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Background Health and Safety Executive data show that teachers are at heightened risk of mental health difficulties, yet few studies have attempted to address this. Poor teacher mental health may impact on the quality of support provided to young people, who also report increased mental health difficulties themselves. Objective To test the effectiveness of an intervention aiming to improve secondary school teachers’ well-being through mental health support and training. Design A cluster randomised controlled trial with embedded process and economic evaluations. Setting Twenty-five mainstream, non-fee-paying secondary schools in the south-west of England and South Wales, stratified by geographical area and free school meal entitlement, randomly allocated to intervention or control groups following collection of baseline measures (n = 12, intervention; n = 13, control) between May and July 2016. Participants All teachers in the study schools at any data collection. All students in year 8 (baseline) and year 10 (final follow-up). Intervention Each intervention school received three elements: (1) a 1-day mental health first aid for schools and colleges training session delivered to 8% of all teachers; (2) a 1-hour mental health session delivered to all teachers; and (3) 8% of staff trained in the 2-day standard mental health first aid training course set up a confidential peer support service for colleagues. Control schools continued with usual practice. Main outcome measures The primary outcome was teacher well-being (using the Warwick–Edinburgh Mental Wellbeing Scale). Secondary outcomes were teacher depression, absence and presenteeism, and student well-being, mental health difficulties, attendance and attainment. Follow-up was at 12 and 24 months. Data were analysed using intention-to-treat mixed-effects repeated-measures models. Economic evaluation A cost–consequence analysis to compare the incremental cost of the intervention against the outcomes measured in the main analysis. Process evaluation A mixed-methods study (i.e. qualitative focus groups and interviews, quantitative surveys, checklists and logs) to examine intervention implementation, activation of the mechanisms of change outlined in the logic model, intervention acceptability and the wider context. Results All 25 schools remained in the study. A total of 1722 teachers were included in the primary analysis. We found no difference in mean teacher well-being between study arms over the course of follow-up (adjusted mean difference –0.90, 95% confidence interval –2.07 to 0.27). There was also no difference in any of the secondary outcomes (p-values 0.203–0.964 in the fully adjusted models). The average cost of the intervention was £9103 (range £5378.97–12,026.73) per intervention school, with the average cost to Welsh schools being higher because of a different delivery model. The training components were delivered with high fidelity, although target dosage was sometimes missed. The peer support service was delivered with variable fidelity, and reported usage by teachers was low (5.9–6.1%). The intervention had high acceptability, but participants reported low support from senior leadership, and minimal impact on school culture. Limitations Participants and the study team were unblinded, self-report for the main outcome measures and inaccurate measurement of peer support service usage. Conclusions The Wellbeing in Secondary Education (WISE) intervention was not effective at improving teacher or student well-being, or reducing mental health difficulties, possibly because of contextual barriers preventing it becoming embedded in school life. Future work Identification of ways in which to achieve system-level change and sustained support from senior leaders is important for future school-based mental health interventions. Trial registration Current Controlled Trials ISRCTN95909211. Funding This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information. Intervention costs were met by Public Health Wales, Public Health England and Bristol City Council.

School closures and social distancing measures during the pandemic have disrupted young people’s daily routines and social relationships. We explored patterns of change in adolescent mental health and tested the relationship between pre-pandemic levels of school and peer connectedness and changes in mental health and well-being between the first lockdown and the return to school. This is a secondary analysis of a longitudinal 3-wave panel survey. The study sample included 603 students (aged 13–14) in 17 secondary schools across south-west England. Students completed a survey pre-pandemic (October 2019), during lockdown (May 2020) and shortly after returning to school (October 2020). Multilevel models, with random effects, were conducted for anxiety, depression and well-being outcomes with school and peer connectedness as predictor variables. Symptoms of anxiety decreased from pre-pandemic to during the first UK lockdown and increased on the return to school; anxious symptoms decreased the most for students reporting feeling least connected to school pre-pandemic. Students reporting low levels of school and peer connectedness pre-pandemic experienced poorer mental health and well-being at all time points. Low school connectedness pre-pandemic was associated with a greater increase in anxious and depressive symptoms between lockdown and the return to school when compared to students with medium levels of school connectedness. No associations were found with high school connectedness or with low/high peer connectedness. For adolescents with poor school connectedness, the enforced time away from school that the pandemic caused led to reduced anxiety. Going forwards, we need to consider ways in which to promote connection with school as a way of supporting mental health and well-being.

BACKGROUND: There is consistency of evidence on the link between school culture and student health. A positive school culture has been associated with positive child and youth development, effective risk prevention and health promotion efforts, with extensive evidence for the impact on student mental health. Interventions which focus on socio-cultural elements of school life, and which involve students actively in the process, are increasingly understood to be important for student mental health promotion. This qualitative study was undertaken in three UK secondary schools prior to the implementation of a participative action research study bringing students and staff together to identify changes to school culture that might impact student mental health. The aim was to identify how school culture is conceptualised by students, parents and staff in three UK secondary schools. A secondary aim was to explore which components of school culture were perceived to be most important for student mental health. METHODS: Across three schools, 27 staff and seven parents participated in in-depth interviews, and 28 students participated in four focus groups. The Framework Method of thematic analysis was applied. RESULTS: Respondents identified elements of school culture that aligned into four dimensions; structure and context, organisational and academic, community, and safety and support. There was strong evidence of the interdependence of the four dimensions in shaping the culture of a school. CONCLUSIONS: School staff who seek to shape and improve school culture as a means of promoting student mental health may have better results if this interdependence is acknowledged, and improvements are addressed across all four dimensions., National Institute for Health Research (NIHR) School for Public Health Research (Grant Reference Number PD–SPH–2015).

Mental health (MH) difficulties are on the increase among children and young people (CYP). Evidence has shown that educational settings contain both risk and protective factors for MH. This review investigated which structural and cultural factors and interventions within educational settings promote positive MH and prevent poor MH in 4–18 year olds. Searches were conducted in PsychINFO, Embase, ERIC, ASSIA and British Education Index, and reference lists from key studies and relevant systematic reviews were hand-searched. Intervention, cohort, and qualitative studies were included. Of the 62 included papers, 36 examined cultural factors (30 social/relational and six value-related) while 12 studies examined structural factors (eight organisational and four physical) and 14 studies examined multiple factors. There was strong evidence for the impact of positive classroom management techniques, access to physical activity, and peer mentoring on student MH. Studies examining the impact of positive school culture, teacher training in MH and parent involvement in school MH activities also found predominantly positive results for student MH, albeit the evidence was of lower quality or from a low number of studies. Few studies explicitly examined the impact of interventions on MH inequalities; those that did indicated limited if any reduction to inequalities. A very small number of studies suggested that interventions targeting those at risk of poor MH due to socioeconomic factors could successfully improve wellbeing and reduce depression, anxiety and behavioural problems. Studies exploring the effect of management and leadership strategies within schools, policies, and aspects of the physical environment other than green space were scarce or absent in the literature. This review highlights the need to consider the ways in which educational settings are organised, the culture that is created and the physical space in order to improve the MH of CYP.

Despite a rising prevalence of mental health difficulties in the young,existing prior to, but also exacerbated by the current COVID-19 pandemic, mentalhealth needs in this population remain unmet even in economically wealthycountries. Increasingly, supportive school environments have been suggested ashaving a significant impact on young people's mental health. The idea of healthpromoting schools, initiated by the World Health Organisation (WHO), highlights the ongoing need for both health education via the curriculum but also a school environment that is conducive to students' health and emotional well-being.Despite this promising public health measure, existing studies into mental healthrelated interventions delivered in schools have been found to have a small or no effect. One explanation for this is that previous studies did not sufficiently address or focus on the school environment, which may in itself pose barriers toacceptability and successful implementation of mental health interventions. Thispaper will highlight a novel methodological approach to public mental healthresearch - Participatory Action Research (PAR). The PAR method is unique inenabling study participants to become co-researchers of their own experiences in a specific context. A growing body of educational PAR research suggests that thismethod can also generate collaborative and participative processes foundational to positive school culture and mental health outcomes. This paper will provide anoverview of such outcomes, as well as outline methodological strengths andchallenges common to the PAR approach in educational mental health settings.

Teaching staff report poorer mental health and wellbeing than the general working population. Intervention to address this issue is imperative, as poor wellbeing is associated with burnout, presenteeism, and adverse student mental health outcomes. The Wellbeing in Secondary Education (WISE) intervention is a secondary school-based programme aimed at improving the mental health and wellbeing of teachers and students. There are three components: awareness-raising for staff; a peer support service delivered by staff trained in Mental Health First Aid (MHFA); and Schools and Colleges Mental Health First Aid (MHFA) training for teachers. A cluster randomised controlled trial with integrated process and economic evaluation was conducted with 25 secondary schools in the UK (2016–2018). The intervention was largely ineffective in improving teacher mental health and wellbeing. This paper reports process evaluation data on acceptability to help understand this outcome. It adopts a complex systems perspective, exploring how acceptability is a dynamic and contextually contingent concept. Data sources were as follows: interviews with funders (n = 3); interviews with MHFA trainers (n = 6); focus groups with peer supporters (n = 8); interviews with headteachers (n = 12); and focus groups with teachers trained in Schools and Colleges MHFA (n = 7). Results indicated that WISE intervention components were largely acceptable. Initially, the school system was responsive, as it had reached a ‘tipping point’ and was prepared to address teacher mental health. However, as the intervention interacted with the complexities of the school context, acceptability became more ambiguous. The intervention was seen to be largely inadequate in addressing the structural determinants of teacher mental health and wellbeing (e.g. complex student and staff needs, workload, and system culture). Future teacher mental health interventions need to focus on coupling skills training and support with whole school elements that tackle the systemic drivers of the problem.

Funder: Public Health England, Funder: Public Health Wales, Funder: Bristol City Council, BACKGROUND: Teachers are at heightened risk of poor mental health and well-being, which is likely to impact on the support they provide to students, and student outcomes. We conducted a cluster randomised controlled trial, to test whether an intervention to improve mental health support and training for high school teachers led to improved mental health and well-being for teachers and students, compared to usual practice. We also conducted a cost evaluation of the intervention. METHODS AND FINDINGS: The intervention comprised (i) Mental Health First Aid training for teachers to support students; (ii) a mental health awareness session; and (iii) a confidential staff peer support service. In total 25 mainstream, non-fee-paying secondary schools stratified by geographical area and free school meal entitlement were randomly allocated to intervention (n = 12) or control group (n = 13) after collection of baseline measures. We analysed data using mixed-effects repeated measures models in the intention-to-treat population, adjusted for stratification variables, sex, and years of experience. The primary outcome was teacher well-being (Warwick-Edinburgh Mental Well-being Scale). Secondary outcomes were teacher depression, absence, and presenteeism, and student well-being, mental health difficulties, attendance, and attainment. Follow-up was at months 12 (T1) and 24 (T2). We collected process data to test the logic model underpinning the intervention, to aid interpretation of the findings. A total of 1,722 teachers were included in the primary analysis. Teacher well-being did not differ between groups at T2 (intervention mean well-being score 47.5, control group mean well-being score 48.4, adjusted mean difference -0.90, 95% CI -2.07 to 0.27, p = 0.130). The only effect on secondary outcomes was higher teacher-reported absence among the intervention group at T2 (intervention group median number of days absent 0, control group median number of days absent 0, ratio of geometric means 1.04, 95% CI 1.00 to 1.09, p = 0.042). Process measures indicated little change in perceived mental health support, quality of relationships, and work-related stress. The average cost of the intervention was ��9,103 per school. The study's main limitations were a lack of blinding of research participants and the self-report nature of the outcome measures. CONCLUSIONS: In this study, we observed no improvements to teacher or student mental health following the intervention, possibly due to a lack of impact on key drivers of poor mental health within the school environment. Future research should focus on structural and cultural changes to the school environment, which may be more effective at improving teacher and student mental health and well-being. TRIAL REGISTRATION: www.isrctn.com ISRCTN95909211.

Background Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people. Objective The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people. Design This study comprised a systematic review, a network meta-analysis and an economic evaluation. Data sources The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied. Main outcomes The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms. Review methods Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted. Results A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student. Limitations The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions. Conclusions There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component. Future work Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured. Study registration This study is registered as PROSPERO CRD42016048184. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Background Factors within the school environment may impact young people's mental health and wellbeing. The aim of this study was to understand the association between teacher and student mental health and wellbeing. Further, it seeked to identify possible explanations by examining whether the strength of any association is weakened once quality of teacher-student relationships, teacher presenteeism and absence are considered. Methods Cross-sectional data were collected from 3216 year 8 (aged 12–13 years) students and from 1182 teachers in 25 secondary schools in England and Wales. The association between teacher wellbeing (measured by Warwick Edinburgh Mental Wellbeing Scale (WEMWBS)) with student wellbeing (WEMWBS) and with student psychological distress (Total Difficulties Score (TDS)) was assessed using Random Effects Mixed Models. Analyses were repeated using teacher depression (measured by Patient Health Questionnaire) as the explanatory variable. Results Better teacher wellbeing was associated with i) better student wellbeing (standardised effect = 0·07, 95% CI = 0·02 to 0·12) and ii) lower student psychological distress (standardised effect = −0·10, 95% CI = −0·16 to −0·04). Teacher presenteeism and the quality of the teacher-student relationship appeared to be on the pathway of these relationships. Higher levels of teacher depressive symptoms were associated with poorer student wellbeing and psychological distress (standardised effect = −0·06, 95% CI = −0·11 to −0·01 & 0·09, 95% CI = 0·03 to 0·15). This association did not withstand adjustment for teacher presenteeism. Limitations Cross sectional in design so unable to establish temporal associations. Conclusions Associations were found between teacher wellbeing and student wellbeing and psychological distress. There were also an association between teacher depression and student wellbeing. Both may be partially explained by teacher presenteeism and quality of teacher-student relationships.

Background: Young people spend a large proportion of their time in school, which presents both risk and protective factors for their mental health. A supportive school culture can promote and protect good mental health by creating experiences of safety and belonging amongst staff and students. In this qualitative study, we seek to explore whether a participatory action research (PAR) approach is an effective way to promote and improve student mental health. Methods: Participatory action research is an approach in which people collaboratively research their own experience: the researched communities become co-researchers of their own experiences in a specific context. We will work with four secondary schools in the UK to develop PAR projects. In each school, a group of 2–4 staff and 6–8 students will work together to develop a shared understanding of their school culture and to introduce activities or changes to make the culture more supportive of student mental health. We will evaluate the effectiveness of the PAR approach through i) a review of school documents pertaining to mental health (e.g., policies and Ofsted reports), ii) interviews with staff members ( n = 40), parents ( n = 8) and students ( n = 24–40) before and after the PAR intervention, iii) observations and reports of the PAR group meetings and iv) interviews with members of the PAR groups after the PAR intervention. Discussion: We anticipate that our research findings will advance knowledge on effective methods to develop a positive school culture that will contribute to the improvement of young people’s mental health and well-being. We will seek to identify the mechanisms through which school culture can have a positive impact on mental health and develop a logic model and a school culture toolkit that can be utilised as a resource to inform public health interventions to promote mental health in a range of educational settings.

Heavy alcohol use and associated needs are prevalent amongst arrestees. The custody suite offers an opportunity to identify and intervene with this population. However, it is unclear whether functions of care can be effectively delivered within an environment of containment. This study aimed to examine custody staff experiences of screening and delivering brief alcohol interventions to heavy drinking arrestees. Qualitative interviews were conducted with 25 custody staff (detention officers and assessment, intervention and referral staff), involved in a pilot feasibility trial of alcohol screening and brief interventions in the police custody suite. We examined the tension between containment and care using concepts of role security and therapeutic commitment to guide our analysis. Our findings show that custody staff considered brief interventions to be legitimate in the custody suite setting, although there were differing views relating to which staff are best placed to deliver them. Detention officers reported vacillating therapeutic commitment to intervening with heavy drinking arrestees, compounded by some arrestees being perceived to be ‘undeserving’ of care. Tensions inherent in the need for ‘containment’ as well as ‘care’ must be addressed if brief alcohol interventions are to be implemented within the custody suite.

BackgroundThere is increasing evidence that domestic violence (DV) is an important risk factor for suicidal behaviour. The level of risk and its contribution to the overall burden of suicidal behaviour among men and women has not been quantified in South Asia. We carried out a large case-control study to examine the association between DV and self-poisoning in Sri Lanka.MethodsCases (N = 291) were patients aged ⩾18 years, admitted to a tertiary hospital in Kandy Sri Lanka for self-poisoning. Sex and age frequency matched controls were recruited from the hospital's outpatient department (N = 490) and local population (N = 450). Exposure to DV was collected through the Humiliation, Afraid, Rape, Kick questionnaire. Multivariable logistic regression models were conducted to estimate the association between DV and self-poisoning, and population attributable fractions were calculated.ResultsExposure to at least one type of DV within the previous 12 months was strongly associated with self-poisoning for women [adjusted OR (AOR) 4.08, 95% CI 1.60–4.78] and men (AOR 2.52, 95% CI 1.51–4.21), compared to those reporting no abuse. Among women, the association was strongest for physical violence (AOR 14.07, 95% CI 5.87–33.72), whereas among men, emotional abuse showed the highest risk (AOR 2.75, 95% CI 1.57–4.82). PAF% for exposure to at least one type of DV was 38% (95% CI 32–43) in women and 22% (95% CI 14–29) in men.ConclusionsMulti-sectoral interventions to address DV including enhanced identification in health care settings, community-based strategies, and integration of DV support and psychological services may substantially reduce suicidal behaviour in Sri Lanka.

Background Improving children and young people’s provision for mental health is a current health priority in England. Secondary school teachers have worse mental health outcomes than the general working population, which the Wellbeing in Secondary Education (WISE) cluster randomised controlled trial aimed to improve. The WISE intervention comprised a Mental Health First Aid (MHFA) training package delivered to at least 16% of staff, a short mental health awareness session to all teachers and development of a staff peer support service. Twenty-five schools were randomised to intervention or control arms. This paper reports findings regarding the extent of uptake and fidelity of the intervention. Methods Mixed methods data collection comprised researcher observations of training delivery, training participant evaluation forms, trainer and peer supporter interviews, peer supporter feedback meetings, logs of support provided, and teacher questionnaires. Quantitative data were summarised descriptively, while thematic analysis was applied to the qualitative data. Results In the 12 schools assigned to the intervention arm, 113 (8.6%) staff completed the 2-day standard MHFA training course, and a further 146 (11.1%) staff completed the 1-day MHFA for schools and colleges training. In seven (58.3%) schools, the required 8% of staff completed the MHFA training packages. A 1-h mental health awareness-raising session was attended by 666 (54.5%) staff. Delivery of the MHFA training package was achieved with high levels of fidelity and quality across schools. All schools set up the peer support service following training, with a majority adhering to most of the operational guidelines developed from the pilot study at the outset. Teachers reported limited use of the peer support service during follow-up. At the 1-year follow-up, only three (25.0%) schools indicated they had re-advertised the service and there was evidence of a reduction in support from senior leadership. Conclusion The MHFA training package was delivered with reasonably high fidelity, and a staff peer support service was established with general, but not complete, adherence to guidelines. In some schools, insufficient staff received MHFA training and levels of delivery of the peer support service compromised intervention dose and reach. Trial registration ISRCTN 95909211. Registered on 15 January 2016

Objectives: Most of the evidence on the effects of internet use on mental health derives from cross-sectional research. We set out to explore prospective associations between internet use (hours online and specific internet experiences) and future mental health problems. Methods: Participants were 1,431 respondents from the Avon Longitudinal Study of Parents and Children (ALSPAC), a UK birth cohort, who completed a questionnaire on internet use (time online and ten different internet experiences) when they were aged 18 years. Outcomes included past year self-harm, assessed at 21 years and high levels of depression and anxiety symptoms, assessed at 22 years. Associations were investigated using logistic regression models and analyses were conducted separately for males and females.Results: Females reporting high levels of internet use (number of hours online) were found to be at increased risk of depression at follow-up (highest tertile vs lowest tertile OR= 1.41, 95% CI 0.90 to 2.20), whereas males with high levels of internet use were at increased risk for self-harm (highest tertile vs lowest tertile OR=2.53, 95%CI 0.93 to 6.90). There was no evidence to suggest an association between hours spent online and anxiety. With regards to the specific internet experiences, associations were found for females but not for males. In fully adjusted models, being bullied online (OR=1.76, 95% CI 1.09 to 2.86) and meeting someone face to face (OR=1.55, 95% CI 1.00 to 2.41) were associated with an increased risk of future depression. Being bullied online was also associated with an increased risk of future self-harm (OR= 2.42, 95% CI 1.41 to 4.15), along with receiving unwanted sexual comments or material, and coming across pornography and violent/gruesome material.Conclusions: Our findings highlight the importance of digital citizenship training to help teach young people to use technology safely and responsibly.

Background: When students experience serious mental health difficulties, universities face the dilemma of deciding whether to notify trusted others such as parents. This study investigates the key factors underpinning students’ decisions not to opt-in to ‘consent to contact’, which would allow their university to notify an emergency contact of their choice in the event of serious mental health difficulties.Methods: An online survey was administered to university students in a UK institution with an active consent to contact policy. Students self-reported: (1) whether they had opted-in or opted-out of the policy, (2) socio-demographics, and (3) mental health outcomes including depression (PHQ-9) and anxiety (GAD-7). Students who recalled not opting-in were invited to explain their decision via qualitatively analysed free-text responses.Results: 2637 students responded, 648 (24.57%) recalled opting-in, 463 (17.56%) recalled not opting-in and 1432 (54.30%) were unsure how they opted. Students currently experiencing moderate/severe anxiety and depression demonstrated lower rates of opting-in than students not experiencing these difficulties. The most common reasons for not opting-in were ‘not wanting emergency contacts to worry’ and ‘preferring to tell emergency contacts themselves’. These policy decisions were underpinned by four qualitative themes: ‘unhelpful anticipated outcomes’, ‘seriousness of student difficulties experienced’, ‘quality of relationship with their emergency contact’ and ‘situational appropriateness’.Limitations: This study focussed on students at a single university.Conclusions: Students who are at greater risk of mental health difficulties may be resistant to wider support networks being contacted. Future research is required to address barriers to opting-in for students most at-risk.

Background The COVID-19 pandemic, school closures, and social distancing measures have disrupted young people's daily routines, learning, and social relationships. We examine the changes in adolescent mental health over time and explore the relationship between how connected students felt to their school and peers before the pandemic and how this affected their mental health during school closures and on return to school. Methods This is a longitudinal three-wave panel survey with students aged 13–15 years in 17 secondary schools across the South West of England. Students completed a self-report survey before the pandemic (October, 2019), during the first UK lockdown (May, 2020), and shortly after returning to school (October, 2020). Matched data across all three waves were available for 603 students. Anxiety and depression were measured using the Hospital Anxiety & Depression Scale (HADS). School connectedness was measured using six items adapted from the Psychological Sense of School Membership (PSSM) scale. Peer connectedness was measured using a seven-item subscale as published by Jose, Ryan, and Pryor (2012). The study was approved by the University of Bristol Medical School ethics committee (reference 84883). Findings There was an overall decrease in anxiety score from before the pandemic (median 7, IQR 4–11) to during the first UK lockdown (median 6, IQR 3–10). Wilcoxon signed-rank tests indicated that this difference was statistically significant (z=–7·061, p

Background Teachers are reported to be at increased risk of common mental health disorders compared to other occupations. Failure to support teachers adequately may lead to serious long-term mental disorders, poor performance at work (presenteeism), sickness absence and health-related exit from the profession. It also jeopardises student mental health, as distressed staff struggle to develop supportive relationships with students, and such relationships are protective against student depression. A number of school-based trials have attempted to improve student mental health, but these have mostly focused on classroom based approaches and have failed to establish effectiveness. Only a few studies have introduced training for teachers in supporting students, and none to date have included a focus on improving teacher mental health. This paper sets out the protocol (version 4.4 20/07/16) for a study aiming to address this gap. Methods Cluster randomised controlled trial with secondary schools as the unit of randomisation. Intervention schools will receive: i) Mental Health First Aid (MHFA) training for a group of staff nominated by their colleagues, after which they will set up a confidential peer support service for colleagues ii) training in MHFA for schools and colleges for a further group of teachers, which will equip them to more effectively support student mental health iii) a short mental health awareness raising session and promotion of the peer support service for all teachers. Comparison schools will continue with usual practice. The primary outcome is teacher wellbeing measured using the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS). Secondary outcomes are teacher depression, absence and presenteeism, and student wellbeing, mental health difficulties, attendance and attainment. Measures will be taken at baseline, one year follow up (teachers only) and two year follow up. Economic and process evaluations will be embedded within the study. Discussion This study will establish the effectiveness and cost-effectiveness of an intervention that supports secondary school teachers’ wellbeing and mental health, and improves their skills in supporting students. It will also provide information regarding intervention implementation and sustainability. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered 24/03/16 Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3756-8) contains supplementary material, which is available to authorized users.

BackgroundTeachers have been shown to have high levels of stress and common mental disorder, but few studies have examined which factors within the school environment are associated with poor teacher mental health.MethodsTeachers (n=555) in 8 schools completed self-report questionnaires. Levels of teacher wellbeing (Warwick Edinburgh Mental Wellbeing Scale-WEMWBS) and depressive symptoms (Patient Health Questionnaire-PHQ-9) were measured and associations between these measures and school-related factors were examined using multilevel multivariable regression models.ResultsThe mean (SD) teacher wellbeing score (47.2 (8.8)) was lower than reported in working population samples, and 19.4% had evidence of moderate to severe depressive symptoms (PHQ-9 scores >10). Feeling unable to talk to a colleague when feeling stressed or down, dissatisfaction with work and high presenteeism were all strongly associated with both poor wellbeing (beta coefficients ranged from −4.65 [−6.04, −3.28] to −3.39 [−5.48, −1.31]) and depressive symptoms (ORs ranged from 2.44 [1.41, 4.19] to 3.31 [1.70, 6.45]). Stress at work and recent change in school governance were also associated with poor wellbeing (beta coefficients=−4.22 [−5.95, −2.48] and −2.17 [−3.58, −0.77] respectively), while sickness absence and low student attendance were associated with depressive symptoms (ORs=2.14 [1.24, 3.67] and 1.93 [1.06, 6.45] respectively).Limitationsi) This was a cross-sectional study; causal associations cannot be identified ii) several of the measures were self-report iii) the small number of schools reduced study power for the school-level variablesConclusionsWellbeing is low and depressive symptoms high amongst teachers. Interventions aimed at improving their mental health might focus on reducing work related stress, and increasing the support available to them.

Secondary school teachers have low levels of wellbeing and high levels of depression compared with the general population. Teachers are in a key position to support students, but poor mental health may be a barrier to doing so effectively. The Wellbeing in Secondary Education (WISE) project is a cluster randomised controlled trial (RCT) of an intervention to improve the mental health support and training available to secondary school teachers through delivery of the training package Mental Health First Aid and a staff peer support service. We will conduct a process evaluation as part of the WISE trial to support the interpretation of trial outcomes and refine intervention theory. The domains assessed will be: the extent to which the hypothesised mechanisms of change are activated; system level influences on these mechanisms; programme differentiation and usual practice; intervention implementation, including any adaptations; intervention acceptability; and intervention sustainability. Research questions will be addressed via quantitative and qualitative methods. All study schools (n = 25) will provide process evaluation data, with more detailed focus group, interview and observation data being collected from a subsample of case study schools (4 intervention and 4 control). Mechanisms of change, as outlined in a logic model, will be measured via teacher and student surveys and focus groups. School context will be explored via audits of school practice that relate to mental health and wellbeing, combined with stakeholder interviews and focus groups. Implementation of the training and peer support service will be assessed via training observations, training participant evaluation forms, focus groups with participants, interviews with trainers and peer support service users, and peer supporter logs recording help provided. Acceptability and sustainability will be examined via interviews with funders, head teachers, trainers and peer support services users, and focus groups with training participants. The process evaluation embedded within the WISE cluster RCT will illuminate how and why the intervention was effective, ineffective or conferred iatrogenic effects. It will contribute to the refinement of the theory underpinning the intervention, and will help to inform any future implementation. International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered on 24 March 2016.

Background: Secondary school teachers have low levels of wellbeing and high levels of depression compared with\ud the general population. Teachers are in a key position to support students, but poor mental health may be a barrier to\ud doing so effectively. The Wellbeing in Secondary Education (WISE) project is a cluster randomised controlled trial (RCT)\ud of an intervention to improve the mental health support and training available to secondary school teachers through\ud delivery of the training package Mental Health First Aid and a staff peer support service. We will conduct a process\ud evaluation as part of the WISE trial to support the interpretation of trial outcomes and refine intervention theory. The\ud domains assessed will be: the extent to which the hypothesised mechanisms of change are activated; system level\ud influences on these mechanisms; programme differentiation and usual practice; intervention implementation, including\ud any adaptations; intervention acceptability; and intervention sustainability.\ud Methods: Research questions will be addressed via quantitative and qualitative methods. All study schools (n = 25) will\ud provide process evaluation data, with more detailed focus group, interview and observation data being collected from\ud a subsample of case study schools (4 intervention and 4 control). Mechanisms of change, as outlined in a logic model,\ud will be measured via teacher and student surveys and focus groups. School context will be explored via audits of\ud school practice that relate to mental health and wellbeing, combined with stakeholder interviews and focus groups.\ud Implementation of the training and peer support service will be assessed via training observations, training participant\ud evaluation forms, focus groups with participants, interviews with trainers and peer support service users, and peer\ud supporter logs recording help provided. Acceptability and sustainability will be examined via interviews with funders,\ud head teachers, trainers and peer support services users, and focus groups with training participants.\ud Discussion: The process evaluation embedded within the WISE cluster RCT will illuminate how and why the intervention\ud was effective, ineffective or conferred iatrogenic effects. It will contribute to the refinement of the theory underpinning\ud the intervention, and will help to inform any future implementation.\ud Trial registration: International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered on\ud 24 March 2016.\ud Keywords: Mental health, Wellbeing, Schools, Children, Adolescents, Teachers, Process evaluation, Cluster\ud Randomised Controlled Trial

Background Low IQ is associated with an increased risk of suicide and suicide attempt in adults, but less is known about the relationship between IQ and aspects of suicidal/self-harm behaviours in adolescence. Methods We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based prospective UK cohort. Binomial and multinomial logistic regression models were used to examine the association of IQ measured at age 8 with suicide-related outcomes amongst 4810 adolescents aged 16–17 years. Results There was some evidence that associations differed in boys and girls (p values for interaction ranged between 0.06 and 0.25). In boys higher IQ was associated with increased risk of suicidal thoughts (adjusted odds ratio per 10 point increase in IQ score=1.14, 95% Confidence Interval [CI] 1.01–1.28) and suicidal plans (1.15, 95% CI 0.93–1.43), although statistical evidence for the latter association was limited. There was also evidence for an association with non-suicidal self-harm (1.24, 95% CI 1.08–1.45) but not suicidal self-harm (1.04, 95% CI 0.86–1.25). In girls higher IQ was associated with increased risk of non-suicidal self-harm (1.11, 95% CI 1.02–1.22) but not suicidal thoughts, suicidal plans or suicidal self-harm. Limitations Loss to follow up and questionnaire non-response may have led to selection bias. Conclusion In contrast to previous studies of IQ–suicide associations in adults, we found that higher IQ was associated with an increased risk of non-suicidal self-harm in male and female adolescents and suicidal thoughts in males. Associations of IQ with self-harm differed for self-harm with and without suicidal intent, suggesting that the aetiology of these behaviours may differ.

Background School teachers are at heightened risk of mental health difficulties. A small number of trials have introduced teacher training to improve support for students, but none have increased support available for teachers themselves. We aimed to evaluate the effect of a mental health support and training intervention on secondary school teachers’ and students’ wellbeing and mental health. Methods Drawing on social support theory and an ecological view of school connectedness, we developed an intervention that comprised training in Mental Health First Aid, a 1-h mental health awareness raising session, and a confidential staff peer support service. This cluster-randomised controlled trial tested intervention effectiveness compared with usual practice. Mainstream, non-fee paying, secondary schools in England and Wales, stratified by geographical area and free school meal entitlement (a proxy for student deprivation), were randomly allocated to intervention or control groups after collection of baseline measures. Participants and study team were aware of group assignment. We analysed data using mixed-effects repeated measures models in the intention-to-treat population, adjusted for stratification variables, sex, and years of experience (teacher outcomes only). A mixed-methods process evaluation was done. The primary outcome was teacher wellbeing (Warwick-Edinburgh Mental Wellbeing Scale). Secondary outcomes were teacher depression, absence, and presenteeism, and student wellbeing, mental health difficulties, attendance, and attainment. Follow-up was done at months 12 and 24. This trial is registered with ISRCTN, number 95909211. Findings Between March 24 and June 30, 2016, 25 schools (12 intervention, 13 control) were recruited; cluster sizes were 40–119 teachers. 1722 teachers were included in the primary analysis. Teacher wellbeing did not differ between groups (adjusted mean difference −0·90, 95% CI −2·07 to 0·27; intracluster correlation coefficient 0·01), nor did any of the secondary outcomes (adjusted p=0·203–0·964). Participant checklists showed good fidelity to training content (mean score 4·7/5 [SD 0·6]), and peer support reports indicated good adherence to service delivery guidelines. Teacher focus group data showed good initial acceptability, but usage of the peer support service waned over 2 years. Participants reported that the intervention had little impact on school culture and lacked genuine buy-in from senior leaders. Interpretation The intervention did not achieve population-level improvement to teacher or student mental health, possibly due to a failure to instigate sustained, school-level cultural change. Future research should focus on how to create systemic change in schools to improve the effectiveness of interventions. Funding National Institute for Health Research Public Health Research programme, Public Health Wales, Public Health England, and Bristol City Council.

Background Secondary school teachers are at heightened risk of psychological distress, which can lead to poor work performance, poor quality teacher-student relationships and mental illness. A pilot cluster randomised controlled trial (RCT) – the WISE study – evaluated the feasibility of a full-scale RCT of an intervention to support school staff’s own mental health, and train them in supporting student mental health. Methods Six schools were randomised to an intervention or control group. In the intervention schools i) 8–9 staff received Mental Health First Aid (MHFA) training and became staff peer supporters, and ii) youth MHFA training was offered to the wider staff body. Control schools continued with usual practice. We used thematic qualitative data analysis and regression modelling to ascertain the feasibility, acceptability and potential usefulness of the intervention. Results Thirteen training observations, 14 staff focus groups and 6 staff interviews were completed, and 438 staff (43.5 %) and 1,862 (56.3 %) students (years 8 and 9) completed questionnaires at baseline and one year later. MHFA training was considered relevant for schools, and trainees gained in knowledge, confidence in helping others, and awareness regarding their own mental health. Suggestions for reducing the length of the training and focusing on helping strategies were made. A peer support service was established in all intervention schools and was perceived to be helpful in supporting individuals in difficulty – for example through listening, and signposting to other services - and raising the profile of mental health at a whole school level. Barriers to use included lack of knowledge about the service, concerns about confidentiality and a preference for accessing support from pre-existing networks. Conclusions The WISE intervention is feasible and acceptable to schools. Results support the development of a full-scale cluster RCT, if steps are taken to improve response rates and implement the suggested improvements to the intervention. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN13255300 retrospectively registered 28/09/16. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3737-y) contains supplementary material, which is available to authorized users.

The need for schools to support children and young people’s mental and emotional health is increasingly emphasised in policy initiatives, yet the role of teachers in this has been under explored. This paper reports findings from qualitative, semi‐structured interviews with 14 school staff at eight secondary schools in England, examining emotional health and well‐being (EHWB) activities in which they were involved. Three emergent themes are discussed: (1) a strongly held belief that teaching and EHWB are inevitably linked; (2) a perception that many colleagues outside the study sample are reluctant to engage in EHWB work; and (3) a concern that teachers’ own emotional health needs are neglected, leaving them unable or unwilling to consider those of pupils. The findings endorse whole‐school approaches to emotional health, with a focus on teachers’ training and support needs and clearer aims, including consideration of how such work fits with the broader goals of schools.

Defining and therefore evaluating the effectiveness of school sex education is problematic because of its location at the site of struggle between competing discourses. Those discourses—summarised here as ‘moralistic’, ‘harm reductionist’ and ‘empowering’—each emphasise a different conceptualisation of sex education's intended outcomes. The challenges that these discursive tensions present for research are examined by drawing on a study investigating the effectiveness of involving young mothers in school sex education. Through a discussion of some of the study's findings, the value of adopting a multi‐method approach as a way of managing different understandings of effectiveness is explored. The article concludes that research in the area of sex education needs to make use of complex study designs, which take into consideration these contested understandings regarding its purpose.

This paper presents data from a study of four projects in which young mothers deliver school sex education sessions, with the aim of giving pupils ‘informed choices’ regarding their sexual behaviour. Eleven focus group discussions were carried out with pupils, and semi‐structured interviews were carried out with 14 young mothers in order to assess the extent to which the sessions were of value in this way. The findings show that pupils perceived the sessions to be beneficial, not necessarily through providing new information as implied by the notion of ‘informed choice’, but because they fostered a deeper level of understanding and acceptance of the potential consequences of their decisions regarding sex and contraception. The main reason for this outcome, that is pupils' beliefs that they were hearing the whole truth from their peers, is demonstrated and critically explored in relation to the young mothers' own perceptions of the sessions. The implications of the somewhat different understandings of the ...

Background Several aspects of school life are thought to be associated with increased risk of self-harm in adolescence, but these have rarely been investigated in prospective studies. Methods Members of the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort completed postal surveys of school experiences aged 14, and self-harm behaviour aged 16 (n=3939). Associations between school experiences (feeling connected to school, enjoyment of school and perception of teachers as fair) and subsequent self-harm were examined using multivariable logistic regression models. Results Self-harm aged 16 was associated with earlier perceptions of school, specifically not getting on well with or feeling accepted by others (OR=2.43 [1.76, 3.35] and OR=2.69 [2.16, 3.35] respectively), not liking school or the work done in class (OR=1.40 [1.17, 1.69] and OR=1.36 [1.10, 1.67]), and feeling that teachers are not clear about behaviour or fail to address misbehaviour consistently (OR=1.59 [1.20, 2.12] OR=1.89 [1.51, 2.37]). These associations were partially attenuated in models controlling for mental health concurrent with the outcome. Poor school experiences were related to both suicidal and non-suicidal self-harm, with slightly stronger associations visible for the former. Limitations (i) There was some loss to follow up, (ii) experience of bullying was not measured, and (iii) exposure and outcome measures were self-report. Conclusions Students who feel unconnected to school, unhappy at school, or feel that teachers are unfair are more likely to self-harm in the future. Assessing students׳ perceptions of school may serve to identify those at risk of self-harm who would benefit from preventative interventions.

Objective Parental suicidal behavior is associated with offspring's risk of suicidal behavior. However, much of the available evidence is from population registers or clinical samples. We investigated the associations of self-reported parental suicide attempt (SA) with offspring self-harm and suicidal thoughts in the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective birth cohort. Method Parental SA was self-reported on 10 occasions from pregnancy until their child was 11 years of age. Offspring self-reported lifetime self-harm, with and without suicidal intent, suicidal thoughts, and suicide plans, at age 16 to 17 years. Multivariable regression models quantified the association between parental SA and offspring outcomes controlling for confounders. Results Data were available for 4,396 mother–child and 2,541 father–child pairs. Adjusting for confounders including parental depression, maternal SA was associated with a 3-fold increased risk of self-harm with suicidal intent in their children (adjusted odds ratio [aOR] = 2.94, 95% confidence interval [CI] = 1.43–6.07) but not with self-harm without suicidal intent (aOR = 0.83, 95% CI = 0.35–1.99). Children whose mother attempted suicide were more likely to report suicidal thoughts and plans (aOR = 5.04, 95% CI = 2.24–11.36; aOR = 2.17, 95% CI = 1.07–4.38, respectively). Findings in relation to paternal SA were somewhat weaker and not significant. Conclusions Maternal SA increased their offspring's risk of self-harm with suicidal intent and of suicidal thoughts, but was unrelated to self-harm without intent; findings for paternal suicide attempt were weaker and not significant. Maternal SA, which may not come to the attention of health care professionals, represents a major risk for psychiatric morbidity in their offspring.

BACKGROUND AND OBJECTIVES: The evidence base for the importance of the school environment for adolescent emotional health has never been systematically reviewed. We aimed to synthesize the evidence for the effect on adolescent emotional health of (1) interventions targeting the school environment and (2) the school environment in cohort studies. METHODS: Searches of Medline, Embase, PsychINFO, CINAHL, ERIC, the Social Citation Index, and the gray literature were conducted. Criteria for inclusion were (1) cohort or controlled trial designs, (2) participants aged 11 to 18 years, (3) emotional health outcomes, and (4) school environment exposure or intervention. Relevant studies were retrieved and data extracted by 2 independent reviewers. RESULTS: Nine papers reporting 5 controlled trials were reviewed, along with 30 cohort papers reporting 23 studies. Two nonrandomized trials found some evidence that a supportive school environment improved student emotional health, but 3 randomized controlled trials did not. Six (20%) cohort papers examined school-level factors but found no effect. There was some evidence that individual perceptions of school connectedness and teacher support predict future emotional health. Multilevel studies showed school effects were smaller than individual-level effects. Methodological shortcomings were common. CONCLUSIONS: There is limited evidence that the school environment has a major influence on adolescent mental health, although student perceptions of teacher support and school connectedness are associated with better emotional health. More studies measuring school-level factors are needed. Randomized controlled trials evaluating 1 or 2 environmental components may have more success in establishing effective and feasible interventions compared with complex whole-school programs.

Background Schools have been identified as an important place in which to support adolescent emotional health, although evidence as to which interventions are effective remains limited. Relatively little is known about student and staff views regarding current school-based emotional health provision and what they would like to see in the future, and this is what this study explored. Methods A random sample of 296 English secondary schools were surveyed to quantify current level of emotional health provision. Qualitative student focus groups (27 groups, 154 students aged 12-14) and staff interviews (12 interviews, 15 individuals) were conducted in eight schools, purposively sampled from the survey respondents to ensure a range of emotional health activity, free school meal eligibility and location. Data were analysed thematically, following a constant comparison approach. Results Emergent themes were grouped into three areas in which participants felt schools did or could intervene: emotional health in the curriculum, support for those in distress, and the physical and psychosocial environment. Little time was spent teaching about emotional health in the curriculum, and most staff and students wanted more. Opportunities to explore emotions in other curriculum subjects were valued. All schools provided some support for students experiencing emotional distress, but the type and quality varied a great deal. Students wanted an increase in school-based help sources that were confidential, available to all and sympathetic, and were concerned that accessing support should not lead to stigma. Finally, staff and students emphasised the need to consider the whole school environment in order to address sources of distress such as bullying and teacher-student relationships, but also to increase activities that enhanced emotional health. Conclusion Staff and students identified several ways in which schools can improve their support of adolescent emotional health, both within and outside the curriculum. However, such changes should be introduced as part of a wider consideration of how the whole school environment can be more supportive of students' emotional health. Clearer guidance at policy level, more rigorous evaluation of current interventions, and greater dissemination of good practice is necessary to ensure adolescents' emotional health needs are addressed effectively within schools.

Background Emotional disorders in young people are increasing but studies have found that this age group do not always recognise the signs and symptoms of mental health problems in themselves or others. The Mental Health Foundation’s school-based Peer Education Project (PEP) has the potential to improve young people’s understanding of their own mental health at a critical developmental stage (early adolescence) using a peer teaching method. This study is a process evaluation to understand: the mechanisms through which PEP might improve young people’s mental health literacy, any challenges with delivery, how the project can be embedded within wider school life and how it can be improved to be of most benefit to the widest number of young people. We will also validate a bespoke mental health literacy questionnaire, and test the feasibility of using it to measure outcomes in preparation for a future study evaluating effectiveness. Methods All schools recruited to the study will receive the PEP intervention. The process evaluation will be informed by realist evaluation approaches to build understanding regarding key mechanisms of change and the impact of different school contexts. The evaluation will test and revise an existing intervention logic model which has been developed in partnership with the Mental Health Foundation. Process evaluation data will be collected from newly recruited schools (n = 4) as well as current PEP user schools (n = 2) including training and lesson delivery observations, staff interviews and student focus groups. Baseline and follow-up data will be collected in all newly recruited intervention schools (n = 4) from all students in Year 7/8 (who receive the PEP) and recruited peer educators in Year 12 via a self-report survey. Discussion This study will enable us to refine the logic model underpinning the peer education project and identify areas of the intervention that can be improved. Findings will also inform the design of a future effectiveness study which will test out the extent to which PEP improves mental health literacy.