A Novel Blended Transdiagnostic Intervention (eOrygen) for Youth Psychosis and Borderline Personality Disorder: Uncontrolled Single-Group Pilot Study.

BACKGROUND: Integrating innovative digital mental health interventions within specialist services is a promising strategy to address the shortcomings of both face-to-face and web-based mental health services. However, despite young people's preferences and calls for integration of these services, current mental health services rarely offer blended models of care. OBJECTIVE: This pilot study tested an integrated digital and face-to-face transdiagnostic intervention (eOrygen) as a blended model of care for youth psychosis and borderline personality disorder. The primary aim was to evaluate the feasibility, acceptability, and safety of eOrygen. The secondary aim was to assess pre-post changes in key clinical and psychosocial outcomes. An exploratory aim was to explore the barriers and facilitators identified by young people and clinicians in implementing a blended model of care into practice. METHODS: A total of 33 young people (aged 15-25 years) and 18 clinicians were recruited over 4 months from two youth mental health services in Melbourne, Victoria, Australia: (1) the Early Psychosis Prevention and Intervention Centre, an early intervention service for first-episode psychosis; and (2) the Helping Young People Early Clinic, an early intervention service for borderline personality disorder. The feasibility, acceptability, and safety of eOrygen were evaluated via an uncontrolled single-group study. Repeated measures 2-tailed t tests assessed changes in clinical and psychosocial outcomes between before and after the intervention (3 months). Eight semistructured qualitative interviews were conducted with the young people, and 3 focus groups, attended by 15 (83%) of the 18 clinicians, were conducted after the intervention. RESULTS: eOrygen was found to be feasible, acceptable, and safe. Feasibility was established owing to a low refusal rate of 25% (15/59) and by exceeding our goal of young people recruited to the study per clinician. Acceptability was established because 93% (22/24) of the young people reported that they would recommend eOrygen to others, and safety was established because no adverse events or unlawful entries were recorded and there were no worsening of clinical and social outcome measures. Interviews with the young people identified facilitators to engagement such as peer support and personalized therapy content, as well as barriers such as low motivation, social anxiety, and privacy concerns. The clinician focus groups identified evidence-based content as an implementation facilitator, whereas a lack of familiarity with the platform was identified as a barrier owing to clinicians' competing priorities, such as concerns related to risk and handling acute presentations, as well as the challenge of being understaffed. CONCLUSIONS: eOrygen as a blended transdiagnostic intervention has the potential to increase therapeutic continuity, engagement, alliance, and intensity. Future research will need to establish the effectiveness of blended models of care for young people with complex mental health conditions and determine how to optimize the implementation of such models into specialized services.

The Cost-Effectiveness of a Novel Online Social Therapy to Maintain Treatment Effects From First-Episode Psychosis Services: Results From the Horyzons Randomized Controlled Trial.

BACKGROUND: Digital interventions have potential applications in promoting long-term recovery and improving outcomes in first-episode psychosis (FEP). This study aimed to evaluate the cost-effectiveness of Horyzons, a novel online social therapy to support young people aged 16-27 years following discharge from FEP services, compared with treatment as usual (TAU) from a healthcare sector and a societal perspective. STUDY DESIGN: A cost-effectiveness analysis (CEA), based on the change in social functioning, and a cost-utility analysis (CUA) using quality-adjusted life years were undertaken alongside a randomized controlled trial. Intervention costs were determined from study records; resources used by patients were collected from a resource-use questionnaire and administrative data. Mean costs and outcomes were compared at 18 months and incremental cost-effectiveness ratios were calculated. Uncertainty analysis using bootstrapping and sensitivity analyses was conducted. STUDY RESULTS: The sample included 170 participants: Horyzons intervention group (n = 86) and TAU (n = 84). Total costs were significantly lower in the Horyzons group compared with TAU from both the healthcare sector (-AU$4789.59; P < .001) and the societal perspective (-AU$5131.14; P < .001). In the CEA, Horyzons was dominant, meaning it was less costly and resulted in better social functioning. In the CUA, the Horyzons intervention resulted in fewer costs but also yielded fewer QALYs. However, group differences in outcomes were not statistically significant. When young people engaged more with the platform, costs were shown to decrease and outcomes improved. CONCLUSIONS: The Horyzons intervention offers a cost-effective approach for improving social functioning in young people with FEP after discharge from early intervention services.

A Personalized, Transdiagnostic Smartphone Intervention (Mello) Targeting Repetitive Negative Thinking in Young People With Depression and Anxiety: Pilot Randomized Controlled Trial.

BACKGROUND: Repetitive negative thinking (RNT) is a key transdiagnostic mechanism underpinning depression and anxiety. Using "just-in-time adaptive interventions" via smartphones may disrupt RNT in real time, providing targeted and personalized intervention. OBJECTIVE: This pilot randomized controlled trial evaluates the feasibility, acceptability, and preliminary clinical outcomes and mechanisms of Mello-a fully automated, personalized, transdiagnostic, and mechanistic smartphone intervention targeting RNT in young people with depression and anxiety. METHODS: Participants with heightened depression, anxiety, and RNT were recruited via social media and randomized to receive Mello or a nonactive control over a 6-week intervention period. Assessments were completed via Zoom sessions at baseline and at 3 and 6 weeks after baseline. RESULTS: The findings supported feasibility and acceptability, with high rates of recruitment (N=55), uptake (55/64, 86% of eligible participants), and retention (52/55, 95% at 6 weeks). Engagement was high, with 90% (26/29) and 59% (17/29) of the participants in the Mello condition still using the app during the third and sixth weeks, respectively. Greater reductions in depression (Cohen d=0.50), anxiety (Cohen d=0.61), and RNT (Cohen d=0.87) were observed for Mello users versus controls. Mediation analyses suggested that changes in depression and anxiety were accounted for by changes in RNT. CONCLUSIONS: The results indicate that mechanistic, targeted, and real-time technology-based solutions may provide scalable and effective interventions that advance the treatment of youth mental ill health. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621001701819; http://tinyurl.com/4d3jfj9f.

Developing a Theory of Change for a Digital Youth Mental Health Service (Moderated Online Social Therapy): Mixed Methods Knowledge Synthesis Study.

BACKGROUND: Common challenges in the youth mental health system include low access, poor uptake, poor adherence, and limited overall effectiveness. Digital technologies offer promise, yet challenges in real-world integration and uptake persist. Moderated Online Social Therapy (MOST) aims to overcome these problems by integrating a comprehensive digital platform into existing youth mental health services. Theory of change (ToC) frameworks can help articulate how and why complex interventions work and what conditions are required for success. OBJECTIVE: The objective of this study is to create a ToC for MOST to explain how it works, why it works, who benefits and how, and what conditions are required for its success. METHODS: We used a multimethod approach to construct a ToC for MOST. The synthesis aimed to assess the real-world impact of MOST, a digital platform designed to enhance face-to-face youth mental health services, and to guide its iterative refinement. Data were gathered from 2 completed and 4 ongoing randomized controlled trials, 11 pilot studies, and over 1000 co-design sessions using MOST. Additionally, published qualitative findings from diverse clinical contexts and a review of related digital mental health literature were included. The study culminated in an updated ToC framework informed by expert feedback. The final ToC was produced in both narrative and table form and captured components common in program logic and ToC frameworks. RESULTS: The MOST ToC captured several assumptions about digital mental health adoption, including factors such as the readiness of young people and service providers to embrace digital platforms. External considerations included high service demand and a potential lack of infrastructure to support integration. Young people and service providers face several challenges and pain points MOST seeks to address, such as limited accessibility, high demand, poor engagement, and a lack of personalized support. Self-determination theory, transdiagnostic psychological treatment approaches, and evidence-based implementation theories and their associated mechanisms are drawn upon to frame the intervention components that make up the platform. Platform usage data are captured and linked to short-, medium-, and long-term intended outcomes, such as reductions in mental health symptoms, improvements in functioning and quality of life, reductions in hospital visits, and reduced overall mental health care costs. CONCLUSIONS: The MOST ToC serves as a strategic framework for refining MOST over time. The creation of the ToC helped guide the development of therapeutic content personalization, user engagement enhancement, and clinician adoption through specialized implementation frameworks. While powerful, the ToC approach has its limitations, such as a lack of standardized methodology and the amount of resourcing required for its development. Nonetheless, it provides an invaluable roadmap for iterative development, evaluation, and scaling of MOST and offers a replicable model for other digital health interventions aiming for targeted, evidence-based impact.

An exploration of the relationship between voices, dissociation, and post-traumatic stress disorder symptoms.

OBJECTIVES: Extensive research has shown voice hearing to be associated with symptoms of Post-Traumatic Stress Disorder (PTSD) and dissociation. However, most studies have adopted a quantitative design, using cross-sectional data sampling methods, precluding temporal relationships between variables from being defined. DESIGN: Using a qualitative design, this study sought to identify potential symptom relationships by addressing the research question: what is the nature of the temporal relationship between voices, dissociation and PTSD symptoms? METHODS: Seven voice hearers (aged 27 to 68 years) participated in a semi-structured interview exploring voice hearing, PTSD symptoms, and dissociation. The interviews were analysed using Interpretative Phenomenological Analysis. RESULTS: One superordinate theme was identified in the data. Voices were observed to occur in dynamic interrelationship with PTSD symptoms and dissociation, and were frequently experienced before and after PTSD symptoms and dissociative episodes. CONCLUSIONS: Implications for theoretical understandings of voice hearing and future research are discussed.

Understanding What Drives Long-term Engagement in Digital Mental Health Interventions: Secondary Causal Analysis of the Relationship Between Social Networking and Therapy Engagement.

BACKGROUND: Low engagement rates with digital mental health interventions are a major challenge in the field. Multicomponent digital interventions aim to improve engagement by adding components such as social networks. Although social networks may be engaging, they may not be sufficient to improve clinical outcomes or lead users to engage with key therapeutic components. Therefore, we need to understand what components drive engagement with digital mental health interventions overall and what drives engagement with key therapeutic components. OBJECTIVE: Horyzons was an 18-month digital mental health intervention for young people recovering from first-episode psychosis, incorporating therapeutic content and a private social network. However, it is unclear whether use of the social network leads to subsequent use of therapeutic content or vice versa. This study aimed to determine the causal relationship between the social networking and therapeutic components of Horyzons. METHODS: Participants comprised 82 young people (16-27 years) recovering from first-episode psychosis. Multiple convergent cross mapping was used to test causality, as a secondary analysis of the Horyzons intervention. Multiple convergent cross mapping tested the direction of the relationship between each pair of social and therapeutic system usage variables on Horyzons, using longitudinal usage data. RESULTS: Results indicated that the social networking aspects of Horyzons were most engaging. Posting on the social network drove engagement with all therapeutic components (r=0.06-0.36). Reacting to social network posts drove engagement with all therapeutic components (r=0.39-0.65). Commenting on social network posts drove engagement with most therapeutic components (r=0.11-0.18). Liking social network posts drove engagement with most therapeutic components (r=0.09-0.17). However, starting a therapy pathway led to commenting on social network posts (r=0.05) and liking social network posts (r=0.06), and completing a therapy action led to commenting on social network posts (r=0.14) and liking social network posts (r=0.15). CONCLUSIONS: The online social network was a key driver of long-term engagement with the Horyzons intervention and fostered engagement with key therapeutic components and ingredients of the intervention. Online social networks can be further leveraged to engage young people with therapeutic content to ensure treatment effects are maintained and to create virtuous cycles between all intervention components to maintain engagement. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12614000009617; https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12614000009617.

Integrating digital interventions with clinical practice in youth mental health services.

OBJECTIVE: Integrating digital technologies with clinical practice promises to improve access and enhance care in the context of high service demand and constrained capacity. METHOD: We outline the emerging research in the integration of digital tools in clinical care, known as blended care, and provide case examples of mental health technology platforms currently in use, summarise findings regarding novel technologies such as virtual reality, and outline real-world implementation challenges and potential solutions. RESULTS: Recent evidence shows that blended care approaches are clinically effective and improve service efficiency. Youth-specific technologies such as moderated online social therapy (MOST) are achieving a range of positive clinical and functional outcomes, while emerging technologies like virtual reality have strong evidence in anxiety disorder, and accumulating evidence in psychotic conditions. Implementation science frameworks show promise in helping overcome the common challenges faced in real-world adoption and ongoing use. CONCLUSION: The integrated, blended use of digital mental health technologies with face-to-face clinical care has the potential to improve care quality for young people while helping overcome the growing challenges faced by youth mental health service providers.

Ownership, Use of, and Interest in Digital Mental Health Technologies Among Clinicians and Young People Across a Spectrum of Clinical Care Needs: Cross-sectional Survey.

BACKGROUND: There is currently an increased interest in and acceptance of technology-enabled mental health care. To adequately harness this opportunity, it is critical that the design and development of digital mental health technologies be informed by the needs and preferences of end users. Despite young people and clinicians being the predominant users of such technologies, few studies have examined their perspectives on different digital mental health technologies. OBJECTIVE: This study aims to understand the technologies that young people have access to and use in their everyday lives and what applications of these technologies they are interested in to support their mental health. The study also explores the technologies that youth mental health clinicians currently use within their practice and what applications of these technologies they are interested in to support their clients' mental health. METHODS: Youth mental health service users (aged 12-25 years) from both primary and specialist services, young people from the general population (aged 16-25 years), and youth mental health clinicians completed a web-based survey exploring technology ownership, use of, and interest levels in using different digital interventions to support their mental health or that of their clients. RESULTS: A total of 588 young people and 73 youth mental health clinicians completed the survey. Smartphone ownership or private access among young people within mental health services and the general population was universal (611/617, 99%), with high levels of access to computers and social media. Youth technology use was frequent, with 63.3% (387/611) using smartphones several times an hour. Clinicians reported using smartphones (61/76, 80%) and video chat (69/76, 91%) commonly in clinical practice and found them to be helpful. Approximately 50% (296/609) of the young people used mental health apps, which was significantly less than the clinicians (χ23=28.8, n=670; P<.001). Similarly, clinicians were significantly more interested in using technology for mental health support than young people (H3=55.90; P<.001), with 100% (73/73) of clinicians being at least slightly interested in technology to support mental health compared with 88% (520/591) of young people. Follow-up tests revealed no difference in interest between young people from the general population, primary mental health services, and specialist mental health services (all P>.23). Young people were most interested in web-based self-help, mobile self-help, and blended therapy. CONCLUSIONS: Technology access is pervasive among young people within and outside of youth mental health services; clinicians are already using technology to support clinical care, and there is widespread interest in digital mental health technologies among these groups of end users. These findings provide important insights into the perspectives of young people and clinicians regarding the value of digital mental health interventions in supporting youth mental health.

Characterizing Use of a Multicomponent Digital Intervention to Predict Treatment Outcomes in First-Episode Psychosis: Cluster Analysis.

BACKGROUND: Multicomponent digital interventions offer the potential for tailored and flexible interventions that aim to address high attrition rates and increase engagement, an area of concern in digital mental health. However, increased flexibility in use makes it difficult to determine which components lead to improved treatment outcomes. OBJECTIVE: This study aims to identify user profiles on Horyzons, an 18-month digital relapse prevention intervention for first-episode psychosis that incorporates therapeutic content and social networking, along with clinical, vocational, and peer support, and to examine the predictive value of these user profiles for treatment outcomes. A secondary objective is to compare each user profile with young people receiving treatment as usual (TAU). METHODS: Participants comprised 82 young people (aged 16-27 years) with access to Horyzons and 84 receiving TAU, recovering from first-episode psychosis. In addition, 6-month use data from the therapy and social networking components of Horyzons were used as features for K-means clustering for joint trajectories to identify user profiles. Social functioning, psychotic symptoms, depression, and anxiety were assessed at baseline and 6-month follow-up. General linear mixed models were used to examine the predictive value of user profiles for treatment outcomes and between each user profile with TAU. RESULTS: A total of 3 user profiles were identified based on the following system use metrics: low use, maintained use of social components, and maintained use of both therapy and social components. The maintained therapy and social group showed improvements in social functioning (F2,51=3.58; P=.04), negative symptoms (F2,51=4.45; P=.02), and overall psychiatric symptom severity (F2,50=3.23; P=.048) compared with the other user profiles. This group also showed improvements in social functioning (F1,62=4.68; P=.03), negative symptoms (F1,62=14.61; P<.001), and overall psychiatric symptom severity (F1,63=5.66; P=.02) compared with the TAU group. Conversely, the maintained social group showed increases in anxiety compared with the TAU group (F1,57=7.65; P=.008). No differences were found between the low use group and the TAU group on treatment outcomes. CONCLUSIONS: Continued engagement with both therapy and social components might be key in achieving long-term recovery. Maintained social use and low use outcomes were broadly comparable with TAU, emphasizing the importance of maintaining engagement for improved treatment outcomes. Although the social network may be a key ingredient to increase sustained engagement, as users engaged with this more consistently, it should be leveraged as a tool to engage young people with therapeutic content to bring about social and clinical benefits.

Recommender systems for mental health apps: advantages and ethical challenges.

Recommender systems assist users in receiving preferred or relevant services and information. Using such technology could be instrumental in addressing the lack of relevance digital mental health apps have to the user, a leading cause of low engagement. However, the use of recommender systems for digital mental health apps, particularly those driven by personal data and artificial intelligence, presents a range of ethical considerations. This paper focuses on considerations particular to the juncture of recommender systems and digital mental health technologies. While separate bodies of work have focused on these two areas, to our knowledge, the intersection presented in this paper has not yet been examined. This paper identifies and discusses a set of advantages and ethical concerns related to incorporating recommender systems into the digital mental health (DMH) ecosystem. Advantages of incorporating recommender systems into DMH apps are identified as (1) a reduction in choice overload, (2) improvement to the digital therapeutic alliance, and (3) increased access to personal data & self-management. Ethical challenges identified are (1) lack of explainability, (2) complexities pertaining to the privacy/personalization trade-off and recommendation quality, and (3) the control of app usage history data. These novel considerations will provide a greater understanding of how DMH apps can effectively and ethically implement recommender systems.

The impact of persistent social anxiety on social functioning and health-related quality of life in young people with remitted first-episode psychosis.

OBJECTIVE: Comorbid social anxiety is common in psychotic disorders and is associated with multiple negative consequences. However, the long-term effects of persistent social anxiety versus fluctuating or no anxiety on social functioning and health-related quality of life (HR-QoL) have received scant attention. Therefore, we aimed to examine the prevalence of persistent social anxiety to determine its effect on social functioning and HR-QoL in first-episode psychosis (FEP). METHODS: One hundred and eight individuals with remitted FEP were classified into three groups (persistent, fluctuating or no social anxiety) according to the Social Interaction Anxiety Scale over an 18-month follow-up period. The three groups were then compared at 18 months follow-up to assess the influence of social anxiety on social functioning and HR-QoL before and after controlling for confounders. RESULTS: Of the 108 individuals with FEP, 25 (23.1%) had persistent social anxiety. This group presented lower social functioning and HR-QoL levels compared to the groups with fluctuating or no anxiety symptoms. The effect on HR-QoL remained significant after controlling for positive psychotic and depressive symptoms. CONCLUSIONS: In this study, nearly one-quarter of young people with remitted FEP experienced persistent social anxiety symptoms, which had a negative impact on HR-QoL. Thus, individuals with persistent social anxiety constitute a highly vulnerable group and may require targeted interventions to improve their social functioning and HR-QoL.

Young people's experience of online therapy for first-episode psychosis: A qualitative study.

OBJECTIVES: This study aimed to understand how young people with first-episode psychosis experienced online therapy on a Moderated Online Social Therapy (MOST) platform known as Horyzons. METHODS: Semi-structured in-depth qualitative interviews were conducted with 12 young people who had previously participated in Horyzons, a randomized controlled trial (RCT) of a long-term digital intervention for first-episode psychosis. Interviews were analysed using a phenomenological approach. RESULTS: This study found that the online therapy experience for first-episode psychosis was idiosyncratic, taking on different meaning for different users. The relatively fixed therapeutic content led to experiences that included on-demand help-seeking, positive distraction, revision, generalization and translation, and normalization. We also found that although the experience of online therapy was motivating to some, it was overwhelming for others. CONCLUSIONS: The self-directed and flexible nature of the Horyzons online therapy gave some young people a sense of welcomed control over their mental health journey, and others felt overwhelmed by the high level of choice. Feeling overwhelmed by the level of choice appeared to interrupt their engagement with the platform, and thus their overall ability to use the intervention meaningfully. We also found that on-demand help-seeking and positive distraction were two functions unique to young people through online therapy and may have been related to the significant reduction in the number of overall presentations by young people to emergency departments and a non-significant trend for lower hospitalizations due to psychosis in the intervention group of the Horyzons RCT. PRACTITIONER POINTS: Young people used online therapy for on-demand support to help deal with distress. Young people used online therapy to distract themselves from distress in a positive way. Some young people valued the flexibility of online therapy, which increased their motivation to engage with it. Some young people were overwhelmed by the amount of choice available to them via online therapy, which decreased their motivation to engage.

Correction: Moderated Online Social Therapy for Young People With Active Suicidal Ideation: Qualitative Study.

[This corrects the article DOI: 10.2196/24260.].

The Horyzons project: a randomized controlled trial of a novel online social therapy to maintain treatment effects from specialist first-episode psychosis services.

This study aimed to determine whether, following two years of specialized support for first-episode psychosis, the addition of a new digital intervention (Horyzons) to treatment as usual (TAU) for 18 months was more effective than 18 months of TAU alone. We conducted a single-blind randomized controlled trial. Participants were people with first-episode psychosis (N=170), aged 16-27 years, in clinical remission and nearing discharge from a specialized service. They were randomly assigned (1:1) to receive Horyzons plus TAU (N=86) or TAU alone (N=84) between October 2013 and January 2017. Horyzons is a novel, comprehensive digital platform merging: peer-to-peer social networking; theory-driven and evidence-informed therapeutic interventions targeting social functioning, vocational recovery and relapse prevention; expert clinician and vocational support; and peer support and moderation. TAU involved transfer to primary or tertiary community mental health services. The primary outcome was social functioning at 18 months as measured by the Personal and Social Performance Scale (PSP). Forty-seven participants (55.5%) in the Horyzons plus TAU group logged on for at least 6 months, and 40 (47.0%) for at least 9 months. Social functioning remained high and stable in both groups from baseline to 18-month follow-up, with no evidence of significant between-group differences (PSP mean difference: -0.29, 95% CI: -4.20 to 3.63, p=0.77). Participants in the Horyzons group had a 5.5 times greater increase in their odds to find employment or enroll in education compared with those in TAU (odds ratio, OR=5.55, 95% CI: 1.09-28.23, p=0.04), with evidence of a dose-response effect. Moreover, participants in TAU were twice as likely to visit emergency services compared to those in the Horyzons group (39% vs. 19%; OR=0.31, 95% CI: 0.11-0.86, p=0.03, number needed to treat, NNT=5). There was a non-significant trend for lower hospitalizations due to psychosis in the Horyzons group vs. TAU (13% vs. 27%; OR=0.36, 95% CI: 0.11-1.08, p=0.07, NNT=7). So, although we did not find a significant effect of Horyzons on social functioning compared with TAU, the intervention was effective in improving vocational or educational attainment, a core component of social recovery, and in reducing usage of hospital emergency services, a key aim of specialized first-episode psychosis services. Horyzons holds significant promise as an engaging and sustainable intervention to provide effective vocational and relapse prevention support for young people with first-episode psychosis beyond specialist services.

Perceived Helpfulness of a Moderated Online Social Therapy Network for Young People Experiencing Social Anxiety.

There is a growing need for more effective delivery of digital mental health interventions, particularly for individuals experiencing difficulty accessing or engaging with traditional face-to-face therapy. Young people with social anxiety, and young males with social anxiety in particular need interventions sensitized to their needs. While digital interventions for mental health have proliferated, increasing their accessibility and utility, the data on acceptability and effectiveness of these interventions, however, indicates a need for improvement. The current study sought to utilise qualitative data from semi-structured interviews with 70 participants (male n = 33; age range = 14-25 years, mean age = 19.8) from a single-group pilot study of a novel intervention for young people with social anxiety (Entourage), using a content analysis approach. Results indicated that participants spoke about five main categories: connection, anxiety management, appeal, disengagement and system improvement. No overt gender differences were found in the appeal or perceived helpfulness of the Entourage platform. The current study provides valuable information and suggestions to guide future improvement of digital interventions for young people, particularly those experiencing social anxiety.

Moderated Online Social Therapy for Young People With Active Suicidal Ideation: Qualitative Study.

BACKGROUND: Web-based interventions are a promising approach to support youth at risk of suicide, and those incorporating peer-to-peer social networking may have the added potential to target interpersonal states of perceived burdensomeness and thwarted belongingness. Owing to feasibility and safety concerns, including fear of contagion, this had not been tested until recently. In 2018, we conducted a pilot evaluation to test the feasibility, safety, and acceptability of a Moderated Online Social Therapy intervention, called Affinity, with a sample of young people with active suicidal ideation. OBJECTIVE: The aim of this study is to report qualitative data collected from study participants regarding their experience of the web-based social network and the consequent safety features. METHODS: Affinity is a closed website incorporating 3 key components: therapeutic content delivered via comics, peer-to-peer social networking, and moderation by peers and clinicians. Semistructured interviews were conducted with 17 young people who participated in the pilot study after 8 weeks of exposure to the intervention. Interview data from 2 young people who did not use Affinity were excluded from the analysis. The interviews were analyzed using thematic analysis, with the frequency of responses characterized using the consensual qualitative research method. The results are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist. RESULTS: A total of 4 overarching themes were identified: a safe and supportive environment, the importance of mutual experiences, difficulty engaging and connecting, and the pros and cons of banning discussions about suicide. Interestingly, although Affinity was perceived to be safe and free of judgment, concerns about negative evaluation and triggering others were significant barriers to posting on the social network. Participants generally supported the banning of conversations about suicide, although for some this was perceived to reinforce stigma or was associated with frustration and distress. CONCLUSIONS: The results not only support the safety and potential therapeutic benefit of the social networking aspect of Affinity but also highlight several implementation challenges. There is a need to carefully balance the need for stringent safety and design features while ensuring that the potential for therapeutic benefit is maximized.

Implementation lessons from the transition to telehealth during COVID-19: a survey of clinicians and young people from youth mental health services.

Whilst telehealth may overcome some traditional barriers to care, successful implementation into service settings is scarce, particularly within youth mental health care. This study aimed to leverage the rapid implementation of telehealth due to COVID-19 to understand the perspectives of young people and clinicians on how telehealth impacts service delivery, service quality, and to develop pathways for future uses. Youth mental health service users (aged 12-25) and clinicians took part in an online survey exploring service provision, use, and quality following the adoption of telehealth. Service use data from the period were also examined. Ninety-two clinicians and 308 young people responded to the survey. Service use was reduced compared to the same period in 2019, however, attendance rates were higher. Across eight domains of service quality, the majority of young people reported that telehealth positively impacted service quality, and were significantly more likely to rate telehealth as having a positive impact on service quality than clinicians. There was high interest in continuing to use telehealth as part of care beyond the pandemic, supporting its permanent role in youth mental health care for a segment of service users. Future work should explore how best to support its long-term implementation.

"When I'm Thinking Straight, I Can Put Things in Place for When I'm Not." | Exploring the Use of Advance Statements in First-Episode Psychosis Treatment: Young People, Clinician, and Carer Perspectives.

Advance statements represent a promising but relatively unexplored means to empower young people with first-episode psychosis to actively participate in their own mental health care. This qualitative study explored the use of advance statement's for young people with first-episode psychosis, as well as their carers and clinicians, and provided actionable feedback on how to better meet the needs and preferences of these key stakeholders and more effectively implement advance statements in clinical settings.

The role of social relatedness and self-beliefs in social functioning in first-episode psychosis: Are we overestimating the contribution of illness-related factors?

OBJECTIVE: Numerous research studies have demonstrated an association between higher symptom severity and cognitive impairment with poorer social functioning in first-episode psychosis (FEP). By contrast, the influence of subjective experiences, such as social relatedness and self-beliefs, has received less attention. Consequently, a cohesive understanding of how these variables interact to influence social functioning is lacking. METHOD: We used structural equation modeling to examine the direct and indirect relationships among neurocognition (processing speed) and social cognition, symptoms, and social relatedness (perceived social support and loneliness) and self-beliefs (self-efficacy and self-esteem) in 170 individuals with FEP. RESULTS: The final model yielded an acceptable model fit (χ2 = 45.48, comparative fit index = 0.96; goodness of fit index = 0.94; Tucker-Lewis index = 0.94; root mean square error of approximation = 0.06) and explained 45% of social functioning. Negative symptoms, social relatedness, and self-beliefs exerted a direct effect on social functioning. Social relatedness partially mediated the impact of social cognition and negative symptoms on social functioning. Self-beliefs also mediated the relationship between social relatedness and social functioning. CONCLUSIONS: The observed associations highlight the potential value of targeting social relatedness and self-beliefs to improve functional outcomes in FEP. Explanatory models of social functioning in FEP not accounting for social relatedness and self-beliefs might be overestimating the effect of the illness-related factors.