Theresa Fleming

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.

Self-reported suicide attempts and associated risk and protective factors among secondary school students in New Zealand

Objective: To examine associations between individual, family, school and community characteristics and rates of suicide attempts in a national population sample of New Zealand secondary school students. Method: A total of 9570 randomly selected 9- to 13-year-old students from 114 schools were surveyed, using the New Zealand Adolescent Health Survey. This is a 523-item anonymous self-report comprehensive questionnaire delivered by Multi-Media Computer-Assisted Self-Interviewing. Multivariate analyses were used to examine correlates of self-reported suicide attempts within the last 12 months. Results: In total, 739 participants (4.7% of males and 10.5% of females) reported having made a suicide attempt within the last 12 months. Depressive symptoms, alcohol abuse, -having a friend or family member attempt suicide, family violence and non-heterosexual attractions were independently associated with increased rates of suicide attempts while parents caring, other family members caring, teachers being fair and feeling safe at school were independently associated with decreased rates of suicide attempts. Caring friendships, attending worship frequently, possible sexual abuse and anxiety symptoms were not independently associated with suicide attempts. Risk and protective factors operated in the same way for male and female students and for those with and without other suicide predictors. Conclusions: New Zealand secondary school students, particularly female students, report high rates of suicide attempts. Risk of suicide attempts is lower in students reporting caring home and fair, safe school environments and this effect remains once depression is taken into account. This study confirms the importance of depression, substance use, problem behaviour, negative life events, exposure to suicide behaviour by others and the significance of sexual orientation in suicidal behaviour among school students and provides evidence of the importance of the family and school environments in reducing risk among this group.

A Pragmatic Randomized Controlled Trial of Computerized CBT (SPARX) for Symptoms of Depression among Adolescents Excluded from Mainstream Education

BACKGROUND Adolescents excluded from mainstream education have high mental health needs. The use of computerized Cognitive Behavioural Therapy (cCBT) has not been investigated with this group. AIMS To test the efficacy of the SPARX cCBT programme for symptoms of depression among adolescents in programmes for students excluded or alienated from mainstream education. METHOD Adolescents (32; 34% Maori, 38% Pacific Island, 56% male) aged 13-16 with Child Depression Rating Scale Revised (CDRS-R) scores indicating possible through to almost certain depressive disorder were randomized to SPARX to be completed over the following 5 weeks (n = 20) or to waitlist control (n = 12). Assessments were at baseline, 5 weeks and 10 weeks. Those in the wait condition were invited to complete SPARX after the 5 week assessment. RESULTS Most participants (n = 26, 81%) completed at least 4 levels of SPARX and 22 (69%) completed all 7 levels. Among the 30 (94%) participants who began treatment as randomized and provided 5-week data, significant differences were found between cCBT and wait groups on the CDRS-R (baseline to 5-week mean change -14.7 versus -1.1, p<.001), remission (78% vs. 36%, p = .047) and on the Reynolds Adolescent Depression Scale (-4.6 vs. +3.2 p = .05) but not on other self-rating psychological functioning scales. In intent-to-treat analyses CDRS-R changes and remission remained significant. Gains were maintained at 10-week follow-up. CONCLUSIONS SPARX appears to be a promising treatment for students with symptoms of depression who are in alternative schooling programmes for those excluded from mainstream education.

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.

Hand-held internet tablets for school-based data collection

BackgroundIn the last 20 years, researchers have been using computer self-administered questionnaires to gather data on a wide range of adolescent health related behaviours. More recently, researchers collecting data in schools have started to use smaller hand-held computers for their ease of use and portability. The aim of this study is to describe a new technology with wi-fi enabled hand-held internet tablets and to compare adolescent preferences of laptop computers or hand-held internet tablets in administering a youth health and well-being questionnaire in a school setting.MethodsA total of 177 students took part in a pilot study of a national youth health and wellbeing survey. Students were randomly assigned to internet tablets or laptops at the start of the survey and were changed to the alternate mode of administration about half-way through the questionnaire. Students at the end of the questionnaire were asked which of the two modes of administration (1) they preferred, (2) was easier to use, (3) was more private and confidential, and (4) was easier to answer truthfully.ResultsMany students expressed no preference between laptop computers or internet tablets. However, among the students who expressed a preference between laptop computers or internet tablets, the majority of students found the internet tablets more private and confidential (p < 0.001) and easier to answer questions truthfully (p < 0.001) compared to laptop computers.ConclusionThis study demonstrates that using wi-fi enabled hand-held internet tablets is a feasible methodology for school-based surveys especially when asking about sensitive information.

Do Schools Influence Student Risk-taking Behaviors and Emotional Health Symptoms?

PURPOSE Many schools engage in health promotion, health interventions, and services aimed at improving the health and well-being outcomes for students. The purpose of this study was to examine the effects of schools on student health risk-taking behaviors and depressive symptoms. METHOD A nationally representative sample (n = 9,056) of students from 96 secondary schools completed a health and well-being survey using Internet Tablets that included questions on school climate, health risk-taking behaviors, and mental health. Teachers (n = 2,901) and school administrators (n = 91) completed questionnaires on aspects of the school climate which included teacher well-being and burnout, the staff work environment, health and welfare services for students, and school organizational support for student health and well-being. Multilevel models were used to estimate school effects on the health risk-taking behaviors and depression symptoms among students. RESULTS Schools where students reported a more positive school climate had fewer students with alcohol use problems, and fewer students engaging in violence and risky motor vehicle behaviors. Schools where teachers reported better health and welfare services for students had fewer students engaging in unsafe sexual health behaviors. Schools where teachers reported higher levels of well-being had fewer students reporting significant levels of depressive symptoms. CONCLUSIONS More positive school climates and better school health and welfare services are associated with fewer health risk-taking behaviors among students. However, the overall school effects were modest, especially for cigarette use and suicidal behaviors.

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.

Maximizing the Impact of e-Therapy and Serious Gaming: Time for a Paradigm Shift.

Internet interventions for mental health, including serious games, online programs, and apps, hold promise for increasing access to evidence-based treatments and prevention. Many such interventions have been shown to be effective and acceptable in trials; however, uptake and adherence outside of trials is seldom reported, and where it is, adherence at least, generally appears to be underwhelming. In response, an international Collaboration On Maximizing the impact of E-Therapy and Serious Gaming (COMETS) was formed. In this perspectives’ paper, we call for a paradigm shift to increase the impact of internet interventions toward the ultimate goal of improved population mental health. We propose four pillars for change: (1) increased focus on user-centered approaches, including both user-centered design of programs and greater individualization within programs, with the latter perhaps utilizing increased modularization; (2) Increased emphasis on engagement utilizing processes such as gaming, gamification, telepresence, and persuasive technology; (3) Increased collaboration in program development, testing, and data sharing, across both sectors and regions, in order to achieve higher quality, more sustainable outcomes with greater reach; and (4) Rapid testing and implementation, including the measurement of reach, engagement, and effectiveness, and timely implementation. We suggest it is time for researchers, clinicians, developers, and end-users to collaborate on these aspects in order to maximize the impact of e-therapies and serious gaming.

Health and well-being of secondary school students in New Zealand: Trends between 2001, 2007 and 2012

To describe indicators of health and well‐being for New Zealand secondary school students; explore changes between 2001, 2007 and 2012; and compare these findings to international estimates.