A Review of Systematic Reviews: Gatekeeper Training for Suicide Prevention with a Focus on Effectiveness and Findings.

OBJECTIVES: Suicide prevention gatekeeper training (GKT) is considered an important component of an overall suicide-prevention strategy. The primary aim of this study was to conduct the first robust review of systematic reviews of GKT to examine the overall effectiveness of GKT on knowledge, self-efficacy, attitudes, behavioral intentions, and behavioral change. The study also examined the extent to which outcomes were retained long term, the frequency of refresher sessions, and the effectiveness of GKT with Indigenous populations and e-learning delivery. METHODS: For this review of reviews, MEDLINE, PsycINFO, Embase; and the Cochrane Database of Systematic Reviews were searched. ROBIS was applied to assess risk of bias and findings were synthesized using narrative synthesis. RESULTS: Six systematic reviews were included comprising 61 studies, of which only 10 were randomized controlled trials (RCTs). Immediate positive effects of GKT on knowledge, skills, and self-efficacy were confirmed, including for interventions tailored for Indigenous communities. Evidence was mixed for change in attitude; few studies measured e-learning GKT, retention of outcomes, booster sessions, behavioral intentions, and behavioral change, with some positive results. CONCLUSIONS: Evidence supports the immediate effects of GKT but highlights a need for more high-quality RCTs, particularly for Indigenous and e-learning GKT. This review identified a concerning lack of long-term follow-up assessments at multiple time points, which could capture behavioral change and a significant gap in studies focused on post-training interventions that maintain GKT effects over time.

This first review of systematic reviews for GKT confirmed positive effects for GKT, although mixed evidence exists for changes in attitude.Very few studies include long-term measurement of retention of outcomes and what facilitates retention.There is an urgent need for more research into the effectiveness of GKT with Indigenous populations and e-learning GKT.

Exploring Counselor Practices and Risk Assessment in a Proactive Digital Intervention Through Instagram in Young People: Qualitative Study.

BACKGROUND: Suicide is one of the leading causes of preventable death in young people, and the way young people are communicating suicidality has evolved to include web-based disclosures and help-seeking. To date, mental health intervention services, both on the web and in person, have been conceived in the traditional model, whereby support is provided if a young person (or their family) actively seeks out that support when distressed. On the other hand, proactive outreach is an innovative approach to intervention that has been shown to be effective in other areas of health care. Live for Tomorrow chat was delivered on Instagram and comprised of counselors who reach out to provide brief person-centered intervention to young people who post content indicating distress or suicidality. OBJECTIVE: Our aim was to explore how counselors engaged young people in a proactive digital intervention and how risk assessment was conducted in this context. METHODS: We analyzed 35 transcripts of conversations between counselors and young people aged 13-25 years using the 6-step approach of Braun and Clarke's reflexive thematic analysis. These transcripts included a counseling intervention and a follow-up chat that was aimed at collecting feedback about the counseling intervention. RESULTS: A total of 7 themes emerged: using microskills to facilitate conversations, building confidence and capacity to cope with change, seeking permission when approaching conversations about suicidality or self-harm, conversations about suicidality following a structured approach, providing assurances of confidentiality, validation of the experience of suicidality, and using conversations about suicidality to identify interventions. Counselors were able to translate counseling microskills and structured questioning regarding suicidality into a digital context. In particular, in the digital context, counselors would use the young person's post and emojis to further conversations and build rapport. CONCLUSIONS: The findings highlight the importance of the counselor's role to listen, empathize, validate, and empower young people and that all these skills can be transferred to a digital text counseling intervention. Counselors used a structured approach to understanding suicidality in a permission-seeking, validating, and confidential manner to identify interventions with the young person. These practices allowed the conversation to move beyond traditional risk assessment practices to meaningful conversations about suicidality. Moving beyond traditional risk assessment practices and into conversations about suicidality allowed for the validation of the young person's experience and exploration of interventions and support that made sense and were seen to be helpful to the young person. This study highlighted the benefits of a proactive digital chat-based intervention, which is a novel approach to engaging with young people experiencing psychological distress and suicidality. Furthermore, this research demonstrates the feasibility and benefit of moving mental health intervention and support to a medium where young people are currently disclosing distress and intervening proactively.

Exploring Young Adults' Views About Aroha, a Chatbot for Stress Associated With the COVID-19 Pandemic: Interview Study Among Students.

BACKGROUND: In March 2020, New Zealand was plunged into its first nationwide lockdown to halt the spread of COVID-19. Our team rapidly adapted our existing chatbot platform to create Aroha, a well-being chatbot intended to address the stress experienced by young people aged 13 to 24 years in the early phase of the pandemic. Aroha was made available nationally within 2 weeks of the lockdown and continued to be available throughout 2020. OBJECTIVE: In this study, we aimed to evaluate the acceptability and relevance of the chatbot format and Aroha's content in young adults and to identify areas for improvement. METHODS: We conducted qualitative in-depth and semistructured interviews with young adults as well as in situ demonstrations of Aroha to elicit immediate feedback. Interviews were recorded, transcribed, and analyzed using thematic analysis assisted by NVivo (version 12; QSR International). RESULTS: A total of 15 young adults (age in years: median 20; mean 20.07, SD 3.17; female students: n=13, 87%; male students: n=2, 13%; all tertiary students) were interviewed in person. Participants spoke of the challenges of living during the lockdown, including social isolation, loss of motivation, and the demands of remote work or study, although some were able to find silver linings. Aroha was well liked for sounding like a "real person" and peer with its friendly local "Kiwi" communication style, rather than an authoritative adult or counselor. The chatbot was praised for including content that went beyond traditional mental health advice. Participants particularly enjoyed the modules on gratitude, being active, anger management, job seeking, and how to deal with alcohol and drugs. Aroha was described as being more accessible than traditional mental health counseling and resources. It was an appealing option for those who did not want to talk to someone in person for fear of the stigma associated with mental health. However, participants disliked the software bugs. They also wanted a more sophisticated conversational interface where they could express themselves and "vent" in free text. There were several suggestions for making Aroha more relevant to a diverse range of users, including developing content on navigating relationships and diverse chatbot avatars. CONCLUSIONS: Chatbots are an acceptable format for scaling up the delivery of public mental health and well-being-enhancing strategies. We make the following recommendations for others interested in designing and rolling out mental health chatbots to better support young people: make the chatbot relatable to its target audience by working with them to develop an authentic and relevant communication style; consider including holistic health and lifestyle content beyond traditional "mental health" support; and focus on developing features that make users feel heard, understood, and empowered.

Enhancing an online cognitive behavioural therapy intervention for depression: Harnessing the feedback of sexual and gender minority youth to help improve SPARX.

OBJECTIVE: SPARX is an online cognitive behavioural therapy self-help intervention for adolescent depression provided in serious game format. Since 2014, it has been freely available in Aotearoa New Zealand (NZ) due to funding from the NZ government. In 2020/21, feedback from sexual and gender minority youth (SGMY) was used to refine and update SPARX. METHOD: Three online focus groups and follow-up email consultations involved 12 SGMY (16 to 25 years old) in NZ. A general inductive approach was used to analyse data. RESULTS: SGMY had specific needs as well as preferences and four themes were identified: attend to our contextual realities; portrayals of sexual and gender minority people in games; envisaged ideals for serious gaming and appraisals of SPARX. SGMY feedback was used to improve SPARX for this unique population, with the updates launched in October 2021. CONCLUSIONS: SGMY are underserved in terms of their mental health needs. Refining or tailoring existing interventions proffers a potential way forward in terms of addressing these needs.

Concentration of Selected Essential and Toxic Trace Elements in Horse Hair as an Important Tool for the Monitoring of Animal Exposure and Health.

The main purpose of the study was to analyse the concentrations of selected essential and toxic trace elements in the hair of sports and recreational riding horses from studs located in central Poland and thus test the usefulness of this matrix for monitoring the exposure of these animals. We also measured the concentration of heavy metals in oats used as a basic component of the equine diet to investigate the interactions between these elements in the feed and hair. The basic chemical composition of oats was analysed. Elemental analysis was performed using an EcaFlow 150 GLP electrochemical analyser with an E-104L electrode and reference to a calibration curve. The chemical composition of oats was investigated by near infrared transmission (NIR) spectroscopy calibrated for an artificial neural network (ANN) using a Foss InfraXact spectrometer. Among all elements, the coefficient of variation was highest for Pb and lowest for Cd, regardless of the study group. The content of elements in horse hair was in the range of 153.56 to 185.79 mg·kg-1 for Zn, 6.10 to 11.99 mg·kg-1 for Cu, 0.578 to 0.813 mg·kg-1 for Pb and 0.011 to 0.015 mg·kg-1 for Cd (in kg of d.w.). For hair, we found a significant negative correlation for Zn-Cu (rxy = -0.539) and Cd-Cu (rxy = -0.676) at p ≤ 0.05. For feed, there was a highly significant positive correlation for Cu-Pb (rxy = 0.723) and Zn-Cd (rxy = 0.714) at p ≤ 0.01. We found significant negative oats-hair interactions for Cu-Zn, Pb-Cu, Cd-Cu and Zn-Pb, and a positive oats-hair interaction for Cu-Cu.

A Chatbot to Support Young People During the COVID-19 Pandemic in New Zealand: Evaluation of the Real-World Rollout of an Open Trial.

BACKGROUND: The number of young people in New Zealand (Aotearoa) who experience mental health challenges is increasing. As those in Aotearoa went into the initial COVID-19 lockdown, an ongoing digital mental health project was adapted and underwent rapid content authoring to create the Aroha chatbot. This dynamic digital support was designed with and for young people to help manage pandemic-related worry. OBJECTIVE: Aroha was developed to provide practical evidence-based tools for anxiety management using cognitive behavioral therapy and positive psychology. The chatbot included practical ideas to maintain social and cultural connection, and to stay active and well. METHODS: Stay-at-home orders under Aotearoa's lockdown commenced on March 20, 2020. By leveraging previously developed chatbot technology and broader existing online trial infrastructure, the Aroha chatbot was launched promptly on April 7, 2020. Dissemination of the chatbot for an open trial was via a URL, and feedback on the experience of the lockdown and the experience of Aroha was gathered via online questionnaires and a focus group, and from community members. RESULTS: In the 2 weeks following the launch of the chatbot, there were 393 registrations, and 238 users logged into the chatbot, of whom 127 were in the target age range (13-24 years). Feedback guided iterative and responsive content authoring to suit the dynamic situation and motivated engineering to dynamically detect and react to a range of conversational intents. CONCLUSIONS: The experience of the implementation of the Aroha chatbot highlights the feasibility of providing timely event-specific digital mental health support and the technology requirements for a flexible and enabling chatbot architectural framework.

Effects of age and sex on the content of heavy metals in the hair, liver and the longissimus lumborum muscle of roe deer Capreolus capreolus L.

The aim of the study was to investigate the effects of age and sex on the content of heavy metals (Pb, Cd, Zn and Cu) in the hair, liver and the longissimus lumborum muscle of roe deer (Capreolus capreolus L.). In addition, correlations between heavy metals in individual tested matrices were studied as well as an attempt was made to explain the reasons for their accumulation in specific research matrices. The levels of Zn and Cu were measured using atomic absorption spectroscopy (F-AAS). The levels of Pb and Cd were analysed by means of electrothermal atomic absorption spectroscopy (ET-AAS). In the own research, sex-related statistically significant differences in concentrations of analysed elements were confirmed. Higher levels of the elements were observed in samples collected from does (except for Cd in the liver samples of 6-7-month-old male fawns) but only in some cases, these values were statistically significantly higher. In some cases, age-related differences in the content of individual metals were also confirmed. Age-dependent increased Pb levels in the muscle and liver were reported in 6-7-month-old, <3-4-year-old, <5-6-year-old males. Similar relationships were confirmed for Zn in the bucks' muscles. In the group of does, the increase in heavy metal concentrations with aging was observed for Zn in the muscle and for Pb in the liver. In the other cases, the trend of age-related level changes regarding heavy metals was not clearly demonstrated. Significant positive correlations between Cu and Cd were found for all samples, and significant negative correlations of Cu with Pb were found for the hair and liver. There was a negative correlation of Zn with Cu in all matrices. The study also revealed a negative correlation between Zn and Pb in muscle and a strong significant negative correlation between Zn and Cd in hair and in the liver.

Recruitment and Retention of Parents of Adolescents in a Text Messaging Trial (MyTeen): Secondary Analysis From a Randomized Controlled Trial.

BACKGROUND: Parenting programs are well established as an effective strategy for enhancing both parenting skills and the well-being of the child. However, recruitment for family programs in clinical and nonclinical settings remains low. OBJECTIVE: This study aims to describe the recruitment and retention methods used in a text messaging program (MyTeen) trial for parents of adolescents (10-15 years) and identify key lessons learned. We aim to provide insights and direction for researchers who seek to recruit parents and build on the limited literature on recruitment and retention strategies for parenting program trials. METHODS: A recruitment plan was developed, monitored, and modified as needed throughout the course of the project. Strategies to facilitate recruitment were identified (eg, program content and recruitment material, staff characteristics, and study procedures). Traditional and web-based recruitment strategies were used. RESULTS: Over a 5-month period, 319 parents or caregivers expressed interest in our study, of which 221 agreed to participate in the study, exceeding our recruitment target of 214 participants. Attrition was low at the 1-month (4.5% overall; intervention group: n=5, 4.6%; control group: n=5, 4.5%) and 3-month follow-ups (9% overall; intervention group: n=10, 9.2%; control group: n=10, 8.9%). CONCLUSIONS: The use of web-based recruitment strategies appeared to be most effective for recruiting and retaining parents in a text-messaging program trial. However, we encountered recruitment challenges (ie, underrepresentation of ethnic minority groups and fathers) similar to those reported in the literature. Therefore, efforts to engage ethnic minorities and fathers are needed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000117213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374307.

Spermatozoon head size - the main differentiating feature between spermatozoa of blue and white Arctic fox (Vulpes lagopus).

Morphology and sperm morphometry, this is an important determinant of male reproductive capacity. Morphometric data may provide relevant information in studies focused on evolutionary biology, sperm quality assessment, including prediction of the potential fertility, semen cryopreservation, or the effect of reprotoxicants. The paper presents the morphometric analysis of spermatozoa from two colour morphs of Arctic fox (Vulpes lagopus), and attempts to determine the relationship between selected quality indicators and dimensions and shape of spermatozoa. The research material consisted of ejaculates collected once by manual stimulation from 20 one-year-old Arctic foxes (10 individuals of the blue morph and 10 of the white morph). Ejaculates were analysed for standard parameters (volume, sperm concentration, total number of spermatozoa in the ejaculate) and used for the preparation of microscopic specimens. It was found that, the dimensions of spermatozoa from Arctic foxes depend on the male colour morphs. Spermatozoa from white Arctic foxes were significantly longer (by 1.82 µm) and had larger heads (0.32 µm longer and 0.15 µm wider) compared to spermatozoa from blue Arctic foxes (P<0.05). The interactions between particular sperm dimensions indicated the occurrence of gametes differing in shape. The all correlation coefficients between the morphometric traits of spermatozoa were statistically significant. Our research proved that in the blue Arctic foxes, sperm dimensions (tail length and total sperm length) can be related to the percentage of spermatozoa with primary changes (respectively: r = -0.68 and r = -0.75; at P <0.05). However, in the case of white Arctic foxes, these characteristics depend on the ejaculate volume (respectively: r = 0.65 and r = 0.68; at P <0.05).

Effects of Probiotics, Prebiotics and Synbiotics Injected in Ovo on the Microstructure of the Breast Muscle in Different Chicken Genotypes.

The aim of the study was to analyse the effect of probiotics, prebiotics and synbiotics injected in ovo on day 12 of embryonic development on the microstructure of the superficial pectoral muscle (musculus pectoralis superficialis) from 42-day-old chickens of different genotypes: broilers (Ross 308) and general-purpose type (green-legged partridge (GP) chickens Zk-11, native chickens). Incubated eggs were divided into four groups (each genotype separately) depending on the substance injected in ovo: normal saline (C, control); Lactococcus lactis subsp. cremoris (PRO); galactooligosaccharides, GOS (PRE) or GOS + L. lactis (SYN). After hatching, chicks were placed in eight replicated pens (four pens/genotype group). There were eight birds per pen. In total, 64 birds were used in the experiment. Birds were slaughtered at the age of 42 days, and samples of superficial pectoral muscles were taken for analysis. The microstructure of the pectoral muscles was evaluated using the cryosectioning (frozen tissue sectioning) technique and staining with haematoxylin and eosin. Statistical analysis revealed that the in ovo injection of probiotics, prebiotics and synbiotics had no significant effect on the diameter of muscle fibres from chickens of the two genotypes. The number of fibres in the muscles from green-legged partridge chickens was about three-fold higher than the fibre density in the muscles from broiler chickens, with the fibre diameter being two-fold smaller. This fact may indicate a greater tenderness of meat from GP chickens compared to the meat from Ross 308 broilers. In the case of broilers, a prebiotic (GOS) was the most effective bioactive substance in reducing the number of histopathological changes. Considering muscles from GP chickens, the number of normal fibres was highest in birds treated with the probiotic. These findings indicate that the microstructural features of pectoral muscles depend not only on the type of the injected bioactive substance but also on the genotype of chickens.

A Cognitive Behavioral Therapy-, Biofeedback-, and Game-Based eHealth Intervention to Treat Anxiety in Children and Young People With Long-Term Physical Conditions (Starship Rescue): Co-design and Open Trial.

BACKGROUND: Approximately 10%-12% of New Zealand children and young people have long-term physical conditions (chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse health care and poorer long-term outcomes. Recently, eHealth interventions, especially those based on principles of cognitive behavioral therapy and biofeedback, have been shown to be moderately effective in reducing anxiety. However, these modalities have rarely been combined. Young people have expressed a preference for well-designed and technology-based support to deal with psychological issues. OBJECTIVE: This study aims to co-design and evaluate the acceptability and usability of a cognitive behavioral therapy and biofeedback-based, 5-module eHealth game called Starship Rescue and to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions. METHODS: Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in New Zealand. Following this, 24 others aged 10-17 years participated in an open trial of the game, accessing it over an 8-week period. The acceptability of the game to all participants was assessed using a brief, open-ended questionnaire. More detailed feedback was obtained from a subset of 10 participants via semistructured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale. Anxiety levels were measured at baseline, completion, and 3 months after completion of the game using the Generalized Anxiety Disorder 7-item scale and Spence Child Anxiety Scale, and at the start of each module and on completion using an embedded Likert visual analog scale. Quality of life was measured at baseline, completion, and 3 months after completion using the Pediatric Quality of Life Inventory scale. RESULTS: Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10) and a mean score of 71 out of 100 (SD 11.7; minimum 47.5; maximum 90) on the System Usability Scale. The mean period for the use of the game was just over 11 weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder 7-item scale (-4.6; P<.001), Spence Child Anxiety Scale (-9.6; P=.005), and the Likert visual analog scales (-2.4; P=.001). Quality of life also improved on the Pediatric Quality of Life Inventory scale (+4.3; P=.04). All changes were sustained at the 3-month follow-up. CONCLUSIONS: This study provides preliminary evidence for Starship Rescue as an acceptable, usable, and effective eHealth intervention for treating anxiety in young people with long-term physical conditions. Further evaluation is planned via a randomized controlled trial. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Network Registry (ANZCTR) ACTRN12616001253493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443.

Evidence for the Effectiveness and Acceptability of e-SBI or e-SBIRT in the Management of Alcohol and Illicit Substance Use in Pregnant and Post-partum Women.

Alcohol and illicit psychoactive drug use during pregnancy have increased worldwide, putting women and their children's health and development at risk. Multiple drug use, comorbid psychiatric disorders, sexual and physical abuse are common in women who use alcohol and drugs during pregnancy. The effects on the mother include poor reproductive and life-long health, legal, family, and social problems. Additionally, the exposed child is at increased risk of long-term physical health, mental health, and developmental problems. The stigma associated with substance use during pregnancy and some clinicians' reticence to inquire about substance use means many women are not receiving adequate prenatal, substance abuse, and mental health care. Evidence for mHealth apps to provide health care for pregnant and post-partum women reveal the usability and effectiveness of these apps to reduce gestational weight gain, improve nutrition, promote smoking cessation and manage gestational diabetes mellitus, and treat depression and anxiety. Emerging evidence suggests mHealth technology using a public health approach of electronic screening, brief intervention, or referral to treatment (e-SBIRT) for substance use or abuse can overcome the typical barriers preventing women from receiving treatment for alcohol and drug use during pregnancy. This brief intervention delivered through a mobile device may be equally effective as SBIRT delivered by a health care professional in preventing maternal drug use, minimizing the effects to the exposed child, and providing a pathway to therapeutic options for a substance use disorder. However, larger studies in more diverse settings with women who have co-morbid mental illness and a constellation of social risk factors that are frequently associated with substance use disorders are needed.

"Just Be Strong, You Will Get through It" a Qualitative Study of Young Migrants' Experiences of Settling in New Zealand.

Migration, when it occurs during adolescence, is particularly challenging as it coincides with a myriad of other developmental and social changes. The present study set out to explore recent young migrants' experiences of settling in New Zealand. The qualitative study aimed to identify areas of particular challenge, examples of resilience and new insights into the acculturation process. Focus group interviews were conducted with migrant youth aged 16-19 from three urban secondary schools in Auckland The interviews were audio-recorded, transcribed and analyzed using a general inductive method. Key themes centered on new beginnings, confronting new realities, acceptance, support seeking and overcoming challenges. Young migrants in this study shared similar challenges during the early post-migration period. They were often faced with additional responsibility, being caught between two cultures while struggling with communication and language. However, they were able to draw on their own self-growth, gratitude, and social connections. This study provides an insight into experiences of young migrants in New Zealand, and offers suggestions for developing culturally relevant support to foster migrant youth wellbeing.

Intersex adolescents seeking help for their depression: the case study of SPARX in New Zealand.

OBJECTIVE: SPARX is a computerized cognitive behavioral therapy self-help program for adolescent depression that is freely available in New Zealand. At registration, users identify themselves as either male, female, intersex, or transgender. We aimed to describe the mental health of adolescent intersex users. METHOD: A secondary analysis of SPARX usage data over 5 years. RESULTS: Of the 8922 adolescents users, 0.6% (n = 50) identified as intersex. Based on Patient Health Questionnaire 9 - modified for Adolescents (PHQ-A) results, 78.3% of intersex users had high levels of depression and/or self-harm and suicidal ideation. The mean PHQ-A scores for intersex users were significantly higher than for males and females (p < .001). As only three intersex users completed SPARX Level 4 or more (of the seven-level program), we were unable to meaningfully investigate any reductions in their depressive symptoms over time. CONCLUSIONS: There is a dearth of empirical data on the mental health of intersex adolescents. These results suggest that intersex adolescents seeking help from an online resource have high mental health needs compared with other young people, possibly because they defer seeking help.

Technology Matters: SPARX - computerised cognitive behavioural therapy for adolescent depression in a game format.

Adolescent depression is common, and its prevalence is thought to be increasing in many high income nations. Addressing adolescent depression has proven challenging using traditional face-to-face psychotherapies, with major barriers including workforce shortages internationally and reluctance to seek help among some adolescents. There is substantial evidence to support the use of digital tools to treat mental health problems, with the National Institute for Health and Care Excellence (NICE) now recommending such tools as a first-line treatment. In this article, we outline the evidence base for SPARX, a digital tool named specifically in NICE guideline NG134, and discuss its use in clinical settings. We also consider implementation issues and future research directions.

Computerized cognitive behavioural therapy for gender minority adolescents: Analysis of the real-world implementation of SPARX in New Zealand.

OBJECTIVE: SPARX is a form of computerized cognitive behavioural therapy in serious game format funded via the Ministry of Health to be freely available in New Zealand. At registration users identify themselves as male, female, transgender or intersex. We aimed to establish whether adolescent transgender users of SPARX, compared to adolescent male and female users, were more likely to have high mental health needs at baseline and were more likely to complete SPARX. We also sought to determine changes in transgender adolescents' depressive symptoms after using SPARX. METHODS: Quantitative analysis of 5 years of usage data from the nation-wide delivery of SPARX in New Zealand. RESULTS: There were 9079 adolescents who completed the registration process and used SPARX, 2.3% (n = 207) identified as transgender. The majority of transgender registrants (69.0%) completing a baseline Patient Health Questionnaire - modified for Adolescents were categorized as having high mental health needs, significantly more so than male and female registrants (p < 0.001). Over half of all SPARX registrants completed the first module of the program, with subsequently lower proportions of transgender registrants completing Module 4 (p = 0.005) and Module 7 (i.e. the last module, p = 0.048). Of those registrants completing a baseline and subsequent Patient Health Questionnaire - modified for Adolescents, both male (n = 247) and female (n = 630) registrants, on average, had improvements in their scores (2.68 and 3.15, respectively), whereas transgender registrants (n = 14) did not (-0.43) (p = 0.048). CONCLUSION: This is the first study describing the impact of an e-therapy on transgender young people. The analysis of data from this free self-help intervention suggests that transgender adolescents seeking treatment for depression have particularly high mental health needs, and an existing well tested tool may be less effective for them than it is for others. Taken together the results appear to suggest targeted efforts may be required for transgender adolescents.

Debate: Supporting the mental health of school students in the COVID-19 pandemic in New Zealand - a digital ecosystem approach.

The pandemic is creating unprecedented demand for mental health support for young people. While schools often facilitate mental health support for their students, the demands for online teaching and the uncertainty created by the pandemic make traditional delivery of support through schools challenging. Technology provides a potential way forward. We have developed a digital ecosystem, HABITS, that can be integrated into school and healthcare systems. This has allowed us to deploy specific evidence-based interventions directly, and through schools, to students and to parents in New Zealand during the current pandemic. Chatbot architecture is particularly suited to rapid iteration to provide specific information while apps can provide more generalised support. While technology can provide some solutions, it is important to be aware of the potential to increase current inequities, with those facing the greatest challenges to health and well-being, also least able to afford the resources to access digital interventions. Development of an integrated and equitable digital system will take time and collaboration.

Effect of Clinician Training in the Modular Approach to Therapy for Children vs Usual Care on Clinical Outcomes and Use of Empirically Supported Treatments: A Randomized Clinical Trial.

Importance: The Modular Approach to Therapy for Children (MATCH) was developed to address the comorbidities common among clinically referred youth, with beneficial outcomes shown in 2 US randomized clinical trials, where it outperformed both usual clinical care and single disorder-specific treatments. Objective: To determine whether MATCH training of clinicians would result in more use of empirically supported treatment (EST) and better clinical outcomes than usual care (UC) in the publicly funded, multidisciplinary context of New Zealand. Design, Setting, and Participants: This multisite, single-blind, computer-randomized clinical effectiveness trial compared MATCH with UC in child and adolescent mental health services in 5 regions of New Zealand. Recruitment occurred from March 2014 to July 2015, and a 3-month follow-up assessment was completed by May 2016. Clinicians at participating child and adolescent mental health services were randomized (1:1) to undertake training in MATCH or to deliver UC, and young people with anxiety, depression, trauma-related symptoms, or disruptive behavior seeking treatment at child and adolescent mental health services were randomized (1:1) to receive MATCH or UC. Participants and research assistants were blind to allocation. Data analysis was performed from April 2016 to July 2017. Interventions: MATCH comprises EST components for flexible management of common mental health problems. UC includes case management and psychological therapies. Both can include pharmacotherapy. Main Outcomes and Measures: There were 3 primary outcomes: trajectory of change of clinical severity, as measured by weekly ratings on the Brief Problem Monitor (BPM); fidelity to EST content, as measured by audio recordings of therapy sessions coded using the Therapy Integrity in Evidence Based Interventions: Observational Coding System; and efficiency of service delivery, as measured by duration of therapy (days) and clinician time (minutes). Results: The study included 65 clinicians (mean age, 38.7 years; range, 23.0-64.0 years; 54 female [83%]; MATCH, 32 clinicians; UC, 33 clinicians) and 206 young people (mean age, 11.2 years; range 7.0-14.0 years; 122 female [61%]; MATCH, 102 patients; UC, 104 patients). For the BPM total ratings for parents, there was a mean (SE) slope of -1.04 (0.14) (1-year change, -6.12) in the MATCH group vs -1.04 (0.10) (1-year change, -6.17) in the UC group (effect size, 0.00; 95% CI, -0.27 to 0.28; P = .96). For the BPM total for youths, the mean (SE) slope was -0.74 (0.15) (1-year change, -4.35) in the MATCH group vs -0.73 (0.10) (1-year change, -4.32) in the UC group (effect size, -0.02; 95% CI, -0.30 to 0.26; P = .97). Primary analyses (intention-to-treat) showed no difference in clinical outcomes or efficiency despite significantly higher fidelity to EST content in the MATCH group (58 coded sessions; mean [SD], 80.0% [20.0%]) than the UC group (51 coded sessions; mean [SD], 57.0% [32.0%]; F(1,108) = 23.0; P < .001). With regard to efficiency of service delivery, there were no differences in total face-to-face clinician time between the MATCH group (mean [SD], 806 [527] minutes) and the UC group (mean [SD], 677 [539] minutes) or the overall duration of therapy between the MATCH group (mean [SD], 167 [107 days]) and the UC group (mean [SD], 159 [107] days). Conclusions and Relevance: MATCH significantly increased adherence to EST practices but did not improve outcomes or efficiency. The nonsuperiority of MATCH may be attributable to high levels of EST use in UC in New Zealand. Trial Registration: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12614000297628.

Practitioner review: Co-design of digital mental health technologies with children and young people.

BACKGROUND: There is increasing interest in digital technologies to help improve children and young people's mental health, and the evidence for the effectiveness for these approaches is rising. However, there is concern regarding levels of user engagement, uptake and adherence. Key guidance regarding digital health interventions stress the importance of early user input in the development, evaluation and implementation of technologies to help ensure they are engaging, feasible, acceptable and potentially effective. Co-design is a process of active involvement of stakeholders, requiring a change from the traditional approaches to intervention development. However, there is a lack of literature to inform the co-design of digital technologies to help child and adolescent mental health. METHODS: We reviewed the literature and practice in the co-design of digital mental health technologies with children and young people. We searched Medline, PsycInfo and Web of Science databases, guidelines, reviews and reference lists, contacted key authors for relevant studies, and extracted key themes on aspects of co-design relevant to practice. We supplemented this with case studies and methods reported by researchers working in the field. RESULTS: We identified 25 original articles and 30 digital mental health technologies that were designed/developed with children and young people. The themes identified were as follows: principles of co-design (including potential stakeholders and stages of involvement), methods of involving and engaging the range of users, co-designing the prototype and the challenges of co-design. CONCLUSIONS: Co-design involves all relevant stakeholders throughout the life and research cycle of the programme. This review helps to inform practitioners and researchers interested in the development of digital health technologies for children and young people. Future work in this field will need to consider the changing face of technology, methods of engaging with the diversity in the user group, and the evaluation of the co-design process and its impact on the technology.