Digital therapeutics in the hospital for suicide crisis - content and design recommendations from young people and hospital staff.

Objective: Hospital emergency departments lack the resources to adequately support young people who present for suicidal crisis. Digital therapeutics could fill this service gap by providing psychological support without creating additional burden on hospital staff. However, existing research on what is needed for successful integration of digital therapeutics in hospital settings is scant. Thus, this study sought to identify key considerations for implementing digital therapeutics to manage acute suicidal distress in hospitals. Method: Participants were 17 young people who recently presented at the hospital for suicide-related crisis, and 12 hospital staff who regularly interacted with young people experiencing mental ill-health in their day-to-day work. Interviews were conducted via videoconference. Framework analysis and reflexive thematic analysis were used to interpret the data obtained. Results: Qualitative insights were centred around three major themes: hospital-specific content, therapeutic content, and usability. Digital therapeutics were seen as a useful means for facilitating hospital-based assessment and treatment planning, and for conducting post-discharge check-ins. Therapeutic content should be focused on helping young people self-manage suicide-related distress while they wait for in-person services. Features to promote usability, such as the availability of customisable features and the use of inclusive design or language, should be considered in the design of digital therapeutics. Conclusions: Digital therapeutics in hospital settings need to benefit both patients and staff. Given the unique context of the hospital setting and acute nature of suicidal distress, creating specialty digital therapeutics may be more viable than integrating existing ones.

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals.

BACKGROUND: Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability. OBJECTIVE: This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration. METHODS: We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems. RESULTS: Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration. CONCLUSIONS: Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

Co-design and Development of Implementation Strategies: Enhancing the PAX Good Behaviour Game in Australian Schools.

Effective implementation strategies are important for take-up of programs in schools. However, to date, few implementation strategies have been co-designed with teachers and support staff (including principals) in Australia. The aim of this study was to iteratively co-design multiple implementation strategies to enhance the delivery of mental health prevention program, PAX Good Behaviour Game, in New South Wales primary schools. The secondary aim was to evaluate the acceptability of the implementation strategies from the perspective of school staff. Twenty-nine educational staff (including principals) informed the co-design of the implementation strategies across three phases. Phase 1 involved a rapid review of the literature and stakeholder meetings to agree upon potential evidence-based strategies. Phase 2 involved focus group discussions with educational staff to co-design implementation strategies. Phase 3 involved semi-structured interviews with school staff to assess strategy acceptability after implementation at 6-months post-baseline. Data were analysed using deductive, framework analysis. The final co-designed intervention included nine implementation strategies accessible through a toolkit delivered to the school's leadership team. These strategies were deemed acceptable in school settings that experienced periods of both face-to-face and remote learning due to the changing COVID-19 situation in 2021. This paper contributes to the implementation literature by transparently reporting how educational staff-informed implementation strategies were iteratively co-designed. This will provide a roadmap for other researchers to co-design implementation strategies to further support the delivery of evidence-based prevention programs in schools.

Self-harm in 5-to-24 year olds: Retrospective examination of hospital presentations to emergency departments in New South Wales, Australia, 2012 to 2020.

There is some evidence that self-harm presentations in children and young people have increased over the past decade, yet there are few up-to-date studies examining these trends. This study aims to describe trends in the rates and severity of emergency department self-harm presentations for youth aged 5-24 years in New South Wales, Australia between 1 January 2012 and 31 December 2020. We analysed self-harm hospital presentations using join point analysis to compare quarterly growth in rates and urgency of presentation since 2012 by age group and sex. Binomial logistic modelling was used to identify risks for re-presentation for self-harm, including age group, sex, country of birth, mode of arrival, inpatient status, triage category, rurality, and socio-economic disadvantage. In total, 83,111 self-harm presentations for 51,181 persons were analysed. Overall rates of self-harm among those aged 5-24 years increased by 2.4% (p < .001) per quarter in females and 1.6% (p < .001) per quarter in males, with statistically significant average quarterly increases observed across all age groups. Overall and age-specific self-harm triage urgency rates increased statistically significantly for potentially serious, and potentially- and immediately life-threatening categories. A higher likelihood of re-presentation to any emergency department for self-harm was associated with younger age, female, residing in a regional area, arriving by ambulance, admitted as an in-patient, and a more severe index self-harm presentation. Hospital self-harm presentations have been growing steadily over the past decade, with the greatest growth in the youngest people. Understanding the reasons for these sustained upward trends is a priority for suicide prevention.

Parents of Adolescents Who Experience Suicidal Phenomena-A Scoping Review of Their Experience.

High prevalence rates of self-harm and suicide in adolescence provide unique challenges for parents. The aim of this scoping review was to explore key gaps in our understanding of the current scientific literature on the experience of parents who have adolescent children experiencing suicide crisis or self-harm. Four academic databases were searched using three broad concepts: self-harming behaviour or suicidal crisis; adolescents or young people; and the experiences or behaviour of parents, between journal inception and March 2022. Information reporting on the parents' experience was extracted and a qualitative synthesis was conducted. Twenty-two articles met inclusion criteria and were assessed in detail. The experience of parents with an adolescent engaged in self-harm or suicidal crisis were classified into three temporal themes: discovery of the suicidal phenomena, management of suicidal phenomena, and after the suicidal phenomena had ceased. Parents caring for an adolescent experiencing self-harm or suicidal crisis experience poorer psychological wellbeing, difficulty accessing support services, and changes in the parent-child relationship. Parents desire greater support for both themselves and their child and further investigation is required to understand specifically which supports would be most appropriate at each stage.

Promoting Engagement With Smartphone Apps for Suicidal Ideation in Young People: Development of an Adjunctive Strategy Using a Lived Experience Participatory Design Approach.

BACKGROUND: Suicide among young people is a worrying public health concern. Despite this, there is a lack of suitable interventions aligned with the needs of this priority population. Emerging evidence supports the effectiveness of digital interventions in alleviating the severity of suicidal thoughts. However, their efficacy may be undermined by poor engagement. Technology-supported strategies (eg, electronic prompts and reminders) have been deployed alongside digital interventions to increase engagement with the latter. However, evidence of their efficacy is inconclusive. User-centered design approaches may be key to developing feasible and effective engagement strategies. Currently, no study has been published on how such an approach might be expressly applied toward developing strategies for promoting engagement with digital interventions. OBJECTIVE: This study aimed to detail the processes and activities involved in developing an adjunctive strategy for promoting engagement with LifeBuoy-a smartphone app that helps young people manage suicidal thoughts. METHODS: Development of the engagement strategy took place in 2 phases. The discovery phase aimed to create an initial prototype by synthesizing earlier findings-from 2 systematic reviews and a cross-sectional survey of the broader mental health app user population-with qualitative insights from LifeBuoy users. A total of 16 web-based interviews were conducted with young people who participated in the LifeBuoy trial. Following the discovery phase, 3 interviewees were invited by the research team to take part in the workshops in the design phase, which sought to create a final prototype by making iterative improvements to the initial prototype. These improvements were conducted over 2 workshops. Thematic analysis was used to analyze the qualitative data obtained from the interviews and workshops. RESULTS: Main themes from the interviews centered around the characteristics of the strategy, timing of notifications, and suitability of social media platforms. Subsequently, themes that emerged from the design workshops emphasized having a wider variety of content, greater visual consistency with LifeBuoy, and a component with more detailed information to cater to users with greater informational needs. Thus, refinements to the prototype were focused on (1) improving the succinctness, variety, and practical value of Instagram content, (2) creating a blog containing articles contributed by mental health professionals and young people with lived experience of suicide, and (3) standardizing the use of marine-themed color palettes across the Instagram and blog components. CONCLUSIONS: This is the first study to describe the development of a technology-supported adjunctive strategy for promoting engagement with a digital intervention. It was developed by integrating perspectives from end users with lived experience of suicide with evidence from the existing literature. The development process documented in this study may be useful for guiding similar projects aimed at supporting the use of digital interventions for suicide prevention or mental health.

Intervention Programs Targeting the Mental Health, Professional Burnout, and/or Wellbeing of School Teachers: Systematic Review and Meta-Analyses.

This paper outlines a systematic review and meta-analyses to identify, describe, and evaluate randomised and non-randomised controlled trials of psychological programs targeting the mental health, professional burnout, and/or wellbeing of school classroom teachers. Eighty-eight unique studies were identified for inclusion in the review, and of those 46 were included in the meta-analyses (23 randomised controlled trials). In randomised controlled trials, the programs examined had large effects on stress (g=0.93), and moderate effects on anxiety (g=0.65), depression (g=0.51), professional burnout (g=0.57), and wellbeing (g=0.56) at post. In non-randomised controlled trials, programs had moderate effects on stress (g=0.50), and small effects on anxiety (g=0.38) and wellbeing (g=0.38) at post. Studies were heterogeneous in design and methodological quality was generally poor, particularly in non-randomised controlled trials. There was an inadequate number of comparisons to perform sub-group analyses, meta-regression, or publication bias analyses. Most of the programs examined required significant time, effort, and resources to deliver and complete. These programs may not translate well outside of research trials to real-world contexts due to teachers being time-poor. Priorities for research include using methodologically rigorous designs, developing programs for teachers with teachers (i.e. co-design), and considering implementation factors to ensure feasibility, acceptability, and uptake. Systematic Review Registration Number: PROPSERO - CRD42020159805. Supplementary Information: The online version contains supplementary material available at 10.1007/s10648-023-09720-w.

The Effectiveness of a Smartphone Intervention Targeting Suicidal Ideation in Young Adults: Randomized Controlled Trial Examining the Influence of Loneliness.

BACKGROUND: Loneliness is commonly reported by young people and has been shown to contribute to the rapid onset and escalation of depression and suicidal ideation during adolescence. Lonely people may also be particularly susceptible to disengaging from treatment early given the likelihood of their more complex clinical profiles leading to cognitive fatigue. While a smartphone intervention (LifeBuoy) has been shown to effectively reduce suicidal ideation in young adults, poor engagement is a well-documented issue for this therapeutic modality and has been shown to result in poorer treatment outcomes. OBJECTIVE: This study aims to determine whether loneliness affects how young people experiencing suicidal ideation engage with and benefit from a therapeutic smartphone intervention (LifeBuoy). METHODS: A total of 455 community-based Australian young adults (aged 18-25 years) experiencing recent suicidal ideation were randomized to use a dialectical behavioral therapy-based smartphone intervention (LifeBuoy) or an attention-matched control app (LifeBuoy-C) for 6 weeks. Participants completed measures of suicidal ideation, depression, anxiety, and loneliness at baseline (T0), post intervention (T1), and 3 months post intervention (T2). Piecewise linear mixed models were used to examine whether loneliness levels moderated the effect of LifeBuoy and LifeBuoy-C on suicidal ideation and depression across time (T0 to T1; T1 to T2). This statistical method was then used to examine whether app engagement (number of modules completed) influenced the relationship between baseline loneliness and suicidal ideation and depression across time. RESULTS: Loneliness was positively associated with higher levels of overall suicidal ideation (B=0.75, 95% CI 0.08-1.42; P=.03) and depression (B=0.88, 95% CI 0.45-1.32; P<.001), regardless of time point or allocated condition. However, loneliness did not affect suicidal ideation scores across time (time 1: B=1.10, 95% CI -0.25 to 2.46; P=.11; time 2: B=0.43, 95% CI -1.25 to 2.12; P=.61) and depression scores across time (time 1: B=0.00, 95% CI -0.67 to 0.66; P=.99; time 2: B=0.41, 95% CI -0.37 to 1.18; P=.30) in either condition. Similarly, engagement with the LifeBuoy app was not found to moderate the impact of loneliness on suicidal ideation (B=0.00, 95% CI -0.17 to 0.18; P=.98) or depression (B=-0.08, 95% CI -0.19 to 0.03; P=.14). CONCLUSIONS: Loneliness was not found to affect young adults' engagement with a smartphone intervention (LifeBuoy) nor any clinical benefits derived from the intervention. LifeBuoy, in its current form, can effectively engage and treat individuals regardless of how lonely they may be. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001671156; https://tinyurl.com/yvpvn5n8. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/23655.

Exploring Sociodemographic Correlates of Suicide Stigma in Australia: Baseline Cross-Sectional Survey Findings from the Life-Span Suicide Prevention Trial Studies.

The risk of suicidal behaviour in Australia varies by age, sex, sexual preference and Indigenous status. Suicide stigma is known to affect suicide rates and help-seeking for suicidal crises. The aim of this study was to investigate the sociodemographic correlates of suicide stigma to assist in prevention efforts. We surveyed community members and individuals who had attended specific emergency departments for suicidal crisis. The respondents were part of a large-scale suicide prevention trial in New South Wales, Australia. The data collected included demographic characteristics, measures of help-seeking and suicide stigma. The linear regression analyses conducted sought to identify the factors associated with suicide stigma. The 5426 participants were predominantly female (71.4%) with a mean (SD) age of 41.7 (14.8) years, and 3.9% were Indigenous. Around one-third of participants reported a previous suicide attempt (n = 1690, 31.5%) with two-thirds (n = 3545, 65.3%) seeking help for suicidal crisis in the past year. Higher stigma scores were associated with Indigenous status (ß 0.123, 95%CI 0.074-0.172), male sex (ß 0.527, 95%CI 0.375-0.626) and regional residence (ß 0.079, 95%CI 0.015-0.143). Lower stigma scores were associated with younger age (ß -0.002, 95%CI -0.004--0.001), mental illness (ß -0.095, 95%CI -0.139 to -0.050), male bisexuality (ß -0.202, 95%CI -0.351 to -0.052) and males who glorified suicide (ß -0.075, 95%CI -0.119 to -0.031). These results suggested that suicide stigma differed across the community, varying significantly by sex, sexual orientation and Indigenous status. Targeted educational programs to address suicide stigma could assist in suicide prevention efforts.

Promoting engagement with self-guided digital therapeutics for mental health: Insights from a cross-sectional survey of end-users.

BACKGROUND: Poor engagement has hindered the dissemination of self-guided digital therapeutics for mental health. Evidence on the efficacy of technology-supported strategies designed for increasing engagement with these interventions is currently inconclusive. Few studies have examined user perceptions of such strategies, which could yield key insights for enhancing their effectiveness. METHODS: Two hundred and eleven participants completed a cross-sectional online survey. All participants were aged 18 years and above, living in Australia, fluent in English, and self-reported prior use of digital therapeutics for mental health needs. Survey items elicited participants' views on factor(s) contributing to their engagement/disengagement with digital therapeutics, and perceptions of engagement strategies, including: automated electronic reminders, fun facts, quizzes, and social media platforms. χ2 tests of independence were used to analyse nominal data. Inductive thematic analysis was used to analyse free-text data. RESULTS: Factors facilitating engagement included digestible content, assurance of confidentiality, and esthetically appealing design. Factors hindering engagement included lack of time, forgetfulness, and lack of perceived intervention efficacy. Participants had mixed views over the feasibility and acceptability of the strategies explored toward promoting engagement. CONCLUSIONS: Regardless of strategy type, succinct and easily applicable content was identified as an important feature for promoting engagement. Conversely, content that could trigger psychological distress among intervention users should be avoided. Overall, the diverse range of user perspectives highlighted that engagement strategies for any specific digital intervention should be co-designed with individuals with lived experience of mental health difficulties.

Risk of repeat self-harm and suicide death following an episode of hospital self-harm presentation among adolescents and young adults.

BACKGROUND: Self-harm is a critical issue affecting young people which could result in adverse outcomes including repeat episodes and suicide. In this study, we aimed to estimate the short-term and long-term risk of repeat self-harm and subsequent suicide death following self-harm presentations among adolescents and young adults. METHODS: Using linked data from the New South Wales (NSW) Emergency Department Data Collection (EDDC), the NSW Admitted Patient Data Collection (APDC), and cause of death unit record file (COD-URF), we collected all self-harm presentations to emergency departments and/or hospitals and suicide deaths between 2012 and 2019 in NSW, Australia. We used survival analysis models to estimate the incidence of repeat self-harm and suicide by time since the index self-harm and relative risks by sex, type of hospital presentation and count of self-harm records. RESULTS: In total, we identified 81,133 self-harm episodes among 48,547 individuals aged 10-29 years. Of 48,547 individuals who engaged in an index self-harm during the study period, 39.5 % (19,180) were aged between 15 and 19 years. The incidence of both repeat self-harm and suicide were highest in the year following the index self-harm presentation (repeat self-harm: 188.84 per 1000 person-years; suicide: 3.30 per 1000 person-years) and declined to 14.51 and 0.28 per 1000 person-years after five years. Among individuals indexed for self-harm at 15-29 years, males and those who were admitted to hospital for the index self-harm had the highest risk of both subsequent repeat self-harm and suicide death and those with 2 or more self-harm presentation records had the higher risk for subsequent suicide death. CONCLUSION: Adolescents and young adults with self-harm presentations were at a high risk of subsequent repeat self-harm and suicide death, especially the first year after presentations. Youth-specific early intervention and long-term management should be delivered accordingly, especially for those at early adolescence .

Hotel Suicides in Australia 2006-2017.

Background: This study investigated the frequency, characteristics, and geospatial clustering of hotel suicides in Australia to inform suicide prevention efforts. Aims: (1) To determine the proportion of suicide deaths that occurred in hotels, (2) to determine differences in demographic characteristics of hotel deaths compared to other locations, (3) to assess level of planning, and (4) to determine whether these deaths form geographic clusters amenable to targeted suicide prevention activities. Methods: Archival data on suicide mortality were used to examine associations between incident location (hotels, home, away from home), demographic characteristics, and suicide means. Kernel density visualization was used to assess geospatial clustering of hotel suicides, and the degree of planning involved was assessed using the modified Suicide Intent Scale. Results: Hotels accounted for 2% of all suicide deaths and 6.2% of suicides occurring away from home. Females were over-represented (p < .0001), as were deaths by drug overdoses (p < .0001) and falls (p < .0001). Approximately 40% of incidents occurred within seven geospatial clusters. 85% of those who died were state residents, with a median distance from home of 13.0 km. Most individuals checked in to the hotel alone, for short stays, and displayed a high degree of suicidal planning. Limitations: Coronial records had limited information on narrative circumstances of deaths; other indicators of risk may not have been identified. A comparison against a general population of hotel guests, rather than all other suicide deaths would be more useful in terms of preventative activities, however these data were not readily available. Conclusion: This study identified characteristics, behaviors, and geographic locations associated with hotel suicides to inform training of hotel staff to recognize and respond to signs of risk. Males of working age who live locally and arrive alone for short stays could be considered at a higher risk of suicide, and prevention efforts should be prioritized in the identified high-risk areas.

Strategies for Enhancing the Implementation of Universal Mental Health Prevention Programs in Schools: A Systematic Review.

A number of school-based mental health prevention programs have been found to be effective in research trials, but little is known about how to support implementation in real-life settings. To address this translational problem, this systematic review aims to identify effective strategies for enhancing the implementation of mental health prevention programs for children in schools. Four electronic databases were searched for empirical, peer-reviewed articles in English from January 2000 to October 2021 reporting the effects of implementation strategies for school-based universal mental health programs. Twenty-one articles were included in the narrative synthesis and assessed for quality using the Mixed Methods Appraisal Tool. Twenty-two strategies were found to be effective at improving program fidelity or adoption. The strategies with the strongest positive evidence base were those that involved monitoring and provision of feedback, engaging principals as program leaders, improving teachers' buy-in and organising school personnel implementation meetings. We recommend school-based practitioners trial strategies with positive findings from this review as part of their continuous quality improvement. This review highlights the pressing need for large-scale, randomised controlled trials to develop and trial more robust strategies to enhance adoption, as the five implementation studies found to measure adoption used qualitative methods limited by small samples sizes and case study designs.

Understanding Emergency Department Healthcare Professionals' Perspectives of Caring for Individuals in Suicidal Crisis: A Qualitative Study.

Help seekers regularly present to Emergency Departments (EDs) when in suicidal crisis for intervention to ensure their immediate safety, which may assist in reducing future attempts. The emergency health workforce have unique insights that can inform suicide prevention efforts during this critical junction in an individual's experience with suicide. This paper explores the treatment and care delivery experiences of 54 health professionals working in EDs within one of the LifeSpan suicide prevention trial sites in Australia. Data was collected via six focus groups and six interviews. Thematic analysis resulted in three themes: (1) physicality of the emergency department, (2) juggling it all-the bureaucracy, practicalities, and human approach to care, and (3) impact of care delivery on ED staff. Findings highlight the need for workplace training that incorporates responding to the uncertainty of suicidal crisis, to compliment the solution-focused medical model of care. Broader policy changes to the ED system are also considered to ensure better outcomes for health professionals and help-seekers alike.

Technology-supported strategies for promoting user engagement with digital mental health interventions: A systematic review.

Background: Although digital mental health interventions (DMHIs) offer a potential solution for increasing access to mental health treatment, their integration into real-world settings has been slow. A key reason for this is poor user engagement. A growing number of studies evaluating strategies for promoting engagement with DMHIs means that a review of the literature is now warranted. This systematic review is the first to synthesise evidence on technology-supported strategies for promoting engagement with DMHIs. Methods: MEDLINE, EmbASE, PsycINFO and PubMed databases were searched from 1 January 1995 to 1 October 2021. Experimental or quasi-experimental studies examining the effect of technology-supported engagement strategies deployed alongside DMHIs were included, as were secondary analyses of such studies. Title and abstract screening, full-text coding and quality assessment were performed independently by two authors. Narrative synthesis was used to summarise findings from the included studies. Results: 24 studies (10,266 participants) were included. Engagement strategies ranged from reminders, coaching, personalised information and peer support. Most strategies were disseminated once a week, usually via email or telephone. There was some empirical support for the efficacy of technology-based strategies towards promoting engagement. However, findings were mixed regardless of strategy type or study aim. Conclusions: Technology-supported strategies appear to increase engagement with DMHIs; however, their efficacy varies widely by strategy type. Future research should involve end-users in the development and evaluation of these strategies to develop a more cohesive set of strategies that are acceptable and effective for target audiences, and explore the mechanism(s) through which such strategies promote engagement.

A cluster randomised effectiveness-implementation trial of an intervention to increase the adoption of PAX Good Behaviour Game, a mental health prevention program, in Australian primary schools: Study protocol.

Introduction: Implementation of evidence-based programs in school settings can be challenging, undermining the benefits these programs deliver for children. The primary aim of this study is to assess whether an enhanced implementation intervention increases adoption of the PAX Good Behaviour Game in New South Wales (NSW) primary schools in Australia. A secondary outcome is to investigate the impact of the PAX Good Behaviour Game on children's mental health in the Australian context. Methods and analysis: The study uses a cluster randomised hybrid type 3 effectiveness-implementation design and will involve 40 NSW primary schools. Randomisation will occur at the school level. All NSW primary schools trained in the PAX Good Behaviour Game are eligible for participation. The intervention is a multicomponent implementation strategy that has been iteratively co-designed by our research team and local stakeholders. Intervention schools will have access to eight implementation support strategies in addition to the training received as usual delivery to build knowledge and skills. Research staff will assess implementation and effectiveness outcomes using self-report online surveys with teachers and support staff at baseline, 6-weeks, 6-months and 12-months follow up. Semi-structured interviews with teachers and support staff will be used to examine which implementation strategies worked for whom and under what conditions. Discussion: If successful, this study will highlight effective strategies schools or education departments can use internationally to improve their translation of evidence-based programs into routine practices. This will lead to better outcomes for children and young people.

Three-arm randomised controlled trial of an m-health app and digital engagement strategy for improving treatment adherence and reducing suicidal ideation in young people: study protocol.

INTRODUCTION: Youth suicidal ideation and behaviour is concerning due to its widespread prevalence, morbidity and potentially fatal consequences. Digital mental health interventions have been found to improve access to low-cost and high-quality support for a range of mental health issues, yet there are few digital interventions available for suicide prevention in young people. In addition, no studies have examined how digital engagement strategies may impact the engagement and efficacy of digital interventions in suicide prevention. The current protocol describes a three-arm parallel randomised controlled trial. A therapeutic smartphone application ('LifeBuoy'; intervention condition) will be tested against a condition that consists of the LifeBuoy application plus access to a digital engagement strategy ('LifeBuoy+engagement'; intervention condition) to determine whether the addition of the digital strategy improves app engagement metrics. To establish the efficacy of the LifeBuoy application, both of these intervention conditions will be tested against an attention-matched control condition (a placebo app). METHODS AND ANALYSIS: 669 young Australians aged 17-24 years who have experienced suicidal ideation in the past 30 days will be recruited by Facebook advertisement. The primary outcomes will be suicidal ideation severity and level of app engagement. Primary analyses will use an intention-to-treat approach and compare changes from baseline to 30-day, 60-day and 120-day follow-up time points relative to the control group using mixed-effect modelling. A subset of participants in the intervention groups will be interviewed on their experience with the app and engagement strategy. Qualitative data will be analysed using an inductive approach, independent of a theoretical confirmative method to identify the group themes. ETHICS AND DISSEMINATION: The study has been approved by the University of New South Wales Human Research Ethics Committee (HC210400). The results of the trial will be disseminated via peer-reviewed publications in scientific journals and conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001247864.

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.

Machine learning algorithms to classify self-harm behaviours in New South Wales Ambulance electronic medical records: A retrospective study.

BACKGROUND: There is increasing interest in suicide surveillance solutions to identify non-fatal suicidal and self-harming behaviours in the Australian community not currently captured through national administrative datasets. OBJECTIVE: The aim of the present study was to develop machine learning models to classify self-harm related behaviours using unstructured clinical note text from New South Wales (NSW) Ambulance data and compare their performance via traditional methods. METHODS: Primary data were derived from NSW Ambulance electronic medical records (eMRs) for potential self-harm related NSW Ambulance attendances for the period 2013-2019. Data included paramedic clinical notes detailing the nature of the attendance, clinical outcome, and narrative information. We assessed sensitivity, specificity, positive predictive value, negative predictive value, F-score, and the Matthews correlation coefficient (MCC) for four algorithms (Support Vector Machine, random forest, decision tree, and logistic regression). RESULTS: The performance of these algorithms was compared using the MCC measure. In a test sample of 3157 ambulance attendances (1349 self-harm related behaviours and 1808 unrelated), the MCC for classification of self-harm related behaviour ranged from +0.681 to +0.730. The Support Vector Machine (sensitivity = 82.7%, specificity = 89.6%, MCC = 0.730) and the logistic regression (sensitivity = 83.1%, specificity = 89.3%, MCC = 0.727) models performed best. CONCLUSIONS: This study demonstrates that machine learning models can be applied to paramedic notes within unstructured medical records to classify self-harm related behaviours. The resulting model could be used to compliment current manual abstraction of self-harm behaviours and provide more timely approximations to be used for self-harm surveillance.

Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional.

BACKGROUND: Prevalence of suicidal ideation increases rapidly in adolescence, and many choose not to seek help and disclose their ideation. Young people who do disclose suicidal ideation, prefer to do so with peers and family compared to mental health professionals, who are best placed to provide evidence-based treatment. This study aimed to identify key factors associated with young people's decision to, or not to disclose suicidal thoughts to their mental health practitioner. METHODS: A community-based sample of young Australians (16 - 25 years), who had experienced suicidal ideation and engaged with a mental health professional, completed an online questionnaire (N=513) which assessed demographic characteristics, severity of depression, anxiety, psychological distress, and suicidal ideation, lifetime suicide attempts, exposure to suicide loss, personal suicide stigma, prioritisation of mental health issues, and therapeutic alliance. Logistic regression analyses were used to identify factors associated with disclosure. RESULTS: Though the full sample had engaged in therapy, 39% had never disclosed suicidal ideation to their clinician. Those who had disclosed were more likely to report greater therapeutic alliance (OR=1.04, 95% CI=1.02-1.06), personal suicide stigma (OR=1.04, 95% CI=1.01-1.06), prioritisation of suicidal ideation (OR=.24, 95% CI=0.14-0.42), and lifetime history of suicide attempt (OR=.32, 95% CI=0.18-0.57). The most common reason for not disclosing was concern that it would not remain confidential. CONCLUSION: These findings provide new insights into why young people may not seek help by disclosing suicidal ideation, despite having access to a mental health professional, and establish evidence to inform practice decisions and the development of prevention strategies to support young people for suicide.