Lesbian, gay, bisexual, and transgender (LGBT) youth and other young people diverse in terms of their sexuality and gender (LGBT+) are at an elevated risk of mental health problems such as depression. Factors such as isolation and stigma mean that accessing mental health services can be particularly challenging for LGBT+ young people, and previous studies have highlighted that many prefer to access psychological support on the Web. Research from New Zealand has demonstrated promising effectiveness and acceptability for an LGBT+ focused, serious game-based, computerized cognitive behavioral therapy program, Rainbow Smart, Positive, Active, Realistic, X-factor thoughts (SPARX). However, there has been limited research conducted in the area of electronic therapy (e-therapy) for LGBT+ people.This study aimed to explore how and why LGBT+ young people use the internet to support their mental health. This study also sought to explore LGBT+ young people's and professionals' views about e-therapies, drawing on the example of Rainbow SPARX.A total of 3 focus groups and 5 semistructured interviews were conducted with 21 LGBT+ young people (aged 15-22 years) and 6 professionals (4 health and social care practitioners and 2 National Health Service commissioners) in England and Wales. A general inductive approach was used to analyze data.LGBT+ youth participants considered that the use of the internet was ubiquitous, and it was valuable for support and information. However, they also thought that internet use could be problematic, and they highlighted certain internet safety and personal security considerations. They drew on a range of gaming experiences and expectations to inform their feedback about Rainbow SPARX. Their responses focused on the need for this e-therapy program to be updated and refined. LGBT+ young people experienced challenges related to stigma and mistreatment, and they suggested that strategies addressing their common challenges should be included in e-therapy content. Professional study participants also emphasized the need to update and refine Rainbow SPARX. Moreover, professionals highlighted some of the issues associated with e-therapies needing to demonstrate effectiveness and challenges associated with health service commissioning processes.LGBT+ young people use the internet to obtain support and access information, including information related to their mental health. They are interested in LGBT-specific e-therapies; however, these must be in a contemporary format, engaging, and adequately acknowledge the experiences of LGBT+ young people.
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.
Requires a broad public health approach and refinement of interventions
The individual and societal costs of depressive disorder have been well documented, and the arguments for depression prevention programmes are compelling.1 The prevalence of depression rises steeply in mid-adolescence, so schools are a logical place to deliver prevention programmes. Several studies have investigated the efficacy of interventions aimed at preventing depression in adolescents, and meta-analyses have provided encouraging results.2 However, many studies have had methodological difficulties, including lack of attention controls.
In a linked paper (doi:10.1136/bmj.e6058), Stallard and colleagues have reported the results of a large well conducted pragmatic randomised trial.3 They compared the resourceful adolescent programme—a group programme delivered in schools and based on cognitive behavioural therapy that has shown evidence of effect in universal samples of school students—with an attention control or usual classes.4 5 Facilitators were well trained, and the study was also appropriately powered and had excellent retention and follow-up rates. However, no demonstrable effect was seen, and the findings suggest that the intervention programme may actually have led to an increase in depressive symptoms. These findings are worrying, especially when meta-analyses have shown that …
Background: Outcome measurement in child and adolescent mental health services in New Zealand became mandatory in 2005 and little is known about how this is perceived by service users. Aims: This study aimed to ascertain what service users think about routine outcome measurement in child and adolescent mental health services. Method: Nine semi-structured focus groups of child and adolescent service users ( n=34) and family members ( n=21) were held in different sites in New Zealand to determine their views on outcome measures. Results: Consumers supported outcome assessment with some provisos that have important implications for clinical services: the method of collecting information is critical to acceptance; assessment should be done in the context of an established relationship with the clinician; care is needed over the timing and context of assessment, access to information and feedback of results; and measures should be brief and holistic and their limitations recognised. Conclusion: Service users support outcome measures but their implementation requires care and consultation.
Background: The way in which computerized therapy is presented may be important for its uptake. We aimed to explore adolescents' views on the appeal of a tested computerized cognitive behavioral therapy (CCBT) for depression (SPARX), and a revised version (SPARX-R). The versions were similar but while SPARX is presented explicitly as a treatment for depression, SPARX-R is presented as providing skills that could be useful for young people for when they were depressed, down, angry, or stressed. Methods: We held 9 focus groups with a total of 79 adolescents (13-19 years old; 47 females; 34 New Zealand European; 22 Māori or Pacific; 60 reported having experienced feeling down or low for at least several days in a row). Groups viewed the opening sequences of SPARX and SPARX-R (in random order), then took part in a semi-structured discussion and completed a brief questionnaire. Responses were analyzed using a general inductive approach. Results: Participants considered both SPARX and SPARX-R useful and considered the stated purpose of the program to be important. Four themes contrasted the two approaches. The first, "naming depression is risky", referred to perceptions that an explicit focus on depression could be off-putting, including for adolescents with depression. The second theme of "universality" reflected preferences for a universal approach as young people might not recognize that they were depressed, and all would benefit from the program. In contrast, "validation" reflected the view of a significant minority that naming depression could be validating for some. Finally, the theme of "choice" reflected a near-unanimously expressed preference for both options to be offered, allowing user choice. In questionnaire responses, 40 (68%) of participants preferred SPARX-R, 13 (18%) preferred SPARX, while 10 (14%) "didn't mind". Responses were similar among participants who reported that they had experienced at least a few days of low mood and those who had not. Conclusions: The way a CCBT program is presented may have implications for its appeal. The potential population impact of CCBT programs explicitly targeting depression and those targeting more universal feelings such as being stressed or feeling depressed should be explored for varied user groups.
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.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.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.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.
Migration, when it occurs during adolescence, is particularly challenging as it coincides with a myriad of other developmental and social changes. The present study set out to explore recent young migrants’ experiences of settling in New Zealand. The qualitative study aimed to identify areas of particular challenge, examples of resilience and new insights into the acculturation process. Focus group interviews were conducted with migrant youth aged 16–19 from three urban secondary schools in Auckland The interviews were audio-recorded, transcribed and analyzed using a general inductive method. Key themes centered on new beginnings, confronting new realities, acceptance, support seeking and overcoming challenges. Young migrants in this study shared similar challenges during the early post-migration period. They were often faced with additional responsibility, being caught between two cultures while struggling with communication and language. However, they were able to draw on their own self-growth, gratitude, and social connections. This study provides an insight into experiences of young migrants in New Zealand, and offers suggestions for developing culturally relevant support to foster migrant youth wellbeing.
BACKGROUND Approximately 10% to 12% of New Zealand children and young people have long-term physical conditions (also known as chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse physical and mental healthcare, school absence, and poorer long-term outcomes. Recently, electronic health (eHealth) interventions, especially those based on the principles of Cognitive Behavior Therapy (CBT), have been shown to be moderately effective. Biofeedback techniques have also been shown to enhance relaxation during the treatment of anxiety. However, these modalities have rarely been combined. Young people with long-term physical conditions have expressed a preference for well-designed and technologically-based support to deal with psychological issues, especially anxiety. OBJECTIVE This study aimed to co-design and evaluate the (i) acceptability and (ii) usability of a CBT and biofeedback-based, 5-module eHealth game called ‘Starship Rescue’ and (iii) to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions. METHODS Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in Auckland, New Zealand. Following this, 24 other individuals aged 10 to 17 years were enrolled in an open trial, during which they were asked to use the game for an 8-week period. Acceptability of the game to all participants was assessed using a brief, open-ended questionnaire, and more detailed feedback was obtained from a subset of 10 participants via semi-structured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale (SUS). Anxiety levels were measured prior to commencement, on completion of the game, and 3 months following completion using the Generalized Anxiety Disorder 7-item scale (GAD-7) and Spence Child Anxiety Scales (SCAS), and at the start of each module and at the end of the game using an embedded Likert/visual analog scale. Quality of life was measured prior to commencement, on completion of the game, and 3 months following completion using the Pediatric Quality of Life Scale (PEDS-QL). RESULTS Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10 and a mean score of 71 out of 100 (SD 11.7; min 47.5; max 90) on the System Usability Scale (SUS). The mean time period for use of the game was just over 11-weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the GAD-7 (-4.6 (p=0.000)), SCAS (-9.6 (p=0.005)), and the Likert/visual analogue scales (-2.4 (p=0.001)). Quality of life also improved on the PedsQL scale (+4.3 (p=0.042)). All changes were sustained at 3-month follow-up. CONCLUSIONS This study provides preliminary evidence for Starship Rescue being an acceptable, usable and effective eHealth intervention for addressing anxiety in young people with long-term physical conditions. Further evaluation is planned via a more formal randomized controlled trial. CLINICALTRIAL Australian New Zealand Clinical Trials Network Registry (ANZCTR): ACTRN12616001253493p;https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443 (Archived by WebCite at http://www.webcitation.org/6sYB716lf)
Serious games (computerised interventions which utilise gaming for serious purposes) have been shown to support improved outcomes in several health conditions. We aimed to review evidence regarding serious games for depression. We undertook electronic searches of PsycInfo, EMBASE and Medline, using terms relevant to computer games and depression. We included fulltext articles published in English in peer-reviewed literature since 2000, where the intervention was designed to treat or prevent depression and which included pre-and post-intervention measurement of depression. Nine studies relating to a total of six interventions met inclusion criteria. Most studies were small and were carried out by the developers of the programs. All were tested with young people (ages between 9 and 25 years). Most reported promising results with some positive impact on depression although one universal program had mixed results. Serious gaming interventions show promise for depression, however evidence is currently very limited.
Mental health service scalability needs to be improved to meet the growing global demand. The scalability of Focused Acceptance and Commitment Therapy (fACT), a popular evidence-based brief behavioural intervention used in primary care contexts, could be improved through the development and implementation of a digital tool that supports practitioners to overcome service-delivery problems within their practice context. Through semi-structured in-depth interviews with 12 fACT practitioners, we examined the service-delivery problems that they face within the New Zealand primary care context and identified organisational factors which may be contributing to these problems. From these interviews, six key themes emerged: (1) The brief model works for most clients but is not suitable for every client, (2) practitioners often struggle to access culturally appropriate fACT congruent exercises and psychoeducation material, (3) practitioners feel that they need additional training to maintain good model fidelity, (4) short session times can negatively impact model delivery, (5) public health employed practitioners have high workloads and are often unable to refer clients to secondary or crisis services, and (6) fACT practitioners are unable to effectively follow up with their clients post-session. This study is part of a broader project aimed at developing an adjunctive digital tool to support the delivery of fACT in New Zealand primary care. These interviews will help us to understand the practitioner problems occurring in this service-delivery context, identify context-specific factors that may be causing these problems, and offer insights into the necessary features of an engaging digital tool designed to improve model scalability.
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