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.

Applying the Theoretical Domains Framework to Develop an Intervention to 'Re-implement' Parent-Child Interaction Therapy (PCIT).

Parent-Child Interaction Therapy (PCIT) is an empirically supported treatment for childhood conduct problems, with increasing numbers of clinicians being trained in Aotearoa/New Zealand. However, ensuring sustained delivery of effective treatments by trained clinicians in routine care environments is notoriously challenging. The aims of this qualitative study were to (1) systematically examine and prioritise PCIT implementation barriers and facilitators, and (2) develop a well specified and theory-driven 're-implementation' intervention to support already-trained clinicians to resume or increase their implementation of PCIT. To triangulate and refine existing understanding of PCIT implementation determinants from an earlier cross-sectional survey, we integrated previously unanalysed qualitative survey data (54 respondents; response rate 60%) with qualitative data from six new focus groups with 15 PCIT-trained clinicians and managers in Aotearoa/New Zealand. We deductively coded data, using a directed content analysis process and the Theoretical Domains Framework, resulting in the identification of salient theoretical domains and belief statements within these. We then used the Theory and Techniques Tool to identify behaviour change techniques, possible intervention components, and their hypothesised mechanisms of action. Eight of the 14 theoretical domains were identified as influential on PCIT-trained clinician implementation behaviour (Knowledge; Social/Professional Role and Identity; Beliefs about Capabilities; Beliefs about Consequences; Memory, Attention and Decision Processes; Environmental Context and Resources; Social Influences; Emotion). Two of these appeared to be particularly salient: (1) 'Environmental Context and Resources', specifically lacking suitable PCIT equipment, with (lack of) access to a well-equipped clinic room appearing to influence implementation behaviour in several ways. (2) 'Social/Professional Role and Identity', with beliefs relating to a perception that colleagues view time-out as harmful to children, concerns that internationally-developed PCIT is not suitable for non-Maori clinicians to deliver to Indigenous Maori families, and clinicians feeling obligated yet isolated in their advocacy for PCIT delivery. In conclusion, where initial implementation has stalled or languished, re-implementation may be possible, and makes good sense, both fiscally and practically. This study suggests that re-implementation of PCIT in Aotearoa/New Zealand may be facilitated by intervention components such as ensuring access to a colleague or co-worker who is supportive of PCIT delivery, access to suitable equipment (particularly a time-out room), and targeted additional training for clinicians relating to the safety of time-out for children. The feasibility and acceptability of these intervention components will be tested in a future clinical trial.

Digital technologies to support adolescents with depression and anxiety: review.

Depression and anxiety are common in adolescents, but most affected will not get any formal help. Digital mental health technologies (i.e. resources and interventions to support and improve mental health) are a potential way to extend the reach and increase adolescents' access to therapies, at a relatively low cost. Many young people can access the internet and mobile technologies, including in low- and middle-income countries. There has been increased interest in integrating technologies in a range of settings, especially because of the effect of the COVID-19 pandemic on adolescent mental health, at a time when services are under pressure. This clinical review gives an overview of digital technologies to support the prevention and management of depression and anxiety in adolescence. The technologies are presented in relation to their technological approaches, underlying psychological or other theories, setting, development, evaluations to date and how they might be accessed. There is also a discussion of the potential benefits, challenges and future developments in this field.

Further development and feasibility randomised controlled trial of a digital programme for adolescent depression, MoodHwb: study protocol.

INTRODUCTION: A digital programme, MoodHwb, was codesigned with young people experiencing or at high risk of depression, parents/carers and professionals, to provide support for young people with their mood and well-being. A preliminary evaluation study provided support for the programme theory and found that MoodHwb was acceptable to use. This study aims to refine the programme based on user feedback, and to assess the acceptability and feasibility of the updated version and study methods. METHODS AND ANALYSIS: Initially, this study will refine MoodHwb with the involvement of young people, including in a pretrial acceptability phase. This will be followed by a multicentre feasibility randomised controlled trial comparing MoodHwb plus usual care with a digital information pack plus usual care. Up to 120 young people aged 13-19 years with symptoms of depression and their parents/carers will be recruited through schools, mental health services, youth services, charities and voluntary self-referral in Wales and Scotland. The primary outcomes are the feasibility and acceptability of the MoodHwb programme (including usage, design and content) and of trial methods (including recruitment and retention rates), assessed 2 months postrandomisation. Secondary outcomes include potential impact on domains including depression knowledge and stigma, help-seeking, well-being and depression and anxiety symptoms measured at 2 months postrandomisation. ETHICS AND DISSEMINATION: The pretrial acceptability phase was approved by the Cardiff University School of Medicine Research Ethics Committee (REC) and the University of Glasgow College of Medicine, Veterinary and Life Sciences REC. The trial was approved by Wales NHS REC 3 (21/WA/0205), the Health Research Authority(HRA), Health and Care Research Wales (HCRW), university health board Research and Development (R&D) departments in Wales, and schools in Wales and Scotland. Findings will be disseminated in peer-reviewed open-access journals, at conferences and meetings, and online to academic, clinical, and educational audiences and the wider public. TRIAL REGISTRATION NUMBER: ISRCTN12437531.

Protocol for a randomised pilot study of a novel Parent-Child Interaction Therapy (PCIT) 're-implementation' intervention.

BACKGROUND: Despite a number of clinicians having been trained in Parent-Child Interaction Therapy (PCIT) in Aotearoa/New Zealand, few are regularly delivering the treatment, with barriers to use including a lack of suitable equipment and lack of professional support. This pragmatic, parallel-arm, randomised, controlled pilot trial includes PCIT-trained clinicians who are not delivering, or only rarely utilising, this effective treatment. The study aims to assess the feasibility, acceptability and cultural responsivity of study methods and intervention components and to collect variance data on the proposed future primary outcome variable, in preparation for a future, larger trial. METHODS: The trial will compare a novel 're-implementation' intervention with a refresher training and problem-solving control. Intervention components have been systematically developed to address barriers and facilitators to clinician use of PCIT using implementation theory, and a draft logic model with hypothesised mechanisms of action, derived from a series of preliminary studies. The intervention includes complimentary access to necessary equipment for PCIT implementation (audio-visual equipment, a 'pop-up' time-out space, toys), a mobile senior PCIT co-worker and an optional weekly PCIT consultation group, for a 6-month period. Outcomes will include the feasibility of recruitment and trial procedures; acceptability of the intervention package and data collection methods to clinicians; and clinician adoption of PCIT. DISCUSSION: Relatively little research attention has been directed at interventions to resurrect stalled implementation efforts. Results from this pragmatic pilot RCT will refine and shape knowledge relating to what it might take to embed the ongoing delivery of PCIT in community settings, providing more children and families with access to this effective treatment. TRIAL REGISTRATION: ANZCTR, ACTRN12622001022752, registered on July 21, 2022.

Exploring the Acceptability, Feasibility, and Effectiveness of a Digital Parenting Program to Improve Parental Well-being After the Christchurch Earthquakes: Cluster-Randomized Trial.

BACKGROUND: Up to 6 years after the 2011 Christchurch earthquakes, approximately one-third of parents in the Christchurch region reported difficulties managing the continuously high levels of distress their children were experiencing. In response, an app named Kakano was co-designed with parents to help them better support their children's mental health. OBJECTIVE: The objective of this study was to evaluate the acceptability, feasibility, and effectiveness of Kakano, a mobile parenting app to increase parental confidence in supporting children struggling with their mental health. METHODS: A cluster-randomized delayed access controlled trial was carried out in the Christchurch region between July 2019 and January 2020. Parents were recruited through schools and block randomized to receive immediate or delayed access to Kakano. Participants were given access to the Kakano app for 4 weeks and encouraged to use it weekly. Web-based pre- and postintervention measurements were undertaken. RESULTS: A total of 231 participants enrolled in the Kakano trial, with 205 (88.7%) participants completing baseline measures and being randomized (101 in the intervention group and 104 in the delayed access control group). Of these, 41 (20%) provided full outcome data, of which 19 (18.2%) were for delayed access and 21 (20.8%) were for the immediate Kakano intervention. Among those retained in the trial, there was a significant difference in the mean change between groups favoring Kakano in the brief parenting assessment (F1,39=7, P=.012) but not in the Short Warwick-Edinburgh Mental Well-being Scale (F1,39=2.9, P=.099), parenting self-efficacy (F1,39=0.1, P=.805), family cohesion (F1,39=0.4, P=.538), or parenting sense of confidence (F1,40=0.6, P=.457). Waitlisted participants who completed the app after the waitlist period showed similar trends for the outcome measures with significant changes in the brief assessment of parenting and the Short Warwick-Edinburgh Mental Well-being Scale. No relationship between the level of app usage and outcome was found. Although the app was designed with parents, the low rate of completion of the trial was disappointing. CONCLUSIONS: Kakano is an app co-designed with parents to help manage their children's mental health. There was a high rate of attrition, as is often seen in digital health interventions. However, for those who did complete the intervention, there was some indication of improved parental well-being and self-assessed parenting. Preliminary indications from this trial show that Kakano has promising acceptability, feasibility, and effectiveness, but further investigation is warranted. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12619001040156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377824&isReview=true.

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.

Towards an International Consensus on the Prevention, Treatment, and Management of High-Risk Substance Use and Overdose among Youth.

Background and Objectives: Now more than ever, there is an obvious need to reduce the overall burden of disease and risk of premature mortality that are associated with mental health and substance use disorders among young people. However, the current state of research and evidence-based clinical care for high-risk substance use among youth is fragmented and scarce. The objective of the study is to establish consensus for the prevention, treatment, and management of high-risk substance use and overdose among youth (10 to 24 years old). Materials and Methods: A modified Delphi technique was used based on the combination of scientific evidence and clinical experience of a group of 31 experts representing 10 countries. A semi-structured questionnaire with five domains (clinical risks, target populations, intervention goals, intervention strategies, and settings/expertise) was shared with the panelists. Based on their responses, statements were developed, which were subsequently revised and finalized through three iterations of feedback. Results: Among the five major domains, 60 statements reached consensus. Importantly, experts agreed that screening in primary care and other clinical settings is recommended for all youth, and that the objectives of treating youth with high-risk substance use are to reduce harm and mortality while promoting resilience and healthy development. For all substance use disorders, evidence-based interventions should be available and should be used according to the needs and preferences of the patient. Involuntary admission was the only topic that did not reach consensus, mainly due to its ethical implications and resulting lack of comparable evidence. Conclusions: High-risk substance use and overdoses among youth have become a major challenge. The system's response has been insufficient and needs substantial change. Internationally devised consensus statements provide a first step in system improvement and reform.

Clinician adoption of Parent-Child Interaction Therapy: A systematic review of implementation interventions.

Background: Parent-Child Interaction Therapy (PCIT) is a parent training intervention for childhood conduct problems, distinctive in its use of live clinician coaching of the parent-child dyad via a one-way mirror and discrete earpiece. However, despite a compelling evidence base, uptake of evidence-based parent training programmes such as PCIT by clinicians in routine care settings remains poor. This systematic review aimed to identify and synthesise implementation interventions that have sought to increase clinician adoption of PCIT in usual care settings. Methods: We searched MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), CINAHL (EBSCO), Science Citation Index and Social Sciences Citation Index, and Web of Science Core Collection from inception to October 2020. Articles were included if they tested (by way of randomised controlled trials, controlled clinical trials, interrupted time series and controlled before and after trials) implementation interventions across any and all of the patient, clinician, clinic, system or policy domains. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data - summarising implementation intervention components according to items from the Template for Intervention Description and Replication (TIDieR) checklist ( Hoffmann et al., 2014). Results: Of the 769 articles identified once duplicates were removed, 13 papers relating to three studies met the inclusion criteria - all were quantitative or mixed-methods examinations of the effectiveness of different PCIT clinician training or training-related consultation methods. A narrative description of interventions was provided, as quantitative synthesis was not possible. Conclusions: Research attention has to date been focussed on the establishment of an evidence-base for PCIT's effectiveness, with relatively little attention to the dissemination, implementation and sustainment of this treatment. Those studies that do exist have focused on training methods and training-related expert consultation. Research attention could usefully turn to both adoption and sustainment of this effective treatment in usual care settings. Plain language summary: In this review, we aimed to summarise what is already known about how to implement PCIT in community settings after clinicians have received training in the approach. While research relating to the implementation of other parent training programmes is interesting and informative, implementation efforts are most effective when tailored to a specific programme in a specific context. As such, it was important to review published studies relating to PCIT specifically. We identified three relevant studies, one of which is yet to publish its main implementation findings. The three studies have focused on how best to train clinicians in PCIT, including how best to provide post-training support from expert trainers. We concluded that a fruitful line for future research would be to focus on the post-training period, particularly how best to support clinicians to adopt and sustain PCIT in their practice. Systematic review registration: The study was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 01/10/2020 (CRD42020207118).

Clinicians' experiences of inquiries following mental health related homicide: a qualitative study.

OBJECTIVES: This aim of this qualitative study was to explore the experiences of clinicians involved with inquiries into the mental health care of patients who were perpetrators of homicide in New Zealand. METHODS: Our purposive sample comprised ten clinicians working in New Zealand district health board mental health services. These clinicians were individually interviewed. Interviews were audio-recorded, transcribed and thematically analysed. The coding framework was checked and peer reviewed by an independent researcher. RESULTS: Five themes were identified: the inquiry process; emotional burden; impact on team dynamics; changes to individual clinical practice; and perceptions of inquiries being influenced by organisational culture. Clinicians involved with inquiries reported significant anxiety and disrupted multidisciplinary team dynamics. Some participants found inquiries led to changes to their clinical practice and perceived that a punitive organisational culture limited learning. CONCLUSIONS: Clinicians perceived inquiries as threatening, anxiety provoking and primarily concerned with protecting organisational interests. Communication of the inquiry process and ensuring inquiry findings are disseminated may enhance clinicians' experiences of inquiries and facilitate their participation and their reflection on changes to clinical practice that could contribute to improving services. Support for clinicians and multidisciplinary teams should be emphasised by the commissioning agency.

Barriers to Clinician Implementation of Parent-Child Interaction Therapy (PCIT) in New Zealand and Australia: What Role for Time-Out?

BACKGROUND: Parent-Child Interaction Therapy (PCIT) is an effective parent training approach for a commonly occurring and disabling condition, namely conduct problems in young children. Yet, despite ongoing efforts to train clinicians in PCIT, the intervention is not widely available in New Zealand and Australia. METHODS: We undertook a cross-sectional online survey of clinicians in New Zealand and Australia who had completed at least the 40-h initial PCIT training, to understand the barriers they encountered in their implementation efforts, and the extent to which attitudes toward time-out influenced implementation. The overall response rate was 47.5% (NZ: 60%; Australia: 31.4%). RESULTS: Responses suggested that participants generally viewed PCIT as both acceptable and effective. Australian participants reported seeing significantly more clients for PCIT per week than those in NZ (Medians 0 and 2, respectively; χ2(1) = 14.08, p < 0.001) and tended to view PCIT as more effective in treating disruptive and oppositional behaviour (95% CI: -0.70, -0.13, p = 0.005). Participants currently seeing PCIT clients described it as more enjoyable to implement than those not using PCIT (95% CI: -0.85, -0.10, p = 0.01). Thirty-eight percent of participants indicated that they adapt or tailor the standardised protocol, primarily by adding in content relating to emotion regulation, and removing content relating to time-out. Participants generally felt that they had fewer skills, less knowledge, and less confidence relating to the Parent-Directed Interaction phase of PCIT (which involves time-out), compared with the Child-Directed Interaction phase. CONCLUSION: While we had hypothesised that time-out represented an intra-intervention component that detracted from implementation success, results suggested that clinician concern over the use of time-out was present but not prominent. Rather, the lack of access to suitable equipment (i.e., one-way mirror and ear-piece) and difficulties associated with clients attending clinic-based sessions were barriers most commonly reported by clinicians. We suggest that future research might consider whether and how PCIT might be "re-implemented" by already-trained clinicians, moving beyond simply training more clinicians in the approach.

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.

Editorial: Are our kids getting a fair deal?

With the patchy but increasing roll-out of the COVID-19 vaccine, and as the world begins to emerge in a bumpy fashion from strict lock-downs, the frightening experience of overwhelmed hospitals and alarmingly high mortality rates from COVID-19, we are beginning to take stock of the huge toll from the pandemic. One of the oft-voiced concerns is the impact on mental health, particularly for vulnerable children and adolescents, but how much of a problem is there really? Are we facing a crisis?

Editorial: Optimizing Depression Prevention: The Way Forward?

Since the advent of cognitive-behavioral therapy (CBT) and interpersonal therapy in the 1960s and 1970s, the progress on "talking therapies" has been slow. An extensive review of prevention and treatment studies over the past 50 years has shown that, although the therapies are effective, for depression the effect size is moderate, even for treatment, and has not changed in 50 years,1 with some indication that efficacy may have decreased.2 The approaches used in treatment have also been the mainstay of depression prevention approaches,3,4 with evidence of a small-to-moderate reduction in depressive symptoms but with no convincing evidence of reduction in the incidence of depressive disorder in meta-analyses.3,4.

The conduct of inquiries: a qualitative study of the perspectives of panel members who investigate mental health related homicide.

BACKGROUND: Inquiries into mental health related homicides may be held to identify failures in care and areas for improvement, accountability and to enhance public confidence. However, inquiries do not always achieve these aims. AIM: The aim of this study was to explore the perspectives of members of inquiry panels who conduct inquiries into mental health related homicides in order to identify elements that would constitute a good inquiry. METHODS: We selected a sample of inquiry panel members comprising 15 senior clinicians, legal experts and consumer advisors. Semi-structured interviews were audio-recorded, transcribed and analysed using thematic analysis. RESULTS: Participants raised concerns related to: (1) orientation of the panel to the inquiry task; (2) clarity of the process; and (3) impact of the inquiry. Most participants recognised that inquiries require a focus on mental health systems and sensitivity to families and clinicians. They reported difficulties in clarifying purposes, attending to cultural aspects of the case, having a clear method tailored to the mental health context, formulating recommendations and disseminating findings. CONCLUSIONS: Our participants perceived a number of weaknesses in the process by which inquiries into mental health related homicides had been conducted, and recommendations formulated and implemented. There is an opportunity to address these and thereby potentially improve the effectiveness and value of inquiries.

New generation antidepressants for depression in children and adolescents: a network meta-analysis.

BACKGROUND: Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well-being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications. OBJECTIVES: To investigate, via network meta-analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide-related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician-rated depression (CDRS-R) and suicide-related outcomes. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020. SELECTION CRITERIA: Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs). DATA COLLECTION AND ANALYSIS: Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self-rated), functioning, suicide related outcomes and overall adverse outcomes. Random-effects network meta-analyses were conducted in a frequentist framework using multivariate meta-analysis. Certainty of evidence was assessed using Confidence in Network Meta-analysis (CINeMA). We used "informative statements" to standardise the interpretation and description of the results. MAIN RESULTS: Twenty-six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a "small and unimportant" reduction in depression symptoms on the CDRS-R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD -1.43, 95% CI -3.90, 1.04; vilazodone: MD -0.84, 95% CI -3.03, 1.35; desvenlafaxine MD -0.07, 95% CI -3.51, 3.36; moderate certainty evidence: sertraline: MD -3.51, 95% CI -6.99, -0.04; fluoxetine: MD -2.84, 95% CI -4.12, -1.56; escitalopram: MD -2.62, 95% CI -5.29, 0.04; low certainty evidence: duloxetine: MD -2.70, 95% CI -5.03, -0.37; vortioxetine: MD 0.60, 95% CI -2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were "small and unimportant" differences between most antidepressants in reduction of depression symptoms (high- or moderate-certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self-harm or suicide was an exclusion criterion for the study. Proportions of suicide-related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide-related outcomes compared with placebo. There is low certainty evidence that escitalopram may "at least slightly" reduce odds of suicide-related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may "at least slightly" increase odds of suicide-related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an "at least slightly" increased odds of suicide-related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants. AUTHORS' CONCLUSIONS: Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first-line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide-related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important.

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.