The role of rumination in the relationship between symptoms of insomnia and depression in adolescents.

There is a strong relationship between the symptoms of insomnia and depression, however, little is understood about the factors that mediate this relationship. An understanding of these underlying mechanisms may inform the advancement of existing treatments to optimise reductions in insomnia and depression when they co-occur. This study examined rumination and unhelpful beliefs about sleep as mediators between symptoms of insomnia and depression. It also evaluated the effect of cognitive behavioural therapy for insomnia (CBT-I) on rumination and unhelpful beliefs about sleep, and whether these factors mediated the effect of CBT-I on depressive symptoms. A series of mediation analyses and linear mixed modelling were conducted on data from 264 adolescents (12-16 years) who participated in a two-arm (intervention vs. control) randomised controlled trial of Sleep Ninja®, a CBT-I smartphone app for adolescents. Rumination, but not unhelpful beliefs about sleep, was a significant mediator between symptoms of insomnia and depression at baseline. CBT-I led to reductions in unhelpful beliefs about sleep, but not in rumination. At the between-group level, neither rumination, nor unhelpful beliefs about sleep emerged as mechanisms underlying improvement in depression symptoms, however, rumination mediated within-subject improvements following CBT-I. The findings suggest rumination links symptoms of insomnia and depression and provide preliminary evidence that reductions in depression following CBT-I occurs via improvements in rumination. Targeting rumination may improve current therapeutic approaches.

The effects of a sleep-focused smartphone application on insomnia and depressive symptoms: a randomised controlled trial and mediation analysis.

BACKGROUND: Rates of depression are increasing among adolescents. A novel way to reduce depression is by improving sleep. We evaluated whether an app-based intervention for insomnia improved sleep and depression, and whether changes in insomnia mediated changes in depression. METHODS: We conducted a 2-arm single-blind randomised controlled trial at the Black Dog Institute in Australia. Adolescents 12-16 years experiencing insomnia symptoms were randomly allocated to receive Sleep Ninja, an app-delivered cognitive behavioural therapy program for insomnia, or to an active control group involving weekly text message sleep tips. Assessments took place at baseline, 6 weeks (post-intervention) and 14 weeks (post-baseline). Co-primary outcomes were symptoms of insomnia and depression at post-intervention (primary endpoint). Intent-to-treat analyses were conducted. The trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12619001462178. RESULTS: Between October 25, 2019, and September 6, 2020, 264 participants were randomised to receive Sleep Ninja (n = 131) or to the control group (n = 133). Relative to the control group, those allocated to the intervention reported a greater reduction in insomnia symptoms at 6 weeks (95% CI: -2.96 to -0.41, d = .41) and 14 weeks (95% CI: -3.34 to -0.19, d = .39), and a greater reduction in depression symptoms at 6 weeks (95% CI: -3.46 to -0.56, d = .28) but not 14 weeks (p < 1). Change in insomnia mediated change in depression. No adverse events were reported. CONCLUSIONS: An app-delivered program for insomnia could be a practical, non-stigmatising and scalable way to reduce symptoms of insomnia and depression among adolescents experiencing difficulties getting enough good quality sleep.

Understanding suicidal transitions in Australian adults: protocol for the LifeTrack prospective longitudinal cohort study.

BACKGROUND: The factors that influence transition from suicidal ideation to a suicide attempt or remission of suicidal thoughts are poorly understood. Despite an abundance of research on risk factors for suicidal ideation, no large-scale longitudinal population-based studies have specifically recruited people with suicidal ideation to examine the mechanisms underlying critical transitions to either suicide attempt or recovery from suicidal ideation. Without longitudinal data on the psychological, behavioural, and social determinants of suicide attempt and the remission of suicidal ideation, we are unlikely to see major gains in the prevention of suicide. AIM: The LifeTrack Project is a population-based longitudinal cohort study that aims to identify key modifiable risk and protective factors that predict the transition from suicidal ideation to suicide attempt or remission of suicidal ideation. We will assess theory-informed risk and protective factors using validated and efficient measures to identify distinct trajectories reflecting changes in severity of suicidal ideation and transition to suicide attempt over three years. METHODS: A three-year prospective population-based longitudinal cohort study will be conducted with adults from the general Australian population who initially report suicidal ideation (n = 842). Eligibility criteria include recent suicidal ideation (past 30 days), aged 18 years or older, living in Australia and fluent in English. Those with a suicide attempt in past 30 days or who are unable to participate in a long-term study will be excluded. Participants will be asked to complete online assessments related to psychopathology, cognition, psychological factors, social factors, mental health treatment use, and environmental exposures at baseline and every six months during this three-year period. One week of daily measurement bursts (ecological momentary assessments) at yearly intervals will also capture short-term fluctuations in suicidal ideation, perceived burdensomeness, thwarted belongingness, capability for suicide, and distress. CONCLUSION: This study is intended to identify potential targets for novel and tailored therapies for people experiencing suicidal ideation and improve targeting of suicide prevention programs. Even modest improvements in current treatments may lead to important reductions in suicide attempts and deaths. STUDY REGISTRATION: Australian New Zealand Clinical Trials Registry identifier: ACTRN12623000433606.

Genomics-driven screening for causal determinants of suicide attempt.

OBJECTIVE: Each year, around one million people die by suicide. Despite its recognition as a public health concern, large-scale research on causal determinants of suicide attempt risk is scarce. Here, we leverage results from a recent genome-wide association study (GWAS) of suicide attempt to perform a data-driven screening of traits causally associated with suicide attempt. METHODS: We performed a hypothesis-generating phenome-wide screening of causal relationships between suicide attempt risk and 1520 traits, which have been systematically aggregated on the Complex-Traits Genomics Virtual Lab platform. We employed the latent causal variable (LCV) method, which uses results from GWAS to assess whether a causal relationship can explain a genetic correlation between two traits. If a trait causally influences another one, the genetic variants that increase risk for the causal trait will also increase the risk for the outcome inducing a genetic correlation. Nonetheless, a genetic correlation can also be observed when traits share common pathways. The LCV method can assess whether the pattern of genetic effects for two genetically correlated traits support a causal association rather than a shared aetiology. RESULTS: Our approach identified 62 traits that increased risk for suicide attempt. Risk factors identified can be broadly classified into (1) physical health disorders, including oesophagitis, fibromyalgia, hernia and cancer; (2) mental health-related traits, such as depression, substance use disorders and anxiety; and (3) lifestyle traits including being involved in combat or exposure to a war zone, and specific job categories such as being a truck driver or machine operator. CONCLUSIONS: Suicide attempt risk is likely explained by a combination of behavioural phenotypes and risk for both physical and psychiatric disorders. Our results also suggest that substance use behaviours and pain-related conditions are associated with an increased suicide attempt risk, elucidating important causal mechanisms that underpin this significant public health problem.

Sleep-specific outcomes attributable to digitally delivered cognitive behavioral therapy for insomnia in adults with insomnia and depressive symptoms.

OBJECTIVE: Randomized controlled trials (RCTs) of digitally delivered Cognitive Behavioral Therapy for insomnia (CBT-I) have demonstrated reductions in insomnia severity, depression symptoms, anxiety symptoms, and suicidal ideation. The present study aimed to evaluate the effectiveness of self-guided, digital CBT-I to improve sleep-specific outcomes. METHOD: An RCT of Australian adults with insomnia and depressive symptoms (N = 1149) compared SHUTi, a digital CBT-I intervention, with HealthWatch, an attention-matched control internet program, at baseline, posttest (9 weeks) and at 6-, 12-, and 18-month follow-ups. Online sleep diaries were used to derive measures of sleep-onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), number of awakenings, sleep quality, and total sleep time (TST). RESULTS: Participants in the SHUTi condition had greater improvements at posttest compared with control for: SOL, WASO, SE, number of awakenings, and sleep quality. These improvements were sustained at every follow-up (p < .02 for all outcomes except TST, in which statistically significant increases were observed only at 12- and 18-months). CONCLUSIONS: Digitally delivered CBT-I produced lasting improvements in sleep outcomes among adults with insomnia and depressive symptoms. Findings provide further evidence of long-term improvements associated with a digital therapeutic for insomnia, compared to an attention-control condition.

Selective Prevention of Depression in Workers Using a Smartphone App: Randomized Controlled Trial.

BACKGROUND: There is increasing evidence that depression can be prevented; however, universal approaches have had limited success. Appropriate targeting of interventions to at-risk populations has been shown to have potential, but how to selectively determine at-risk individuals remains unclear. Workplace stress is a risk factor for depression and a target for intervention, but few interventions exist to prevent depression among workers at risk due to heightened stress. OBJECTIVE: This trial aimed to evaluate the efficacy of a smartphone-based intervention in reducing the onset of depression and improving related outcomes in workers experiencing at least moderate levels of stress. METHODS: A randomized controlled trial was conducted with participants who were currently employed and reported no clinically significant depression and at least moderate stress. The intervention group (n=1053) were assigned Anchored, a 30-day self-directed smartphone app-based cognitive behavioral- and mindfulness-based intervention. The attention-control group (n=1031) were assigned a psychoeducation website. Assessment was performed via web-based self-report questionnaires at baseline and at 1-, 3-, and 6-month postbaseline time points. The primary outcome was new depression caseness aggregated over the follow-up period. The secondary outcomes included depressive and anxiety symptoms, stress, well-being, resilience, work performance, work-related burnout, and quality of life. Analyses were conducted within an intention-to-treat framework using mixed modeling. RESULTS: There was no significant between-group difference in new depression caseness (z score=0.69; P=.49); however, those in the Anchored arm had significantly greater depressive symptom reduction at 1 month (Cohen d=0.02; P=.049) and 6 months (Cohen d=0.08; P=.03). Anchored participants also showed significantly greater reduction in anxiety symptoms at 1 month (Cohen d=0.07; P=.04) and increased work performance at 1 month (Cohen d=0.07; P=.008) and 6 months (Cohen d=0.13; P=.01), compared with controls. Notably, for Anchored participants completing at least two-thirds of the intervention, there was a significantly lower rate of depression onset (1.1%, 95% CI 0.0%-3.7%) compared with controls (9.0%, 95% CI 6.8%-12.3%) at 1 month (z score=4.50; P<.001). Significant small to medium effect sizes for most secondary outcomes were seen in the highly engaged Anchored users compared with controls, with effects maintained at the 6-month follow-up for depressive symptoms, well-being, stress, and quality of life. CONCLUSIONS: Anchored was associated with a small comparative reduction in depressive symptoms compared with controls, although selective prevention of case-level depression was not observed in the intention-to-treat analysis. When users adequately engaged with the app, significant findings pertaining to depression prevention, overall symptom reduction, and functional improvement were found, compared with controls. There is a need for a greater focus on engagement techniques in future research. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000178943; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378592.

The Effects of Internet-Based Cognitive Behavioral Therapy for Suicidal Ideation or Behaviors on Depression, Anxiety, and Hopelessness in Individuals With Suicidal Ideation: Systematic Review and Meta-Analysis of Individual Participant Data.

BACKGROUND: Suicide is a global public health problem. Digital interventions are considered a low-threshold treatment option for people with suicidal ideation or behaviors. Internet-based cognitive behavioral therapy (iCBT) targeting suicidal ideation has demonstrated effectiveness in reducing suicidal ideation. However, suicidal ideation often is related to additional mental health problems, which should be addressed for optimal care. Yet, the effects of iCBT on related symptoms, such as depression, anxiety, and hopelessness, remain unclear. OBJECTIVE: We aimed to analyze whether digital interventions targeting suicidal ideation had an effect on related mental health symptoms (depression, anxiety, and hopelessness). METHODS: We systematically searched CENTRAL, PsycInfo, Embase, and PubMed for randomized controlled trials that investigated guided or unguided iCBT for suicidal ideation or behaviors. Participants reporting baseline suicidal ideation were eligible. Individual participant data (IPD) were collected from eligible trials. We conducted a 1-stage IPD meta-analysis on the effects on depression, anxiety, and hopelessness-analyzed as 2 indices: symptom severity and treatment response. RESULTS: We included IPD from 8 out of 9 eligible trials comprising 1980 participants with suicidal ideation. iCBT was associated with significant reductions in depression severity (b=-0.17; 95% CI -0.25 to -0.09; P<.001) and higher treatment response (ie, 50% reduction of depressive symptoms; b=0.36; 95% CI 0.12-0.60; P=.008) after treatment. We did not find significant effects on anxiety and hopelessness. CONCLUSIONS: iCBT for people with suicidal ideation revealed significant effects on depression outcomes but only minor or no effects on anxiety and hopelessness. Therefore, individuals with comorbid symptoms of anxiety or hopelessness may require additional treatment components to optimize care. Studies that monitor symptoms with higher temporal resolution and consider a broader spectrum of factors influencing suicidal ideation are needed to understand the complex interaction of suicidality and related mental health symptoms.

Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial.

BACKGROUND: Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary. OBJECTIVE: This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia. METHODS: A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit. RESULTS: In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it. CONCLUSIONS: The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-020-04686-4.

Evaluating suicide attitudes and suicide literacy in adolescents.

BACKGROUND: Two of the most common modifiable barriers to help-seeking for mental health problems during adolescence are stigma and poor mental health literacy. However, relatively little is known about stigma as it relates to suicide, and knowledge about suicidality in this age group. AIMS: To assess levels of suicide literacy and suicide attitudes in an adolescent sample, and to identify correlates of these constructs. METHODS: Data were drawn from the pre-intervention survey of the Sources of Strength Australia Project. A total of 1019 adolescents aged between 11 and 17 years participated. Suicide literacy and attitudes were measured alongside potential correlates including psychological distress, suicidal ideation, mastery, previous exposure to suicidal thinking and behaviour, and demographics. RESULTS: Participants more strongly endorsed attitudes attributing suicide to isolation/depression, compared to attitudes glorifying or stigmatising suicide. Gaps in knowledge about suicide included the risk factors, signs and symptoms. Key correlates of suicide attitudes and literacy included age, gender and cultural background. CONCLUSION: Findings highlight the need for further education activities in schools and public awareness campaigns that address the gaps in suicide knowledge and attitudes. Such activities would assist in the identification of suicide risk among young people and improve help-seeking in this population.

The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia.

BACKGROUND: Suicidal ideation is a major risk for a suicide attempt in younger people, such that reducing severity of ideation is an important target for suicide prevention. Smartphone applications present a new opportunity for managing ideation in young adults; however, confirmatory evidence for efficacy from randomized trials is lacking. The objective of this study was to assess whether a therapeutic smartphone application ("LifeBuoy") was superior to an attention-matched control application at reducing the severity of suicidal ideation. METHODS AND FINDINGS: In this 2-arm parallel, double-blind, randomized controlled trial, 455 young adults from Australia experiencing recent suicidal ideation and aged 18 to 25 years were randomly assigned in a 2:2 ratio to use a smartphone application for 6 weeks in May 2020, with the final follow-up in October 2020. The primary outcome was change in suicidal ideation symptom severity scores from baseline (T0) to postintervention (T1) and 3-month postintervention follow-up (T2), measured using the Suicidal Ideation Attributes Scale (SIDAS). Secondary outcomes were symptom changes in depression (Patient Health Questionnaire-9, PHQ-9), generalized anxiety (Generalized Anxiety Disorder-7, GAD-7), distress (Distress Questionnaire-5, DQ5), and well-being (Short Warwick-Edinburgh Mental Well-Being Scale, SWEMWBS). This trial was conducted online, using a targeted social media recruitment strategy. The intervention groups were provided with a self-guided smartphone application based on dialectical behavior therapy (DBT; "LifeBuoy") to improve emotion regulation and distress tolerance. The control group were provided a smartphone application that looked like LifeBuoy ("LifeBuoy-C"), but delivered general (nontherapeutic) information on a range of health and lifestyle topics. Among 228 participants randomized to LifeBuoy, 110 did not complete the final survey; among 227 participants randomized to the control condition, 91 did not complete the final survey. All randomized participants were included in the intent-to-treat analysis for the primary and secondary outcomes. There was a significant time × condition effect for suicidal ideation scores in favor of LifeBuoy at T1 (p < 0.001, d = 0.45) and T2 (p = 0.007, d = 0.34). There were no superior intervention effects for LifeBuoy on any secondary mental health outcomes from baseline to T1 or T2 [p-values: 0.069 to 0.896]. No serious adverse events (suicide attempts requiring medical care) were reported. The main limitations of the study are the lack of sample size calculations supporting the study to be powered to detect changes in secondary outcomes and a high attrition rate at T2, which may lead efficacy to be overestimated. CONCLUSIONS: LifeBuoy was associated with superior improvements in suicidal ideation severity, but not secondary mental health outcomes, compared to the control application, LifeBuoy-C. Digital therapeutics may need to be purposefully designed to target a specific health outcome to have efficacy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001671156.

Preventing depression using a smartphone app: a randomized controlled trial.

BACKGROUND: There is evidence that depression can be prevented; however, traditional approaches face significant scalability issues. Digital technologies provide a potential solution, although this has not been adequately tested. The aim of this study was to evaluate the effectiveness of a new smartphone app designed to reduce depression symptoms and subsequent incident depression amongst a large group of Australian workers. METHODS: A randomized controlled trial was conducted with follow-up assessments at 5 weeks and 3 and 12 months post-baseline. Participants were employed Australians reporting no clinically significant depression. The intervention group (N = 1128) was allocated to use HeadGear, a smartphone app which included a 30-day behavioural activation and mindfulness intervention. The attention-control group (N = 1143) used an app which included a 30-day mood monitoring component. The primary outcome was the level of depressive symptomatology (PHQ-9) at 3-month follow-up. Analyses were conducted within an intention-to-treat framework using mixed modelling. RESULTS: Those assigned to the HeadGear arm had fewer depressive symptoms over the course of the trial compared to those assigned to the control (F3,734.7 = 2.98, p = 0.031). Prevalence of depression over the 12-month period was 8.0% and 3.5% for controls and HeadGear recipients, respectively, with odds of depression caseness amongst the intervention group of 0.43 (p = 0.001, 95% CI 0.26-0.70). CONCLUSIONS: This trial demonstrates that a smartphone app can reduce depression symptoms and potentially prevent incident depression caseness and such interventions may have a role in improving working population mental health. Some caution in interpretation is needed regarding the clinical significance due to small effect size and trial attrition.Trial Registration Australian and New Zealand Clinical Trials Registry (www.anzctr.org.au/) ACTRN12617000548336.

The impact of COVID-19 on the lives and mental health of Australian adolescents.

There has been significant disruption to the lives and mental health of adolescents during the COVID-19 pandemic. The purpose of this study was to assess the psychological and lifestyle impact of the pandemic on Australian adolescents, using an online survey, administered during the outbreak. Self-report surveys were administered online to a sample of 760 Australian adolescents aged 12-18 years assessing impact on a range of domains including behaviour, education, relationships, lifestyle factors (exercise, technology use, and sleep), and mental health outcomes (psychological distress, loneliness, health anxiety and well-being). Results showed that three quarters of the sample experienced a worsening in mental health, since the pandemic began, with negative impacts reported on learning, friendships and family relationships. There were also high higher levels of sleep disturbance, psychological distress and health anxiety, relative to normative samples. Effects on mental health were worse among those who reported a previous diagnosis of depression and/or anxiety relative to those without no such history. Adolescents are already vulnerable to the onset of mental illness at this developmental stage, and the current research underscores the need to find rapid and accessible ways to support adolescent mental health during times of crisis.

Spatial Errors in Automated Geocoding of Incident Locations in Australian Suicide Mortality Data.

BACKGROUND: There is increasing interest in the spatial analysis of suicide data to identify high-risk (often public) locations likely to benefit from access restriction measures. The identification of such locations, however, relies on accurately geocoded data. This study aims to examine the extent to which common completeness and positional spatial errors are present in suicide data due to the underlying geocoding process. METHODS: Using Australian suicide mortality data from the National Coronial Information System for the period of 2008-2017, we compared the custodian automated geocoding process to an alternate multiphase process. Descriptive and kernel density cluster analyses were conducted to ascertain data completeness (address matching rates) and positional accuracy (distance revised) differences between the two datasets. RESULTS: The alternate geocoding process initially improved address matching from 67.8% in the custodian dataset to 78.4%. Additional manual identification of nonaddress features (such as cliffs or bridges) improved overall match rates to 94.6%. Nearly half (49.2%) of nonresidential suicide locations were revised more than 1,000 m from data custodian coordinates. Spatial misattribution rates were greatest at the smallest levels of geography. Kernel density maps showed clear misidentification of hotspots relying solely on autogeocoded data. CONCLUSION: Suicide incidents that occur at nonresidential addresses are being erroneously geocoded to centralized fall-back locations in autogeocoding processes, which can lead to misidentification of suicide clusters. Our findings provide insights toward defining the nature of the problem and refining geocoding processes, so that suicide data can be used reliably for the detection of suicide hotspots. See video abstract at, http://links.lww.com/EDE/B862.

Can an online mental health training programme improve physician supervisors' behaviour towards trainees?

BACKGROUND: Physician trainees have elevated rates of psychological distress, mental disorders and suicide. Physician supervisors can support the mental health needs of trainees. AIMS: To test the feasibility and acceptability of a tailored online mental health training programme and to ascertain the potential effectiveness of the programme to alter the confidence and behaviours of physician supervisors. METHODS: Thirty Australian hospital-based physicians who were supervising physician trainees participated in this quasi-experimental pre-post pilot study. All received the intervention that comprised 12 5-min modules to complete over a 3-week period. Baseline and post-intervention data were collected. The primary outcome evaluated participants' confidence to respond to trainees experiencing mental ill-health and promote a mentally healthy workplace. Secondary outcomes evaluated change in self-reported behaviour, mental health knowledge and stigmatising attitudes. Differences in mean scale scores for each outcome measure from baseline and post-intervention were compared using paired sample t-tests. RESULTS: Thirty physicians completed the baseline assessment and 23 (76.7%) completed all programme modules. Most participants found the programme engaging, interesting and useful. Post-intervention data, available for 25 (83.3%) participants, showed a significant increase in participants' knowledge of their role in supporting trainees under their supervision (P = 0.002), confidence to initiate conversations about mental health with staff (P < 0.001), and application of preventive and responsive supervisory behaviours to support the mental health needs of those they supervise (P < 0.001). CONCLUSIONS: This online mental health training programme for physician supervisors was feasible and associated with improved confidence and behaviour to support the mental health needs of trainees they supervised.

e-Mental Health Program Usage Patterns in Randomized Controlled Trials and in the General Public to Inform External Validity Considerations: Sample Groupings Using Cluster Analyses.

BACKGROUND: Randomized controlled trials (RCTs) with vigorous study designs are vital for determining the efficacy of treatments. Despite the high internal validity attributed to RCTs, external validity concerns limit the generalizability of results to the general population. Bias can be introduced, for example, when study participants who self-select into a trial are more motivated to comply with study conditions than are other individuals. These external validity considerations extend to e-mental health (eMH) research, especially when eMH tools are designed for public access and provide minimal or no supervision. OBJECTIVE: Clustering techniques were employed to identify engagement profiles of RCT participants and community users of a self-guided eMH program. This exploratory approach inspected actual, not theorized, RCT participant and community user engagement patterns. Both samples had access to the eMH program over the same time period and received identical usage recommendations on the eMH program website. The aim of this study is to help gauge expectations of similarities and differences in usage behaviors of an eMH tool across evaluation and naturalistic contexts. METHODS: Australian adults signed up to myCompass, a self-guided online treatment program created to reduce mild to moderate symptoms of negative emotions. They did so either by being part of an RCT onboarding (160/231, 69.6% female) or by accessing the program freely on the internet (5563/8391, 66.30% female) between October 2011 and October 2012. During registration, RCT participants and community users provided basic demographic information. Usage metrics (number of logins, trackings, and learning activities) were recorded by the system. RESULTS: Samples at sign-up differed significantly in age (P=.003), with community users being on average 3 years older (mean 41.78, SD 13.64) than RCT participants (mean 38.79, SD 10.73). Furthermore, frequency of program use was higher for RCT participants on all usage metrics compared to community users through the first 49 days after registration (all P values <.001). Two-step cluster analyses revealed 3 user groups in the RCT sample (Nonstarters, 10-Timers, and 30+-Timers) and 2 user groups in the community samples (2-Timers and 20-Timers). Groups seemed comparable in patterns of use but differed in magnitude, with RCT participant usage groups showing more frequent engagement than community usage groups. Only the high-usage group among RCT participants approached myCompass usage recommendations. CONCLUSIONS: Findings suggested that external validity concerns of RCT designs may arise with regards to the predicted magnitude of eMH program use rather than overall usage styles. Following up RCT nonstarters may help provide unique insights into why individuals choose not to engage with an eMH program despite generally being willing to participate in an eMH evaluation study. Overestimating frequency of engagement with eMH tools may have theoretical implications and potentially impact economic considerations for plans to disseminate these tools to the general public.

Factors That Help and Hinder the Implementation of Digital Depression Prevention Programs: School-Based Cross-sectional Study.

BACKGROUND: Digital prevention programs that are delivered in a school environment can inoculate young people against depression. However, little is known about the school-based factors that help and hinder the implementation of these programs. Staff members are integral for supporting mental health programs in schools and are likely to have a wealth of expertise and knowledge about the factors that affect implementation. OBJECTIVE: The primary objective of this study was to explore the barriers and facilitators to implementing a digital depression prevention program in Australian secondary schools with teachers, counselors, and principals. The secondary objective was to explore variations in these factors across different school contexts, including the school type (government or nongovernment), location (capital city, regional/or rural areas), and socioeconomic status (SES) (low, medium, high). METHODS: This quantitative cross-sectional survey study assessed the barriers and facilitators to implementing a hypothetical digital prevention program in Australian schools. The survey was taken by 97 teachers (average age 38.3 years), 93 counselors (average age 39.5 years), and 11 principals (average age 50.9 years) across Australia between November 2017 and July 2018. RESULTS: A range of barriers and facilitators relating to logistics and resources, staff support, and program factors were endorsed by the surveyed staff. Consistent with prior research, common barriers included a lack of time and resources (ie, staff and rooms). These barriers were particularly evident in government, rural/regional, and low socioeconomic schools. Other barriers were specific to digital delivery, including privacy issues and a lack of clarity around staff roles and responsibilities. Facilitators included upskilling staff through training, embedding the program into the curriculum, and other program factors including universal delivery, screening of students' mental health, and clear referral pathways. Knowledge about the program efficacy was also perceived as important by a large proportion of the respondents. CONCLUSIONS: The digital depression prevention program was perceived as suitable for use within different schools in Australia, although certain factors need to be considered to enable effective implementation. Logistics and resources, support, and program factors were identified as particularly important for school-based implementation. To maximize the effectiveness in delivering digital programs, implementation may need to be tailored to the staff roles and school types.

A Brief Intervention to Increase Uptake and Adherence of an Internet-Based Program for Depression and Anxiety (Enhancing Engagement With Psychosocial Interventions): Randomized Controlled Trial.

BACKGROUND: Psychosocial, self-guided, internet-based programs are effective in treating depression and anxiety. However, the community uptake of these programs is poor. Recent approaches to increasing engagement (defined as both uptake and adherence) in internet-based programs include brief engagement facilitation interventions (EFIs). However, these programs require evaluation to assess their efficacy. OBJECTIVE: The aims of this hybrid implementation effectiveness trial are to examine the effects of a brief internet-based EFI presented before an internet-based cognitive behavioral therapy self-help program (myCompass 2) in improving engagement (uptake and adherence) with that program (primary aim), assess the relative efficacy of the myCompass 2 program, and determine whether greater engagement was associated with improved efficacy (greater reduction in depression or anxiety symptoms) relative to the control (secondary aim). METHODS: A 3-arm randomized controlled trial (N=849; recruited via social media) assessed the independent efficacy of the EFI and myCompass 2. The myCompass 2 program was delivered with or without the EFI; both conditions were compared with an attention control condition. The EFI comprised brief (5 minutes), tailored audio-visual content on a series of click-through linear webpages. RESULTS: Uptake was high in all groups; 82.8% (703/849) of participants clicked through the intervention following the pretest survey. However, the difference in uptake between the EFI + myCompass 2 condition (234/280, 83.6%) and the myCompass 2 alone condition (222/285, 77.9%) was not significant (n=565; χ21=29.2; P=.09). In addition, there was no significant difference in the proportion of participants who started any number of modules (1-14 modules) versus those who started none between the EFI + myCompass 2 (214/565, 37.9%) and the myCompass 2 alone (210/565, 37.2%) conditions (n=565; χ21<0.1; P=.87). Finally, there was no significant difference between the EFI + myCompass 2 and the myCompass 2 alone conditions in the number of modules started (U=39366.50; z=-0.32; P=.75) or completed (U=39494.0; z=-0.29; P=.77). The myCompass 2 program was not found to be efficacious over time for symptoms of depression (F4,349.97=1.16; P=.33) or anxiety (F4,445.99=0.12; P=.98). However, planned contrasts suggested that myCompass 2 may have been effective for participants with elevated generalized anxiety disorder symptoms (F4,332.80=3.50; P=.01). CONCLUSIONS: This brief internet-based EFI did not increase the uptake of or adherence to an existing internet-based program for depression and anxiety. Individuals' motivation to initiate and complete internet-based self-guided interventions is complex and remains a significant challenge for self-guided interventions. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001565235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375839.

Mental Health Screening in General Practices as a Means for Enhancing Uptake of Digital Mental Health Interventions: Observational Cohort Study.

BACKGROUND: Digital mental health interventions stand to play a critical role in managing the mental health impact of the COVID-19 pandemic. Thus, enhancing their uptake is a key priority. General practitioners (GPs) are well positioned to facilitate access to digital interventions, but tools that assist GPs in identifying suitable patients are lacking. OBJECTIVE: This study aims to evaluate the suitability of a web-based mental health screening and treatment recommendation tool (StepCare) for improving the identification of anxiety and depression in general practice and, subsequently, uptake of digital mental health interventions. METHODS: StepCare screens patients for symptoms of depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder scale) in the GP waiting room. It provides GPs with stepped treatment recommendations that include digital mental health interventions for patients with mild to moderate symptoms. Patients (N=5138) from 85 general practices across Australia were invited to participate in screening. RESULTS: Screening identified depressive or anxious symptoms in 43.09% (1428/3314) of patients (one-quarter were previously unidentified or untreated). The majority (300/335, 89.6%) of previously unidentified or untreated patients had mild to moderate symptoms and were candidates for digital mental health interventions. Although less than half were prescribed a digital intervention by their GP, when a digital intervention was prescribed, more than two-thirds of patients reported using it. CONCLUSIONS: Implementing web-based mental health screening in general practices can provide important opportunities for GPs to improve the identification of symptoms of mental illness and increase patient access to digital mental health interventions. Although GPs prescribed digital interventions less frequently than in-person psychotherapy or medication, the promising rates of uptake by GP-referred patients suggest that GPs can play a critical role in championing digital interventions and maximizing the associated benefits.

School teachers: the forgotten frontline workers of Covid-19.

OBJECTIVE: Australian school teachers have been affected by the Covid-19 pandemic. Teachers have had to face relentless and challenging working conditions, take on new roles and responsibilities, and embrace new ways of working. We searched reports and the available research literature on teacher mental health between September 2020 and October 2020. In our perspective piece, we summarise this literature and draw attention to the struggles of Australian school teachers and how Covid-19 has impacted their mental health. CONCLUSIONS: To date, there has been a lack of research focusing on teacher mental health both internationally and in Australia. That which is available indicates that teacher mental health is likely to have deteriorated substantially during the pandemic. We position teachers as the forgotten frontline of Covid-19 and make recommendations to facilitate improvements into the future.

'Tell Your Story': a randomized controlled trial of an online intervention to reduce mental health stigma and increase help-seeking in refugee men with posttraumatic stress.

BACKGROUND: Refugees report elevated rates of posttraumatic stress disorder (PTSD), but are relatively unlikely to seek help for their symptoms. Mental health stigma is a key barrier to help-seeking amongst refugees. We evaluated the efficacy of an online intervention in reducing self-stigma and increasing help-seeking in refugee men. METHODS: Participants were 103 refugee men with PTSD symptoms from Arabic, Farsi or Tamil-speaking backgrounds who were randomly assigned to either receive an 11-module online stigma reduction intervention specifically designed for refugees ('Tell Your Story', TYS) or to a wait-list control (WLC) group. Participants completed online assessments of self-stigma for PTSD and help-seeking, and help-seeking intentions and behaviors at baseline, post-intervention, and at a 1 month follow-up. RESULTS: Intent-to-treat analyses indicated that, compared to the WLC, TYS resulted in significantly smaller increases in self-stigma for seeking help from post-treatment to follow-up (d = 0.42, p = 0.008). Further, participants in the TYS conditions showed greater help-seeking behavior from new sources at follow-up (B = 0.69, 95% CI 0.19-1.18, p = 0.007) than those in the WLC. The WLC showed significantly greater increases in help-seeking intentions from post-intervention to follow-up (d = 0.27, p = 0.027), relative to the TYS group. CONCLUSIONS: This is the first investigation of a mental health stigma reduction program specifically designed for refugees. Findings suggest that evidence-based stigma reduction strategies are beneficial in targeting self-stigma related to help-seeking and increasing help-seeking amongst refugees. These results indicate that online interventions focusing on social contact may be a promising avenue for removing barriers to accessing help for mental health symptoms in traumatized refugees.