and well-being. Thus far, evidence supports favorable outcomes when users engage with MHapps, yet there is a relative paucity of reviews on apps that support positive mental health and well-being.

OBJECTIVE

We aimed to systematically review the available research on MHapps that promote emotion regulation, positive mental health, and well-being in the general population aged 18-45 years. More specifically, the review aimed at providing a systematic description of the theoretical background and features of MHapps while evaluating any potential effectiveness.

METHODS

A comprehensive literature search of key databases, including MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL), was performed until January 2021. Studies were included if they described standalone mental health and well-being apps for adults without a formal mental health diagnosis. The quality of all studies was assessed against the Mixed Methods Appraisal Tool. In addition, the Cochrane Risk-of-Bias tool (RoB-2) was used to assess randomized control trials (RCTs). Data were extracted using a modified extraction form from the Cochrane Handbook of Systematic Reviews. A narrative synthesis and meta-analysis were then undertaken to address the review aims.

RESULTS

In total, 3156 abstracts were identified. Of these, 52 publications describing 48 MHapps met the inclusion criteria. Together, the studies evaluated interventions across 15 countries. Thirty-nine RCTs were identified suggesting some support for the role of individual MHapps in improving and promoting mental health and well-being. Regarding the pooled effect, MHapps, when compared to controls, showed a small effect for reducing mental health symptoms (k=19, Hedges g=-0.24, 95% CI -0.34 to -0.14; P<.001) and improving well-being (k=13, g=0.17, 95% CI 0.05-0.29, P=.004), and a medium effect for emotion regulation (k=6, g=0.49, 95% CI 0.23-0.74, P<.001). There is also a wide knowledge base of creative and innovative ways to engage users in techniques such as mood monitoring and guided exercises. Studies were generally assessed to contribute unclear or a high risk of bias, or to be of medium to low methodological quality.

CONCLUSIONS

The emerging evidence for MHapps that promote positive mental health and well-being suggests promising outcomes. Despite a wide range of MHapps, few apps specifically promote emotion regulation. However, our findings may position emotion regulation as an important mechanism for inclusion in future MHapps. A fair proportion of the included studies were pilot or feasibility trials (k=17, 33%), and full-scale RCTs reported high attrition rates and nondiverse samples. Given the number and pace at which MHapps are being released, further robust research is warranted to inform the development and testing of evidence-based programs.

Acceptability, Engagement, and Exploratory Outcomes of an Emotional Well-being App: Mixed Methods Preliminary Evaluation and Descriptive Analysis

BACKGROUND

There is growing evidence suggesting that the emotional well-being of the public has been negatively affected in the past year. Consequently, demand for well-being support has increased. Although there is substantial empirical support for mental health apps that target diagnosed conditions, there is less research on emotional well-being apps. Among existing well-being apps, few studies have been conducted on apps that are based on lived experience and those that seek to enhance users' understanding of their emotional patterns. Thus, the acceptability of these novel apps requires further evaluation before upscaling.

OBJECTIVE

This evaluation aims to describe the acceptability, engagement, and preliminary outcomes of using an app (Paradym) designed to promote emotional well-being and positive mental health.

METHODS

This is a pre-post, mixed-methods, single-arm evaluation that is aggregated with digital analytics data. We anonymously collected real-world data on the demographics and well-being of the participants as well as the usability and acceptance of the app using validated questionnaires and open-ended questions. Participants tested the app for a minimum of 2 weeks before completing the follow-up measures. Google Analytics was used to record the level of app engagement. Chi-square and 2-tailed t tests were conducted to analyze quantitative data, and a thematic analysis approach was adopted for qualitative data.

RESULTS

A total of 115 participants completed baseline questionnaires, of which 79.1% (91/115) users downloaded the app. The sample was diverse in terms of ethnicity, including 43.4% (50/115) people who self-identified as belonging to minority ethnic groups. Most of the participants were female (78/115, 67.8%) and between the ages of 18 and 25 years (39/115, 33.9%). A total of 34 app users who completed questionnaires at baseline and follow-up provided valuable feedback to inform the future directions of Paradym. Favorable themes emerged describing the app's content, functionality, and underlying principles. Although usability feedback varied across items, a considerable number of participants (22/34, 64%) found that the app was easy to use. Google Analytics revealed that at least 79% (27/34) of people used the app daily. On the basis of preliminary observations, app users experience increased mental well-being. Post hoc analyses indicated that the reduction in depression scores (t₃₃=-2.16) and the increase in the well-being measures (t₃₃=2.87) were statistically significant. No adverse events were reported during the follow-up period.

CONCLUSIONS

The findings of this evaluation are encouraging and document positive preliminary evidence for the Paradym app.

Association between single session service attendance and clinical characteristics in administrative data

A large proportion of young people accessing specialist mental health services do so for a single session. The aim of the present study was to examine the characteristics of young people attending specialist mental health services for a single session and to examine associations between single session attendance and clinical characteristics. Secondary analysis of administrative data on N = 23,300 young people (mean age = 12.73 years, 57% female, 64% White British) was conducted. The mean number of sessions attended was 4.33 and 46% (10,669) attended for a single session. Multilevel logistic regression analysis showed that younger children, Black young people (OR = 1.20, 95% CI = 1.01-1.43) or those whose ethnicity was not stated (OR = 1.25, 95% CI = 1.15-1.35), young people with peer relationship difficulties (OR = 1.11, 95% CI = 1.04-1.19) or low frequency problems (OR = 1.06, 95% CI = 0.99-1.14), and those with more complexity factors (OR = 1.07, 95% CI = 1.04-1.10) were more likely to attend services for a single session. The present study sets out research questions to prompt future research: (1) the experience of attending services for a single session, (2) identifying groups of single session attenders who do not require further support compared to those who are not able to sustain engagement with more sessions, and (3) whether new care pathways are needed for these groups who currently access specialist mental health services for a single session.

A Caregiver Digital Intervention to Support Shared Decision Making in Child and Adolescent Mental Health Services: Development Process and Stakeholder Involvement Analysis

Background

Parents and caregivers are generally recognized by literature and the law as key to child and adolescent mental health decisions. Digital interventions are increasingly being used to support care and treatment in child and adolescent mental health services (CAMHS). However, evidence of the design and development process is generally not made available.

Objective

In light of calls for more transparency, this paper aims to describe the development of an evidence-based, theoretically informed digital decision support intervention for parents and caregivers of young people accessing CAMHS.

Methods

The intervention was developed in line with the UK Medical Research Council framework for developing complex interventions. The process incorporated the steps for developing patient decision aids, as follows: assessing need, assessing feasibility; defining objectives; identifying the framework of decision support; and selecting the methods, designs, and dissemination approach. We synthesized theory, research, international guidelines, and input from relevant stakeholders using an iterative design approach.

Results

The development steps resulted in Power Up for Parents, a decision support intervention, with five key features (ie, decisions, goals, journey, support, and resources). The intervention aims to encourage discussion, allow parents to ask questions during sessions or seek further information between sessions, and allow service providers to tailor the shared decision-making process to accommodate the needs of the parent and child.

Conclusions

We confirmed that it is possible to use input from end users—integrated with theory and evidence—to create digital interventions to be used in CAMHS. Key lessons with implications for practice, policy, and implementation science, along with preliminary findings, are presented.

International Registered Report Identifier (IRRID)

RR2-10.2196/14571

Young People Who Meaningfully Improve Are More Likely to Mutually Agree to End Treatment

Objective: Symptom improvement is often examined as an indicator of a good outcome of accessing mental health services. However, there is little evidence of whether symptom improvement is associated with other indicators of a good outcome, such as a mutual agreement to end treatment. The aim of this study was to examine whether young people accessing mental health services who meaningfully improved were more likely to mutually agree to end treatment.

Methods: Multilevel multinomial regression analysis controlling for age, gender, ethnicity, and referral source was conducted on N = 8,995 episodes of care [Female = 5,469, 61%; meanAge = 13.66 (SD = 2.87) years] using anonymised administrative data from young people's mental health services.

Results: Compared to young people with no change in mental health difficulties, those showing positive meaningful changes in mental health difficulties were less likely to have case closure due to non-mutual agreement (Odds Ratio or OR = 0.58, 95% Confidence Interval or CI = 0.50–0.61). Similarly, they were less likely to transfer (OR = 0.61, 95% CI = 0.49–0.74) or end treatment for other reasons (OR = 0.59, 95% CI = 0.50–0.70) than by case closure due to mutual agreement.

Conclusion: The findings suggest that young people accessing mental health services whose symptoms meaningfully improve are more likely to mutually agree to end treatment, adding to the evidence that symptom improvement may be appropriate to examine as an indicator of a good outcome of accessing mental health services.

Feasibility and Acceptability of a Digital Intervention to Support Shared Decision-making in Children's and Young People's Mental Health: Mixed Methods Pilot Randomized Controlled Trial

Background

Interventions to involve parents in decisions regarding children’s and young people’s mental health are associated with positive outcomes. However, appropriately planning effectiveness studies is critical to ensure that meaningful evidence is collected. It is important to conduct pilot studies to evaluate the feasibility and acceptability of the intervention itself and the feasibility of the protocol to test effectiveness.

Objective

This paper reports the findings from a feasibility and acceptability study of Power Up for Parents, an intervention to promote shared decision-making (SDM) and support parents and caregivers making decisions regarding children’s and young people’s mental health.

Methods

A mixed method study design was adopted. In stage 1, health care professionals and parents provided feedback on acceptability, usefulness, and suggestions for further development. Stage 2 was a multicenter, 3-arm, individual, and cluster randomized controlled pilot feasibility trial with parents accessing services related to children’s and young people’s mental health. Outcome measures collected data on demographics, participation rates, SDM, satisfaction, and parents’ anxiety. Qualitative data were analyzed using thematic analysis. Google Analytics estimates were used to report engagement with the prototype. Outcomes from both stages were tested against a published set of criteria for proceeding to a randomized controlled trial.

Results

Despite evidence suggesting the acceptability of Power Up for Parents, the findings suggest that recruitment modifications are needed to enhance the feasibility of collecting follow-up data before scaling up to a fully powered randomized controlled trial. On the basis of the Go or No-Go criteria, only 50% (6/12) of the sites successfully recruited participants, and only 38% (16/42) of parents completed follow-up measures. Nonetheless, health care practitioners and parents generally accessed and used the intervention. Themes describing appearance and functionality, perceived need and general helpfulness, accessibility and appropriateness, and a wish list for improvement emerged, providing valuable information to inform future development and refinement of the intervention.

Conclusions

Owing to the high attrition observed in the trial, proceeding directly to a full randomized controlled trial may not be feasible with this recruitment strategy. Nonetheless, with some minor adjustments and upgrades to the intervention, this pilot study provides a platform for future evaluations of Power Up for Parents.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 39238984; http://www.isrctn.com/ISRCTN39238984.

International Registered Report Identifier (IRRID)

RR2-10.2196/14571

An Affective-Appraisal Approach for Parental Shared Decision Making in Children and Young People's Mental Health Settings: A Qualitative Study

Background: The majority of existing shared decision making (SDM) models are yet to explicitly account for emotion as an influencing factor to the SDM process. This study aimed to explore the role of parents' and carers' emotional experiences as a concept that has implications for SDM in children and young people's mental health (CYPMH) settings. Methods: A social constructivist grounded theory approach, analyzing data from focus groups (n = 4) and semi-structured interviews (n = 33) with parents and healthcare professionals, was undertaken. Participants were identified and selected at CYPMH sites and through social media platforms or in-person advertising as part of a larger feasibility trial. Interviews and focus groups were audio-recorded and transcribed verbatim. Thematic analysis moved from open to focused coding. Results: The majority of the sample consisted of mothers of adolescent girls. Healthcare professionals had an average of 7.54 (SD = 6.24) years of work experience in CYPMH outpatient capacities. Findings suggested that parents are "expected to, but not always able to" engage in SDM. Themes and subthemes described an affective-appraisal SDM process capturing: (1) views and experiences of SDM, (2) parents' emotional states, (3) the influence of emotions on SDM, and (4) key support systems accessed. The emerging affective-appraisal framework highlighted that negative emotional states hindered parents' active involvement in SDM, and positive emotions encouraged involvement in SDM. Conclusion: The current findings describe an SDM model specific to CYPMH. This new understanding contributes to addressing a possible theory to practice gap opening new challenges and opportunities for academic enquiry.

A scoping review and assessment of essential elements of shared decision-making of parent-involved interventions in child and adolescent mental health

Parents play a critical role in child and adolescent mental health care and treatment. With the increasing implementation of shared decision-making (SDM) across health settings, there is a growing need to understand the decision support interventions used to promote SDM in child and adolescent mental health services (CAMHS). The overall aim of this review is to identify and examine the existing decision support interventions available for parents. A broad search was conducted using the key concepts "shared decision-making", "parents" and "child and adolescent mental health". Five electronic databases were searched: PsycInfo, Embase, Medline, Web of Science and the Cochrane Library. In addition to these relevant databases, we searched the Ottawa's Inventory of Decision Aids, Children's Hospital of Eastern Ontario website, Google, Google Play and known CAMHS' websites. The search identified 23 interventions available for use with parents. These interventions targeted parents providing care for children with ADHD, ASD, emotional and behavioural problems including depression (EBD), self-harm or universal mental health care. Various modalities including face-to-face, digital and paper-based versions were adopted. The majority of the interventions were able to "present options" (87%) and "discuss the pros and cons" (83%) of treatment. Time, accessibility and appropriateness of the intervention emerged as factors influencing usage and implementation of interventions. Our findings suggest that SDM interventions involving parents have been implemented differently across various presenting mental health difficulties in CAMHS. This review brings awareness of existing parent-involved interventions and has implications for the development, implementation and usage of new interventions.

Parent/Carer-Reported Experience of Shared Decision Making at Child and Adolescent Mental Health Services: A Multilevel Modelling Approach

Background and Objective: Shared decision making (SDM) has been associated with positive outcomes at child and adolescent mental health services (CAMHS). However, implementing SDM is sometimes challenging. Understanding the factors associated with parent/carer experience of SDM could provide empirical evidence to support targeted efforts to promote SDM. This study aimed to explore the frequency of parent/carer-reported experience of SDM and examine possible associations between SDM and clinician's perceptions of the (a) children's and young people's psychosocial difficulties, (b) additional complex problems, and (c) impact of the psychosocial difficulties. Methods: Secondary analysis was conducted on administrative data collected from CAMHS between 2011 and 2015. The sample was composed of 3,175 cases across 58 sites in England. Frequencies were recorded and associations were explored between clinician-reported measures and parent/carer-reported experiences of SDM using a two-level mixed-effect logistic regression analytic approach. Results: Almost 70% of parents/carers reported experiencing higher levels of SDM. Individual-level variables in model one revealed statistically significant (p <0.05) associations suggesting Asian parents/carers (OR = 1.95, 95% CI [1.4, 2.73]) and parents/carers having children with learning difficulties (OR = 1.45, 95% CI [1.06, 1.97]) were more likely to report higher levels of SDM. However, having two parents/carers involved in the child's care and treatment decisions (OR = 0.3, 95% CI [0.21, 0.44]) and being a parent/carer of a child or young person experiencing conduct problems (OR = 0.78, 95% CI [0.63, 0.98]) were associated with lower levels of SDM. When adjusting for service level data (model two) the presence of conduct problems was the only variable found to be significant and predicted lower levels of SDM (OR = 0.29, 95% CI [0.52, 0.58]). Conclusion: Multilevel modelling of CAMHS administrative data may help identify potential influencing factors to SDM. The current findings may inform useful models to better predict and support SDM.

Engaging Children and Young People in Digital Mental Health Interventions: Systematic Review of Modes of Delivery, Facilitators, and Barriers

BACKGROUND

There is a high prevalence of children and young people (CYP) experiencing mental health (MH) problems. Owing to accessibility, affordability, and scalability, an increasing number of digital health interventions (DHIs) have been developed and incorporated into MH treatment. Studies have shown the potential of DHIs to improve MH outcomes. However, the modes of delivery used to engage CYP in digital MH interventions may differ, with implications for the extent to which findings pertain to the level of engagement with the DHI. Knowledge of the various modalities could aid in the development of interventions that are acceptable and feasible.

OBJECTIVE

This review aimed to (1) identify modes of delivery used in CYP digital MH interventions, (2) explore influencing factors to usage and implementation, and (3) investigate ways in which the interventions have been evaluated and whether CYP engage in DHIs.

METHODS

A literature search was performed in the Cochrane Library, Excerpta Medica dataBASE (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), and PsycINFO databases using 3 key concepts "child and adolescent mental health," "digital intervention," and "engagement." Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least two reviewers. The selected articles were assessed for quality using the mixed methods appraisal tool, and data were extracted to address the review aims. Data aggregation and synthesis were conducted and presented as descriptive numerical summaries and a narrative synthesis, respectively.

RESULTS

This study identified 6 modes of delivery from 83 articles and 71 interventions for engaging CYP: (1) websites, (2) games and computer-assisted programs, (3) apps, (4) robots and digital devices, (5) virtual reality, and (6) mobile text messaging. Overall, 2 themes emerged highlighting intervention-specific and person-specific barriers and facilitators to CYP's engagement. These themes encompassed factors such as suitability, usability, and acceptability of the DHIs and motivation, capability, and opportunity for the CYP using DHIs. The literature highlighted that CYP prefer DHIs with features such as videos, limited text, ability to personalize, ability to connect with others, and options to receive text message reminders. The findings of this review suggest a high average retention rate of 79% in studies involving various DHIs.

CONCLUSIONS

The development of DHIs is increasing and may be of interest to CYP, particularly in the area of MH treatment. With continuous technological advancements, it is important to know which modalities may increase engagement and help CYP who are facing MH problems. This review identified the existing modalities and highlighted the influencing factors from the perspective of CYP. This knowledge provides information that can be used to design and evaluate new interventions and offers important theoretical insights into how and why CYP engage in DHIs.

A Mobile App to Support Parents Making Child Mental Health Decisions: Protocol for a Feasibility Cluster Randomized Controlled Trial

BACKGROUND

Shared decision making (SDM) is recognized as a person-centered approach to improving health care quality and outcomes. Few digital interventions to improve SDM have been tested in child and adolescent mental health (CAMH) settings. One such intervention is Power Up, a mobile phone app for young people (YP), which has shown some evidence of promise that YP who received Power Up reported greater levels of SDM. However, even though parents play a critical role in CAMH care and treatment, they often feel excluded from services.

OBJECTIVE

This protocol is for a pilot trial to determine the feasibility of a large-scale randomized trial to develop and evaluate a Web app called Power Up for Parents (PUfP) to support parents and promote involvement in CAMH decisions.

METHODS

A 2-stage process, consisting of the development stage and pilot-testing stage of the initial PUfP prototype, will be conducted. At the development stage, a qualitative study with parents and clinicians will be conducted. The interviews will aim to capture the experience of making CAMH decisions, preferences for involvement in SDM, and determine situations within which PUfP can be useful. At the pilot-testing stage, up to 90 parents and their clinicians will be invited to participate in the testing of the prototype. Parents will be randomly allocated to receive the intervention or be part of the control group. This study design will allow us to assess the acceptability and usefulness of PUfP in addition to examining the feasibility of a prospective randomized trial. Clinicians' perceptions of the prototype and how it has influenced parents' involvement in SDM will also be examined.

RESULTS

Recruitment began in January 2019 and is scheduled to last for 10 months. Interviews and baseline data collection are currently in progress. To date, 11 CAMH sites have been recruited to take part in the study. It is anticipated that data collection will be completed by October 2019.

CONCLUSIONS

The lack of parents' involvement in CAMH care and treatment can lead to higher rates of dropout from care and lower adherence to therapeutic interventions. There are significant benefits to be gained globally if digital SDM interventions are adopted by parents and shown to be successful in CAMH settings.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN39238984; http://www.isrctn.com/ISRCTN39238984.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14571.