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

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

Coalescing, Cross-Pollinating, Crystalising: Developing and Evaluating an Art Installation About Health Knowledge.

The HIVE is an arts-based knowledge translation (ABKT) project that showcases work undertaken across Maridulu Budyari Gumal: the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE). Here, we present two distinct forms of data (reflective and evaluative) to tell the story of The HIVE and outline the project's achievements and shortcomings. Reflective data are used to describe the process of establishing a creative, cross-disciplinary collaboration, in order to devise and produce The HIVE. Evaluative data are used to assess the impact of The HIVE on audiences. By presenting reflective and evaluative data together, we highlight that impact in ABKT cannot be reduced to an assessment of audience engagement with an ABKT end-product. Although audience impact is vital, in our experience, The HIVE also had a powerful impact on the researchers, health service users, artists and others who worked together to create it. The process of creating The HIVE informed research- and art-practice change, forged interdisciplinary networks, and enabled the growth of new patterns of knowledge sharing and collaboration. The reflective and evaluative data we present attest to different forms of impact resulting from the creation and exhibition of an ABKT project.

'The hardest job I've ever done': a qualitative exploration of the factors affecting junior doctors' mental health and well-being during medical training in Australia.

BACKGROUND: Medical practitioners can experience considerable stress and poor mental health during their careers, with doctors in training known to be particularly vulnerable. Previous research has documented work-related factors that may play a role in the mental health status of junior doctors. However, these and additional factors, need to be explored further by considering theory-driven, social, structural and contextual issues. This qualitative study aimed to explore the experiences of junior doctors working in Australian hospitals to identify factors that impact their mental health during medical training. METHOD: Semi-structured interviews were conducted with 12 junior medical officers (JMOs) employed across six hospitals in Australia. Transcribed de-identified interviews were analysed thematically using a data-driven inductive approach. RESULTS: Four interrelated main themes were identified: i) professional hierarchies; ii) occupational stress; iii) emotional labour, and iv) taking distress home; which detail the complex affective, relational and professional experiences of JMOs. The accounts demonstrate how the social, professional and organisational dimensions of these experiences impact upon trainee's well-being and mental health, both positively and negatively. Together, the findings document the dynamic, nuanced aspects of junior doctors' experiences of medical training and practice and highlights the importance of relational connections and the workplace environment in shaping JMOs' social and emotional well-being. CONCLUSION: The current study adds to the understanding of how junior doctors navigate medical training in Australian hospitals and highlights the complexities of this experience, particularly the ways in which mental health and well-being are shaped by different elements. These findings have important implications to inform new strategies to improve JMO mental health and to leverage work and non-work contexts to better support JMOs during medical training.

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

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

Lived experience research as a resource for recovery: a mixed methods study.

BACKGROUND: Lived experience research is conducted by people who have experience of mental health issues and is therefore better placed than more traditional research to illuminate participants' experiences. Findings that focus on identifying enablers of recovery from a lived experience perspective have the potential to assist people in their recovery process. However, this lived experience research is often difficult to find, access and interpret. We co-produced user-friendly and engaging resources to disseminate findings from six lived experience research studies. This paper seeks to answer the research questions: a) Did exposure to lived experience research increase hopefulness for participants?; and b) How else did interacting with lived experience research resources influence participants' lives? METHODS: Thirty-eight participants were introduced to four resources of their choosing by peer workers over a four-week period. The helpfulness of resources was evaluated using mixed methods, including a quasi-experimental analysis of change in hope, an anonymous survey and in-depth interviews. RESULTS: Findings indicated that the resources promoted hope, but that increases in hopefulness may not be seen immediately. Other impacts include that the resources: encouraged helpful activities; provided a positive experience; increased valued knowledge; encouraged people to reflect on their journey and think constructively about mental health issues; helped people to feel less alone; and assisted people to explain their situation to others. CONCLUSIONS: The research suggests the potential usefulness of lived experience research resources, presented in user-friendly formats, in the lives of people who experience mental health issues and implies a need to nurture this type of research.

Ahead of the game protocol: a multi-component, community sport-based program targeting prevention, promotion and early intervention for mental health among adolescent males.

BACKGROUND: There is a recognised need for targeted community-wide mental health strategies and interventions aimed specifically at prevention and early intervention in promoting mental health. Young males are a high need group who hold particularly negative attitudes towards mental health services, and these views are detrimental for early intervention and help-seeking. Organised sports provide a promising context to deliver community-wide mental health strategies and interventions to adolescent males. The aim of the Ahead of the Game program is to test the effectiveness of a multi-component, community-sport based program targeting prevention, promotion and early intervention for mental health among adolescent males. METHODS: The Ahead of the Game program will be implemented within a sample drawn from community sporting clubs and evaluated using a sample drawn from a matched control community. Four programs are proposed, including two targeting adolescents, one for parents, and one for sports coaches. One adolescent program aims to increase mental health literacy, intentions to seek and/or provide help for mental health, and to decrease stigmatising attitudes. The second adolescent program aims to increase resilience. The goal of the parent program is to increase parental mental health literacy and confidence to provide help. The coach program is intended to increase coaches' supportive behaviours (e.g., autonomy supportive behaviours), and in turn facilitate high-quality motivation and wellbeing among adolescents. Programs will be complemented by a messaging campaign aimed at adolescents to enhance mental health literacy. The effects of the program on adolescent males' psychological distress and wellbeing will also be explored. DISCUSSION: Organised sports represent a potentially engaging avenue to promote mental health and prevent the onset of mental health problems among adolescent males. The community-based design, with samples drawn from an intervention and a matched control community, enables evaluation of adolescent males' incremental mental health literacy, help-seeking intentions, stigmatising attitudes, motivation, and resilience impacts from the multi-level, multi-component Ahead of the Game program. Notable risks to the study include self-selection bias, the non-randomised design, and the translational nature of the program. However, strengths include extensive community input, as well as the multi-level and multi-component design. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000709347 . Date registered 17 May 2017. Retrospectively registered.

Testicular Biopsy for Fertility Preservation in Prepubertal Boys with Cancer: Identifying Preferences for Procedure and Reactions to Disclosure Practices.

PURPOSE: Fertility preservation options are limited in prepubertal boys with cancer. Worldwide there has been growing interest in testicular tissue cryopreservation as a promising experimental strategy to address future infertility. We measured and compared parent, male cancer survivor and provider willingness to accept the risk of testicular biopsy among prepubertal boys with cancer, and identified reactions to disclosure practices. MATERIALS AND METHODS: We conducted a multicenter study that included 153 parents of prepubertal boys with cancer, 77 male survivors of childhood cancer and 30 oncology providers. The threshold technique was used to measure subject relative willingness to accept risk of testicular biopsy under 4 different aspects of care, ie chance of infertility, complications from biopsy, development of technology to use tissue and tissue storage cost. A total of 47 in-depth interviews were conducted to identify reactions to disclosure practices. RESULTS: A total of 52 survivors (67%), 22 providers (73%) and 110 parents (72%) selected to have testicular biopsy (vs no biopsy). Median minimum infertility risk to make biopsy worthwhile varied from 25% to 30% among the 3 respondent groups. Interviews revealed that some providers would not offer biopsy in cases of greater perceived risk than benefit, that parents preferred having information regardless of risk of infertility and that nondisclosure elicited adverse feelings from some parents. CONCLUSIONS: Parents, survivors and providers were willing to accept risk of prepubertal testicular biopsy. Parental/survivor desire for information and provider decision not to disclose suggest that barriers to information delivery need to be addressed.

Resident Evaluation of a Required Telepsychiatry Clinical Experience.

OBJECTIVE: The authors explored resident experiences of telepsychiatry clinical training. This paper describes an analysis of evaluation forms completed by psychiatry residents following a required training experience in telepsychiatry. METHODS: Retrospective numeric and narrative data were collected from 2005 to 2012. Using a five-point Likert-type scale (1 = strongly disagree and 5 = strongly agree), residents ranked the session based on the following characteristics: the overall experience, interest in participating in telepsychiatry in the future, understanding service provision to underserved areas, telepsychiatry as mode of service delivery, and the unique aspects of telepsychiatry work. The authors also conducted a content analysis of narrative comments in response to open-ended questions about the positive and negative aspects of the training experience. RESULTS: In all, 88% of residents completed (n = 335) an anonymous evaluation following their participation in telepsychiatry consultation sessions. Numeric results were mostly positive and indicated that the experience was interesting and enjoyable, enhanced interest in participating in telepsychiatry in the future, and increased understanding of providing psychiatric services to underserved communities. Narrative data demonstrated that the most valuable aspects of training included the knowledge acquired in terms of establishing rapport and engaging with patients, using the technology, working collaboratively, identifying different approaches used, and awareness of the complexity of cases. Resident desire for more training of this nature was prevalent, specifically a wish for more detail, additional time for discussion and debriefing, and further explanation of the unique aspects of telepsychiatry as mode of delivery. CONCLUSIONS: More evaluation of telepsychiatry training, elective or required, is needed. The context of this training offered potential side benefits of learning about interprofessional and collaborative care for the underserved.

Shared decision making in the management of children with newly diagnosed immune thrombocytopenia.

This study aimed to examine the treatment decision-making process for children hospitalized with newly diagnosed immune thrombocytopenia (ITP). Using focus groups, we studied children with ITP, parents of children with ITP, and health care professionals, inquiring about participants' experience with decision support and decision making in newly diagnosed ITP. Data were examined using thematic analysis. Themes that emerged from children were feelings of "anxiety, fear, and confusion"; the need to "understand information"; and "treatment choice," the experience of which was age dependent. For parents, "anxiety, fear, and confusion" was a dominant theme; "treatment choice" revealed that participants felt directed toward intravenous immune globulin (IVIG) for initial treatment. For health care professionals, "comfort level" highlighted factors contributing to professionals' comfort with offering options; "assumptions" were made about parental desire for participation in shared decision making (SDM) and parental acceptance of treatment options; "providing information" was informative regarding modes of facilitating SDM; and "treatment choice" revealed a discrepancy between current practice (directed toward IVIG) and the ideal of SDM. At our center, families of children with newly diagnosed ITP are not experiencing SDM. Our findings support the implementation of SDM to facilitate patient-centered care for the management of pediatric ITP.

Analysis of a support group for children of parents with mental illnesses: managing stressful situations.

We report an ethnographic analysis of a psycho-education and peer-support program for school-aged children of parents with mental illnesses. We conducted a critical discourse analysis of the program manual and observed group interactions to understand whether children shared program goals predetermined by adults, and how, or if, the intervention was responsive to their needs. Children were expected to learn mental illness information because "knowledge is power," and to express difficult feelings about being a child of a mentally ill parent that was risky. Participants used humor to manage group expectations, revealing how they made sense of their parents' problems, as well as their own. Suggestions are made for determining good mental health literacy based on children's preferences for explaining circumstances in ways they find relevant, and for supporting children's competencies to manage relationships that are important to them.

Growing and fostering knowledge translation: Recommendations for health organisations from the SPHERE Envisionarium.

Despite considerable investments in health research, there is a disconnect between what is known to enhance healthcare and how healthcare is delivered in situ. Knowledge translation (KT) plays a vital role in addressing this disconnect. Some governments promote KT via initiatives that encourage collaboration between researchers, clinicians, communities and others; this includes Maridulu Budyari Gumal SPHERE (Sydney Partnership for Health, Education, Research and Enterprise). To promote KT and address the knowledge-to-action gap, we held an envisionarium with SPHERE members, to generate recommendations to promote KT in, and beyond, SPHERE. METHODS: To discern these recommendations, an envisionarium was facilitated with SPHERE members. Participants included researchers, healthcare providers and others (n = 16). Participants considered how KT can be fostered and promoted. Discussion notes and participant responses were thematically analysed. RESULTS: Four recommendations were identified, accompanied by practical steps to action these to enable health and research institutions to foster KT. These include the need to: provide access to resources; reconceptualise impact and innovation; promote the legitimacy of different knowledges; and engage everyone in KT. CONCLUSIONS: These recommendations are important for three reasons. First, they demonstrate that KT requires more than funding - it also requires networks that buoy the dynamic flow of knowledge in its varied manifestations. Second, the recommendations demonstrate the importance of supportive organisational mechanisms that inculcate positive, KT-friendly structures or cultures, while affording individuals the opportunity to organically foster innovation. Third, they demonstrate the methodological value of envisionariums to disrupt the status quo and envision different ways to promote KT.

Enhancing Multiple Ways of Knowing Comment on "Evaluating Public Participation in a Deliberative Dialogue: A Single Case Study".

This commentary reviews the Scurr and colleagues' article published in International Journal of Health Policy and Management in February 2022 on "Evaluating Public Participation in a Deliberative Dialogue: A Single Case Study." Schur adds to the current knowledge base by extending the stakeholder groups in deliberative dialogues (DD) to members of the affected community, a practice not commonly used in such DD strategies. Their study supports the inclusion of public participants in such dialogues, and offers practical guidelines for ways in which to accommodate these important participants. This commentary highlights the need to acknowledge diverse types of knowing into what is considered evidence and advocates for evidence to include a wide-ranging variety of sources including tacit knowledge via experience and ongoing learning.

Parents' Perspectives of an Arts Engagement Program Supporting Children with Anxiety.

Arts engagement programs (AEPs) are non-clinical, structured programs led by artists and educators to support mental health and wellbeing. While evidence demonstrates positive mental health outcomes in adult AEPs, studies of childhood AEPs remain sparse. We created a gallery-based AEP (Culture Dose for Kids) for children with anxiety based on a successful arts engagement pilot for adults with depression. We questioned whether our tailored-for-children adult program would effectively and feasibly support children's mental health. Through parents' perspectives and feedback, this study tested the program's acceptability, feasibility, and effectiveness with children with anxiety. Quantitative and qualitative measures were used to determine whether the program was an effective and acceptable mental health support for children with anxiety. Our findings revealed that the program positively and significantly impacted parental perceptions of their child's anxiety. Our findings illustrate depictions of improved mood, confidence, and sense of empowerment in the child, qualities associated with resilience and mental wellbeing. Open-ended activities provided opportunities for connection, creativity, and experimentation-sources of strength for improving mental health. This study adds to the small but growing evidence base supporting the role of arts-based community care in youth mental health and wellbeing.

Understanding Protective Factors for Men at Risk of Suicide Using the CHIME Framework: The Primacy of Relational Connectedness.

Suicide is a global problem, ranking among the leading causes of death in many countries across the world. Most people who die by suicide are "under the radar", having never seen a mental health professional or been diagnosed with a mental illness. This article describes the protective factors for men experiencing suicidal thoughts, plans, and/or attempts who are "under the radar". Using in-depth qualitative interviews, we aimed to understand stakeholder perspectives on the protective factors that influence men's wellbeing. The pervasiveness of relational connectedness in men's narratives was identified as a central protective factor. Other key protective factors included meaningful activity, empowerment, and hope. These results have the potential to facilitate the development of focused community initiatives. More generally, the current research offers an example of a qualitative inquiry into men's wellbeing that focuses on strengths and positive factors in their lives and may provide a guide for future community-based suicide prevention research.

Implementing a Digital Depression Prevention Program in Australian Secondary Schools: Cross-Sectional Qualitative Study.

BACKGROUND: Depression is common during adolescence and is associated with adverse educational, employment, and health outcomes in later life. Digital programs are increasingly being implemented in schools to improve and protect adolescent mental health. Although digital depression prevention programs can be effective, there is limited knowledge about how contextual factors influence real-world delivery at scale in schools. OBJECTIVE: The purpose of this study was to examine the contextual factors that influence the implementation of the Future Proofing Program (FPP) from the perspectives of school staff. The FPP is a 2-arm hybrid type 1 effectiveness-implementation trial evaluating whether depression can be prevented at scale in schools, using an evidence-based smartphone app delivered universally to year 8 students (13-14 years of age). METHODS: Qualitative interviews were conducted with 23 staff from 20 schools in New South Wales, Australia, who assisted with the implementation of the FPP. The interviews were guided by our theory-driven logic model. Reflexive thematic analysis, using both deductive and inductive coding, was used to analyze responses. RESULTS: Staff perceived the FPP as a novel ("innovative approach") and appropriate way to address an unmet need within schools ("right place at the right time"). Active leadership and counselor involvement were critical for planning and engaging; teamwork, communication, and staff capacity were critical for execution ("ways of working within schools"). Low student engagement and staffing availability were identified as barriers for future adoption and implementation by schools ("reflecting on past experiences"). CONCLUSIONS: Four superordinate themes pertaining to the program, implementation processes, and implementation barriers were identified from qualitative responses by school staff. On the basis of our findings, we proposed a select set of recommendations for future implementation of digital prevention programs delivered at scale in schools. These recommendations were designed to facilitate an organizational change and help staff to implement digital mental health programs within their schools. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-042133.

The Future Proofing Study: Design, methods and baseline characteristics of a prospective cohort study of the mental health of Australian adolescents.

OBJECTIVES: The Future Proofing Study (FPS) was established to examine factors associated with the onset and course of mental health conditions during adolescence. This paper describes the design, methods, and baseline characteristics of the FPS cohort. METHODS: The FPS is an Australian school-based prospective cohort study with an embedded cluster-randomized controlled trial examining the effects of digital prevention programs on mental health. Data sources include self-report questionnaires, cognitive functioning, linkage to health and education records, and smartphone sensor data. Participants are assessed annually for 5 years. RESULTS: The baseline cohort (N = 6388, M = 13.9 years) is broadly representative of the Australian adolescent population. The clinical profile of participants is comparable to other population estimates. Overall, 15.1% of the cohort met the clinical threshold for depression, 18.6% for anxiety, 31.6% for psychological distress, and 4.9% for suicidal ideation. These rates were significantly higher in adolescents who identified as female, gender diverse, sexuality diverse, or Aboriginal and/or Torres Strait Islander (all ps < 0.05). CONCLUSIONS: This paper provides current and comprehensive data about the status of adolescent mental health in Australia. The FPS cohort is expected to provide significant insights into the risk, protective, and mediating factors associated with development of mental health conditions during adolescence.

A Creative Approach to Knowledge Translation: The Use of Short Animated Film to Share Stories of Refugees and Mental Health.

This study used animated film to translate narratives of refugees and mental health into accessible material aimed at enhancing empathy and understanding. It focuses on the use of short animated films in series one and two of the Woven Threads catalogue. Series one shared moments of hope in a refugee's journey, whilst series two focused on people living with mental health challenges. This research was designed to understand the responses to viewing for people who watch these animations. A mixed-method design was used via an online Qualtrics platform that asked respondents to view two short animated films, one from the refugee series and one from the mental health series. 364 members of the general public viewed and responded to the refugee film and 275 responded to the mental health film. The platform collected both quantitative and qualitative data. Survey responses indicated that the majority of viewers found the films challenged public misconceptions about refugees and individuals with mental health challenges and left them with a feeling of hopefulness. Qualitative narratives were organised into one superordinate theme: the power of film as a knowledge translation strategy, with four subthemes: (i) changing perceptions and inspiring empathy, (ii) enhancing literacy, (iii) highlighting the power of storytelling, and (iv) encouraging hope and a sense of belonging. The use of short animated film as a knowledge translation strategy can enhance our understanding, promote deep reflection, increase empathy and has the potential to lead to social change.

Tragedies, Fates, Furies and Fuels: Narratives of Individuals Bereaved by Suicide.

Suicide is the leading cause of death for Australians aged 15 to 44, with fifty to sixty per cent of individuals who die by suicide 'flying under the radar', dying in this way without receiving formal mental health care or treatment. This paper explores how people bereaved by suicide interpret and narrate the lead-up to, act and aftermath of a male family member who died by suicide. We used qualitative semi-structured interviews to explore how narratives of suicide were articulated by loved ones bereaved by suicide. Analytic findings were conceptualised through Bamberg's four layers of cognitive narrative structure-setting, complication, resolution, coda. We derived three complications conveyed by the group as a whole: that the men felt sentenced by fate, charged with fury and were fueled by alcohol. These narratives by individuals bereaved by suicide draw us into the larger picture of meaning-making, the loss of life and finding closure. They also speak to the need for early interventions, as most of these stories are rooted in childhood tragedy that was not sufficiently addressed or supported.

Gaming My Way to Recovery: A Systematic Scoping Review of Digital Game Interventions for Young People's Mental Health Treatment and Promotion.

Nearly all young people use the internet daily. Many youth with mental health concerns, especially since the Covid-19 pandemic, are using this route to seek help, whether through digital mental health treatment, illness prevention tools, or supports for mental wellbeing. Videogames also have wide appeal among young people, including those who receive mental health services. This review identifies the literature on videogame interventions for young people, ages 12-29, and maps the data on game use by those with mental health and substance use problems, focusing on evidence for the capacity of games to support treatment in youth mental health services; how stakeholders are involved in developing or evaluating games; and any potential harms and ethical remedies identified. A systematic scoping review methodology was used to identify and assess relevant studies. A search of multiple databases identified a total of 8,733 articles. They were screened, and 49 studies testing 32 digital games retained. An adapted stepped care model, including four levels, or steps, based on illness manifestation and severity, was used as a conceptual framework for organizing target populations, mental health conditions and corresponding digital games, and study results. The 49 selected studies included: 10 studies (20.4%) on mental health promotion/prevention or education for undiagnosed youth (Step 0: 7 games); 6 studies (12.2%) on at-risk groups or suspected mental problems (Step 1: 5 games); 24 studies (49.0%) on mild to moderate mental conditions (Steps 2-3: 16 games); and 9 studies (18.4%) focused on severe and complex mental conditions (Step 4: 7 games). Two interventions were played by youth at more than one level of illness severity: the SPARX game (Steps 1, 2-3, 4) and Dojo (Steps 2-3 and 4), bringing the total game count to 35 with these repetitions. Findings support the potential integration of digital games in youth services based on study outcomes, user satisfaction, relatively high program retention rates and the potential usefulness of most games for mental health treatment or promotion/prevention. Most studies included stakeholder feedback, and involvement ratings were very high for seven games. Potential harms were not addressed in this body of research. This review provides an important initial repository and evaluation of videogames for use in clinical settings concerned with youth mental health.

An ecological process model of systems change.

In June 2007 the American Journal of Community Psychology published a special issue focused on theories, methods and interventions for systems change which included calls from the editors and authors for theoretical advancement in this field. We propose a conceptual model of systems change that integrates familiar and fundamental community psychology principles (succession, interdependence, cycling of resources, adaptation) and accentuates a process orientation. To situate our framework we offer a definition of systems change and a brief review of the ecological perspective and principles. The Ecological Process Model of Systems Change is depicted, described and applied to a case example of policy driven systems level change in publicly funded social programs. We conclude by identifying salient implications for thinking and action which flow from the Model.