Mathijs Lucassen

The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial

Objective To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual. Design Multicentre randomised controlled non-inferiority trial. Setting 24 primary healthcare sites in New Zealand (youth clinics, general practices, and school based counselling services). Participants 187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to SPARX and 93 to treatment as usual. Interventions Computerised cognitive behavioural therapy (SPARX) comprising seven modules delivered over a period of between four and seven weeks, versus treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists. Outcomes The primary outcome was the change in score on the children’s depression rating scale-revised. Secondary outcomes included response and remission on the children’s depression rating scale-revised, change scores on the Reynolds adolescent depression scale-second edition, the mood and feelings questionnaire, the Kazdin hopelessness scale for children, the Spence children’s anxiety scale, the paediatric quality of life enjoyment and satisfaction questionnaire, and overall satisfaction with treatment ratings. Results 94 participants were allocated to SPARX (mean age 15.6 years, 62.8% female) and 93 to treatment as usual (mean age 15.6 years, 68.8% female). 170 adolescents (91%, SPARX n=85, treatment as usual n=85) were assessed after intervention and 168 (90%, SPARX n=83, treatment as usual n=85) were assessed at the three month follow-up point. Per protocol analyses (n=143) showed that SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children’s depression rating scale-revised (between group difference 2.73, 95% confidence interval −0.31 to 5.77; P=0.079). Remission rates were significantly higher in the SPARX arm (n=31, 43.7%) than in the treatment as usual arm (n=19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P=0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n=47) and treatment as usual arm (58.3%, n=42) (difference 7.9%, −7.9% to 24%; P=0.332). All secondary measures supported non-inferiority. Intention to treat analyses confirmed these findings. Improvements were maintained at follow-up. The frequency of adverse events classified as “possibly” or “probably” related to the intervention did not differ between groups (SPARX n=11; treatment as usual n=11). Conclusions SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings and could be used to address some of the unmet demand for treatment. Trial registration Australian New Zealand Clinical Trials ACTRN12609000249257.

The Health and Well-Being of Transgender High School Students: Results From the New Zealand Adolescent Health Survey (Youth'12)

PURPOSE To report the prevalence of students according to four gender groups (i.e., those who reported being non-transgender, transgender, or not sure about their gender, and those who did not understand the transgender question), and to describe their health and well-being. METHODS Logistic regressions were used to examine the associations between gender groups and selected outcomes in a nationally representative high school health and well-being survey, undertaken in 2012. RESULTS Of the students (n = 8,166), 94.7% reported being non-transgender, 1.2% reported being transgender, 2.5% reported being not sure about their gender, and 1.7% did not understand the question. Students who reported being transgender or not sure about their gender or did not understand the question had compromised health and well-being relative to their non-transgender peers; in particular, for transgender students perceiving that a parent cared about them (odds ratio [OR], .3; 95% confidence interval [CI], .2-.4), depressive symptoms (OR, 5.7; 95% CI, 3.6-9.2), suicide attempts (OR, 5.0; 95% CI, 2.9-8.8), and school bullying (OR, 4.5; 95% CI, 2.4-8.2). CONCLUSIONS This is the first nationally representative survey to report the health and well-being of students who report being transgender. We found that transgender students and those reporting not being sure are a numerically small but important group. Transgender students are diverse and are represented across demographic variables, including their sexual attractions. Transgender youth face considerable health and well-being disparities. It is important to address the challenging environments these students face and to increase access to responsive services for transgender youth.

Serious games and gamification for mental health: current status and promising directions

Computer games are ubiquitous and can be utilized for serious purposes such as health and education. “Applied games” including serious games (in brief, computerized games for serious purposes) and gamification (gaming elements used outside of games) have the potential to increase the impact of mental health internet interventions via three processes. First, by extending the reach of online programs to those who might not otherwise use them. Second, by improving engagement through both game-based and “serious” motivational dynamics. Third, by utilizing varied mechanisms for change, including therapeutic processes and gaming features. In this scoping review, we aim to advance the field by exploring the potential and opportunities available in this area. We review engagement factors which may be exploited and demonstrate that there is promising evidence of effectiveness for serious games for depression from contemporary systematic reviews. We illustrate six major categories of tested applied games for mental health (exergames, virtual reality, cognitive behavior therapy-based games, entertainment games, biofeedback, and cognitive training games) and demonstrate that it is feasible to translate traditional evidence-based interventions into computer gaming formats and to exploit features of computer games for therapeutic change. Applied games have considerable potential for increasing the impact of online interventions for mental health. However, there are few independent trials, and direct comparisons of game-based and non-game-based interventions are lacking. Further research, faster iterations, rapid testing, non-traditional collaborations, and user-centered approaches are needed to respond to diverse user needs and preferences in rapidly changing environments.

Sexual attraction, depression, self-harm, suicidality and help-seeking behaviour in New Zealand secondary school students

Objective: To describe the sexual attractions of New Zealand secondary school students and investigate the associations between sexual attraction and self-reported depression, self-harm, suicidality and help-seeking behaviour. Method: Multiple logistic regression was used to examine the associations between sexual attraction and depressive symptoms, suicidality, self-harming and help-seeking behaviours in a nationally representative secondary school health and well-being survey, undertaken in 2007. Results: Of the students surveyed, 92% were attracted to the opposite sex, 1% to the same sex, 3% to both sexes, 2% were not sure and 2% were attracted to neither sex. Students who were attracted to the same or to both sexes consistently had higher prevalence estimates of depression (p = < 0.0001), suicidality (p = < 0.0001) and self-harming (p = < 0.0001). Odds ratios were highest for students who reported they were attracted to both sexes for depressive symptoms (OR 3.7, 95%CI 2.8–4.7), self-harm (OR 5.8, 95%CI 4.4–7.6) and attempted suicide (OR 7.0, 95%CI 5.2–9.4). Students not exclusively attracted to the opposite sex were more likely to report having seen a health professional for an emotional worry and were more likely to have difficulty accessing help for emotional concerns. Conclusions: The study findings highlight significant mental health disparities faced by students attracted to the same or both sexes, with those attracted to both sexes appearing particularly vulnerable. There is a vital need to ensure primary care and mental health services have the capacity and capability to screen and provide appropriate responsive care for youth who are attracted to the same or both sexes.

Stability and change in the mental health of New Zealand secondary school students 2007–2012: Results from the national adolescent health surveys

Objective: To describe the self-reported mental health of New Zealand secondary school students in 2012 and to investigate changes between 2007 and 2012. Methods: Nationally representative health and wellbeing surveys of students were completed in 2007 (n=9107) and 2012 (n=8500). Logistic regressions were used to examine the associations between mental health and changes over time. Prevalence data and adjusted odds ratios are presented. Results: In 2012, approximately three-quarters (76.2%, 95% CI 74.8–77.5) of students reported good overall wellbeing. By contrast (also in 2012), some students reported self-harming (24.0%, 95% CI 22.7–25.4), depressive symptoms (12.8%, 95% CI 11.6–13.9), 2 weeks of low mood (31%, 95% CI 29.7–32.5), suicidal ideation (15.7%, 95% 14.5–17.0), and suicide attempts (4.5%, 95% CI 3.8–5.2). Between 2007 and 2012, there appeared to be slight increases in the proportions of students reporting an episode of low mood (OR 1.14, 95% CI 1.06–1.23, p=0.0009), depressive symptoms (OR 1.16, 95% CI 1.03–1.30, p=0.011), and using the Strengths and Difficulties Questionnaire - emotional symptoms (OR 1.38, 95% CI 1.23–1.54, p<0.0001), hyperactivity (OR 1.16, 95% CI 1.05–1.29, p=0.0051), and peer problems (OR 1.27, 95% CI 1.09–1.49, p=0.0022). The proportion of students aged 16 years or older reporting self-harm increased slightly between surveys, but there was little change for students aged 15 years or less (OR 1.29, 95% CI 1.15–1.44 and OR 1.10, 95% 0.98–1.23, respectively, p=0.0078). There were no changes in reported suicidal ideation and suicide attempts between 2007 and 2012. However, there has been an improvement in self-reported conduct problems since 2007 (OR 0.78, 95% CI 0.70–0.87, p<0.0001). Conclusions: The findings suggest a slight decline in aspects of self-reported mental health amongst New Zealand secondary school students between 2007 and 2012. There is a need for ongoing monitoring and for evidence-based, accessible interventions that prevent mental ill health and promote psychological wellbeing.

Integrating Health Behavior Theory and Design Elements in Serious Games

Background Internet interventions for improving health and well-being have the potential to reach many people and fill gaps in service provision. Serious gaming interfaces provide opportunities to optimize user adherence and impact. Health interventions based in theory and evidence and tailored to psychological constructs have been found to be more effective to promote behavior change. Defining the design elements which engage users and help them to meet their goals can contribute to better informed serious games. Objective To elucidate design elements important in SPARX, a serious game for adolescents with depression, from a user-centered perspective. Methods We proposed a model based on an established theory of health behavior change and practical features of serious game design to organize ideas and rationale. We analyzed data from 5 studies comprising a total of 22 focus groups and 66 semistructured interviews conducted with youth and families in New Zealand and Australia who had viewed or used SPARX. User perceptions of the game were applied to this framework. Results A coherent framework was established using the three constructs of self-determination theory (SDT), autonomy, competence, and relatedness, to organize user perceptions and design elements within four areas important in design: computer game, accessibility, working alliance, and learning in immersion. User perceptions mapped well to the framework, which may assist developers in understanding the context of user needs. By mapping these elements against the constructs of SDT, we were able to propose a sound theoretical base for the model. Conclusions This study’s method allowed for the articulation of design elements in a serious game from a user-centered perspective within a coherent overarching framework. The framework can be used to deliberately incorporate serious game design elements that support a user’s sense of autonomy, competence, and relatedness, key constructs which have been found to mediate motivation at all stages of the change process. The resulting model introduces promising avenues for future exploration. Involving users in program design remains an imperative if serious games are to be fit for purpose.

What has changed from 2001 to 2012 for sexual minority youth in New Zealand

To provide an overview of the health and well‐being of sexual minority high school students in New Zealand, investigate differences between sexual minority youth (SMY) and exclusively opposite‐sex‐attracted youth (EOSAY), and examine changes across survey waves.

The views of lesbian, gay and bisexual youth regarding computerised self-help for depression: An exploratory study

Abstract Background: Lesbian, gay and bisexual (LGB) youth with depression are often isolated and face the double stigma of mental ill-health and being non-heterosexual. Computerised Cognitive Behavioural Therapy (cCBT) offers a means of providing these youth with evidence-based self-help that is confidential and can be accessed privately. We created a cCBT resource for youth generally and wished to explore what alterations, if any, might be needed to make it acceptable and relevant to LGB youth. Method: Three focus groups were conducted with LGB young people (56% female, aged 16–27 years) ftom two LGB youth organisations in New Zealand. We used the general inductive approach to: Explore the issues faced by LGB youth; and, their views about prototypes of a cCBT program (SPARK). Results: Participants reported a number of challengesftom living in a homophobic and gender-stereotyped world and they recommended that these be incorporated in a cCBT program addressing depression for LGB youth. Participants were mainly positive about the idea of cCBT and the prototypes of the program; however, they made suggestions to ensure that the program was relevant and appealing to them. Conclusion: Prototypes of a‘generic’ cCBT program did not address all the issues that LGB youth face. It proved feasible to adapt a cCBT program to take this feedback into account, and this led to the creation of Rainbow SPARK. The makers of e-therapy interventions should actively involve and respond to the views of consumers.

The association between supportive high school environments and depressive symptoms and suicidality among sexual minority students.

The purpose of this study was to determine if sexual minority students in supportive school environments experienced fewer depressive symptoms and lower rates of suicide ideation, plans and attempts (“suicidality”) than sexual minority students in less supportive school environments. In 2007, a nationally representative sample (N = 9,056) of students from 96 high schools in New Zealand used Internet tablets to complete a health and well-being survey that included questions on sexual attractions, depressive symptoms, and suicidality. Students reported their experience of supportive environments at school and gay, lesbian, bisexual, and transgender (GLBT) bullying, and these items were aggregated to the school level. Teachers (n = 2,901) from participating schools completed questionnaires on aspects of school climate, which included how supportive their schools were toward sexual minority students. Multilevel models were used to estimate school effects on depressive symptoms and suicidality controlling for background characteristics of students. Sexual minority students were more likely to report higher levels of depressive symptoms and suicidality than their opposite-sex attracted peers (p < .001). Teacher reports of more supportive school environments for GLBT students were associated with fewer depressive symptoms among male sexual minority students (p = .006) but not for female sexual minority students (p = .09). Likewise in schools where students reported a more supportive school environment, male sexual minority students reported fewer depressive symptoms (p = .006) and less suicidality (p < .001) than in schools where students reported less favorable school climates. These results suggest that schools play an important role in providing safe and supportive environments for male sexual minority students.

Computer-Based and Online Therapy for Depression and Anxiety in Children and Adolescents

OBJECTIVE The purpose of this study was to provide an overview of computer-based and online therapies (e-therapy) to treat children and adolescents with depression and/or anxiety, and to outline programs that are evidence based or currently being researched. METHODS We began by defining the topic and highlighting the issues at the forefront of the field. We identified computer and Internet-based interventions designed to prevent or treat depression or anxiety that were tested with children and young people <18 years of age (or inclusive of this age range together with emerging adults). We included randomized controlled trials (RCTs). We summarized available relevant systematic reviews. RESULTS There is an increasing body of evidence that supports the use of computers and the Internet in the provision of interventions for depression and anxiety in children and adolescents. A number of programs have been shown to be effective in well-designed RCTs. Replication and long-term follow-up studies are needed to confirm results. CONCLUSIONS There are now a range of effective computerized interventions for young people with depression and anxiety. This is likely to impact positively on attempts to make psychological therapies widely available to children and young people. We expect to see increased program sophistication and a proliferation of programs in the coming years. Research efforts, when developing programs, need to align with technological advances to maximize appeal. Implementation research is needed to determine the optimal modes of delivery and effectiveness of e-therapies in clinical practice. Given the large number of unproven program on the Internet, ensuring that there is clear information for patients about evidence for individual programs is likely to present a challenge.