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Background: With growing evidence suggesting that levels of emotional well-being have been decreasing globally over the past few years, demand for easily accessible, convenient, and affordable well-being and mental health support has increased. Although mental health apps designed to tackle this demand by targeting diagnosed conditions have been shown to be beneficial, less research has focused on apps aiming to improve emotional well-being. There is also a dearth of research on well-being apps structured around users' lived experiences and emotional patterns and a lack of integration of real-world evidence of app usage. Thus, the potential benefits of these apps need to be evaluated using robust real-world data., Objective: This study aimed to explore usage patterns and preliminary outcomes related to mental health and well-being among users of an app (Paradym; Paradym Ltd) designed to promote emotional well-being and positive mental health., Methods: This is a pre-post, single-arm evaluation of real-world data provided by users of the Paradym app. Data were provided as part of optional built-in self-assessments that users completed to test their levels of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder Questionnaire-7), life satisfaction (Satisfaction With Life Scale), and overall well-being (World Health Organization-5 Well-Being Index) when they first started using the app and at regular intervals following initial usage. Usage patterns, including the number of assessments completed and the length of time between assessments, were recorded. Data were analyzed using within-subjects t tests, and Cohen d estimates were used to measure effect sizes., Results: A total of 3237 app users completed at least 1 self-assessment, and 787 users completed a follow-up assessment. The sample was diverse, with 2000 users (61.8%) being located outside of the United States. At baseline, many users reported experiencing strong feelings of burnout (677/1627, 41.6%), strong insecurities (73/211, 34.6%), and low levels of thriving (140/260, 53.8%). Users also experienced symptoms of depression (mean 9.85, SD 5.55) and anxiety (mean 14.27, SD 6.77) and reported low levels of life satisfaction (mean 12.14, SD 7.42) and general well-being (mean 9.88, SD 5.51). On average, users had been using the app for 74 days when they completed a follow-up assessment. Following app usage, small but significant improvements were reported across all outcomes of interest, with anxiety and depression scores improving by 1.20 and 1.26 points on average, respectively, and life satisfaction and well-being scores improving by 0.71 and 0.97 points, respectively., Conclusions: This real-world data analysis and evaluation provided positive preliminary evidence for the Paradym app's effectiveness in improving mental health and well-being, supporting its use as a scalable intervention for emotional well-being, with potential applications across diverse populations and settings, and encourages the use of built-in assessments in mental health app research., (©Athina Marina Metaxa, Shaun Liverpool, Mia Eisenstadt, John Pollard, Courtney Carlsson. Originally published in JMIR Formative Research (https://formative.jmir.org), 23.01.2025.)

It is estimated that disruptions to life caused by the COVID-19 pandemic have led to an increase in the number of children and young people suffering from mental health issues globally. In England one in four children experienced poor mental health in 2022. Social prescribing is gaining traction as a systems-based approach, which builds upon person-centered methods, to refer children and young people with non-clinical mental health issues to appropriate community assets. Recognition of social prescribing benefits for children's mental health is increasing, yet evidence is limited. Inconsistent terminology and variation of terms used to describe social prescribing practices across the literature hinders understanding and assessment of social prescribing's impact on children's mental health. This scoping review thus aims to systematically identify and analyse the various terms, concepts and language used to describe social prescribing with children and young people across the wider health and social care literature base. The scoping review will be undertaken using a six-stage framework which includes: identifying the research question, identifying relevant studies, study selection, charting the data, collating, summarising and reporting the results, and consultation. Electronic databases (MEDLINE, Embase, Cumulative Index to Nursing and Allied Health, PsychInfo, Social Policy Practice, Scopus, Science Direct, Cochrane library and Joanna Briggs), alongside evidence from grey literature, hand search, citation tracking, and use of expert correspondence will be included in the review to ensure published and unpublished literature is captured. Data extraction will be carried out by two reviewers using a predefined form to capture study characteristics, intervention descriptions, outcomes, and key terms used to report social prescribing for children and young people. No formal quality appraisal or risk of bias evaluation will be performed, as this scoping review aims to map and describe the literature. Data will be stored and managed using the Rayaan.ai platform and a critical narrative of the common themes found will be included., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Feather et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Depression affects 5% of adults and it is a major cause of disability worldwide. Digital psychotherapies offer an accessible solution addressing this issue. This systematic review examines a spectrum of digital psychotherapies for depression, considering both their effectiveness and user perspectives., Objective: This review focuses on identifying (1) the most common types of digital psychotherapies, (2) clients' and practitioners' perspectives on helpful and unhelpful aspects, and (3) the effectiveness of digital psychotherapies for adults with depression., Methods: A mixed methods protocol was developed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search strategy used the Population, Intervention, Comparison, Outcomes, and Study Design (PICOS) framework covering 2010 to 2024 and 7 databases were searched. Overall, 13 authors extracted data, and all aspects of the review were checked by >1 reviewer to minimize biases. Quality appraisal was conducted for all studies. The clients' and therapists' perceptions on helpful and unhelpful factors were identified using qualitative narrative synthesis. Meta-analyses of depression outcomes were conducted using the standardized mean difference (calculated as Hedges g) of the postintervention change between digital psychotherapy and control groups., Results: Of 3303 initial records, 186 records (5.63%; 160 studies) were included in the review. Quantitative studies (131/160, 81.8%) with a randomized controlled trial design (88/160, 55%) were most common. The overall sample size included 70,720 participants (female: n=51,677, 73.07%; male: n=16,779, 23.73%). Digital interventions included "stand-alone" or non-human contact interventions (58/160, 36.2%), "human contact" interventions (11/160, 6.8%), and "blended" including stand-alone and human contact interventions (91/160, 56.8%). What clients and practitioners perceived as helpful in digital interventions included support with motivation and accessibility, explanation of task reminders, resources, and learning skills to manage symptoms. What was perceived as unhelpful included problems with usability and a lack of direction or explanation. A total of 80 studies with 16,072 participants were included in the meta-analysis, revealing a moderate to large effect in favor of digital psychotherapies for depression (Hedges g=-0.61, 95% CI -0.75 to -0.47; Z=-8.58; P<.001). Subgroup analyses of the studies with different intervention delivery formats and session frequency did not have a statistically significant effect on the results (P=.48 and P=.97, respectively). However, blended approaches revealed a large effect size (Hedges g=-0.793), while interventions involving human contact (Hedges g=-0.42) or no human contact (Hedges g=-0.40) had slightly smaller effect sizes., Conclusions: Digital interventions for depression were found to be effective regardless of format and frequency. Blended interventions have larger effect size than those involving human contact or no human contact. Digital interventions were helpful especially for diverse ethnic groups and young women. Future research should focus on understanding the sources of heterogeneity based on intervention and population characteristics., Trial Registration: PROSPERO CRD42021238462; https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=238462., (©Joanna Omylinska Thurston, Supritha Aithal, Shaun Liverpool, Rebecca Clark, Zoe Moula, January Wood, Laura Viliardos, Edgar Rodríguez-Dorans, Fleur Farish-Edwards, Ailsa Parsons, Mia Eisenstadt, Marcus Bull, Linda Dubrow-Marshall, Scott Thurston, Vicky Karkou. Originally published in JMIR Mental Health (https://mental.jmir.org), 30.09.2024.)

Background: The use of mental health apps (MHAs) is increasing rapidly. However, little is known about the use of MHAs by racial and ethnic minority groups., Objective: In this review, we aimed to examine the acceptability and effectiveness of MHAs among racial and ethnic minority groups, describe the purposes of using MHAs, identify the barriers to MHA use in racial and ethnic minority groups, and identify the gaps in the literature., Methods: A systematic search was conducted on August 25, 2023, using Web of Science, Embase, PsycINFO, PsycArticles, PsycExtra, and MEDLINE. Articles were quality appraised using the Mixed Methods Appraisal Tool, and data were extracted and summarized to form a narrative synthesis., Results: A total of 15 studies met the inclusion criteria. Studies were primarily conducted in the United States, and the MHAs designed for racial and ethnic minority groups included ¡Aptívate!, iBobbly, AIMhi- Y, BRAVE, Build Your Own Theme Song, Mindful You, Sanadak, and 12 more MHAs used in 1 study. The MHAs were predominantly informed by cognitive behavioral therapy and focused on reducing depressive symptoms. MHAs were considered acceptable for racial and ethnic minority groups; however, engagement rates dropped over time. Only 2 studies quantitatively reported the effectiveness of MHAs among racial and ethnic minority groups. Barriers to use included the repetitiveness of the MHAs, stigma, lack of personalization, and technical issues., Conclusions: Considering the growing interest in MHAs, the available evidence for MHAs for racial and ethnic minority groups appears limited. Although the acceptability seems consistent, more research is needed to support the effectiveness of MHAs. Future research should also prioritize studies to explore the specific needs of racial and ethnic minority groups if MHAs are to be successfully adopted., (©Fiby Saad, Mia Eisenstadt, Shaun Liverpool, Courtney Carlsson, Isabella Vainieri. Originally published in JMIR Mental Health (https://mental.jmir.org), 06.12.2023.)

Background: Numerous studies describe the popularity and usefulness of parenting programs. In particular, parenting programs are generally viewed as effective for supporting parents' mental well-being during key transition periods. However, the evidence base for fathers is limited owing to their lack of involvement in parenting programs and scarcity of tailored support., Objective: This paper aimed to describe the co-design process for a universal digital intervention for fathers (fatherli) and the outline of a logic model with its expected outcomes., Methods: Following established guidelines for co-designing and developing complex interventions, we conducted a nonsystematic review of the available literature to gather key information, developed market surveys to assess fathers' needs and interests, consulted with key stakeholders to obtain expert opinions, and engaged in a rapid iterative prototyping process with app developers. Each step was summarized, and the information was collated and integrated to inform a logic model and the features of the resulting intervention., Results: The steps in the co-design process confirmed a need for and interest in a digital intervention for fathers. In response to this finding, fatherli was developed, consisting of 5 key features: a discussion forum for anyone to post information about various topics (the forum), a socializing platform for fathers to create and engage with others in small groups about topics or points of shared interest (dad hub), a tool for fathers to find other fathers with shared interests or within the same geographic location (dad finder), a resource for fathers to access up-to-date information about topics that interest them (dad wiki), and a portal to book sessions with coaches who specialize in different topics (dad coaching space). The evidence-based logic model proposes that if fatherli is successfully implemented, important outcomes such as increased parental efficacy and mental health help-seeking behaviors may be observed., Conclusions: We documented the co-design and development process of fatherli, which confirmed that it is possible to use input from end users and experts, integrated with theory and research evidence, to create suitable digital well-being interventions for fathers. In general, the key findings suggest that an app that facilitates connection, communication, and psychoeducation may appeal to fathers. Further studies will now focus on acceptability, feasibility, and effectiveness. Feedback gathered during pilot-testing will inform any further developments in the app to increase its applicability to fathers and its usability., (©Shaun Liverpool, Mia Eisenstadt, Aoife Mulligan Smith, Sofia Kozhevnikova. Originally published in JMIR Formative Research (https://formative.jmir.org), 14.08.2023.)

Background: Studies conducted in regions consisting of low and middle income and developing countries often report high prevalence of mental health problems among children and young people (CYP). To identify some of the contributing factors we examined the available evidence from research in one such setting., Methods: Multiple academic databases and grey literature sources were searched until January 2022. We then identified primary research focusing on CYP's mental health in the English-speaking Caribbean region. Data was extracted and summarized to form a narrative synthesis of the factors associated with CYP's mental health. The synthesis was then organised according to the social-ecological model. The Joanna Briggs Institute's critical appraisal tools were used to examine the quality of the reviewed evidence. The study protocol was registered with PROSPERO, CRD42021283161., Results: From 9684 records, 83 publications representing CYP ages 3 to 24 years from 13 countries met our inclusion criteria. The evidence was varied in quality, quantity and consistency for 21 factors associated with CYP's mental health. Adverse events and negative peer to peer and sibling relationships were consistently associated with mental health problems, while helpful coping strategies were associated with better mental health. There were mixed findings for age, sex/gender, race/ethnicity, academic level, comorbidity, positive affect, health risks behaviours, religion/prayer, parent history, parent to parent and parent to child relationships, school/employment, geography and social status. There was also some limited evidence for associations between sexuality, screen time and policies/procedures and CYP's mental health. At least 40% of the evidence contributing to each of the factors was judged as high quality., Conclusion: Individual, relationship, community and societal factors may influence CYP's mental health outcomes in the English-speaking Caribbean. Knowledge of these factors is useful to inform early identification and early interventions. More research is needed to explore inconsistent findings and understudied areas., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Liverpool et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aim: This study aimed to examine the mental health and wellbeing of further and higher education students and the associating factors after returning to face-to-face (in-person) learning after Covid-19 restrictions., Methods: A cross-sectional study informed by student consultations was conducted using a survey design. Mental health and wellbeing were assessed using self-report items on the Depression, Anxiety and Stress Scale (DASS-21) and the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS). Descriptive statistics and stepwise multiple linear regression analyses were conducted on data collected between December 2021 and June 2022., Results: N = 1160 students participated; 69.6% between 16 and 25 years, 67.9% studying in the UK, 66.5% studying away from home, 60.2% identified as she/her, 59.8% studying at the undergraduate degree level, 42.5% belonging to non-White ethnic backgrounds, 29.6% identifying as having additional needs and 22.8% as sexual minority. Moderate anxiety (M = 13.67, SD = 9.92) and depression (M = 17.04, SD = 11.56) scores were mainly reported. Wellbeing scores (M = 20.31, SD = 3.93) were lower than the estimate for the pre-pandemic general population. Gender expression, sexuality, age, ethnicity, having additional needs, and level and location of study was associated with mental health or wellbeing. Individual coping styles, levels of self-efficacy and physical activity were also associated with mental health or wellbeing., Conclusions: Many students returning to further and higher education after Covid-19 restrictions experienced reduced mental health and wellbeing, and some students were at greater risk. Providing student-centred interventions focusing on self-efficacy, coping styles and physical activity may help improve the mental health and wellbeing of students., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Liverpool et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Children and young people (CYP) from low-and-middle-income and developing countries are at risk of poor mental health and wellbeing. Yet these regions are generally under-resourced in terms of mental health services. As a first step to inform service planning and delivery in the English-speaking Caribbean we pooled the available evidence to estimate the prevalence of common mental health problems., Methods: A comprehensive search of CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, LILACS, and Web of Science databases, supplemented by grey literature searches was performed until January 2022. Studies conducted in the English-speaking Caribbean that reported prevalence estimates of mental health symptomology or diagnoses in CYP were included. The Freeman-Tukey transformation was applied to calculate the weighted summary prevalence under a random-effects model. Subgroup analyses were also performed to observe emerging patterns in the data. Studies were quality assessed using the Joanna Briggs Institute Prevalence Critical Appraisal Checklist and the GRADE approach. The study protocol was registered with PROSPERO, CRD42021283161., Results: 33 publications from 28 studies representing 65,034 adolescents from 14 countries met the eligibility criteria. Prevalence estimates ranged from 0.8 to 71.9% with most subgroup estimates between 20 and 30%. The overall pooled prevalence of mental health problems was 23.5% (95% CI 0.175-0.302; I 2  = 99.7%). There was limited evidence of significant variation in prevalence estimates among subgroups. The quality of the body of evidence was judged as moderate., Conclusion: It is estimated that between 1 in 4 and 1 in 5 adolescents in the English-speaking Caribbean experience symptoms of mental health problems. These findings highlight the importance of sensitisation, screening, and provision of appropriate services. Ongoing research identifying risk factors and validating outcome measures is also needed to inform evidence-based practice., Supplementary Information: The online version contains supplementary material available at 10.1007/s44192-023-00037-2., Competing Interests: Competing interestsThe authors declare they have no competing interests., (© The Author(s) 2023.)

Parents living in deprived communities are more likely to report lower parental self-efficacy and wellbeing. Poor parental wellbeing and self-efficacy are known risk factors in the development of a range of health and behavioural problems in childhood, adolescence and adulthood. Parenting interventions are key to prevent adverse outcomes in children, however, the mechanisms by which parents learn to understand and support their children are still not well understood. This study evaluated the acceptability of Kids Matter, a parenting intervention targeting parents who are struggling with financial adversity. Secondarily, the relationship between parental wellbeing and and self-efficacy was examined. The present is a retrospective, consecutive case series design study, comparing routinely collected data at pre-intervention, post-intervention, and at 3-month follow-up. Descriptive frequencies were drawn to explore parents' impressions of the programme. Multivariate analysis of variance and regression modelling were used to evaluate associations between parental wellbeing and self-efficacy at different time points. Parents found the programme enjoyable and useful. The intervention led to significant improvements in parental wellbeing and self-efficacy. Improvements in parental wellbeing were significantly associated with improvements in self-efficacy. This study provides evidence of the acceptability and effectiveness of Kids Matter., (© 2022 Wiley Periodicals LLC.)

Carers may not always express child mental health concerns to health professionals. Therefore, identifying factors delaying help-seeking is important. The aim of this study was to examine the relationship between carer affect and help-seeking. In a secondary analysis of data collected from school-aged children ( N = 1,857, mean age = 9.85 years, 51% female), we used logistic regression to examine the associations between carer worry, help-seeking and child mental health. Regarding worry, higher levels of emotional problems (OR = 1.42, 95% CI = 1.33-1.52), conduct problems (OR = 1.24, 95% CI = 1.12, 1.36), peer problems (OR = 1.17, 95% CI = 1.05-1.27) or functional impairment (OR = 1.37, 95% CI = 1.2-.56) were associated with higher levels of carer worry. Regarding help-seeking, higher levels of functional impairment were associated with higher levels of help-seeking (OR = 1.51, 95% CI = 1.09-2.11). After controlling for mental health problems, carers who reported being worried about their child's mental health were less likely than other carers to seek help (OR = 0.13, 95% CI = 0.05-0.35). Knowledge of these factors may inform early interventions. Alongside implications for future research and practice, limitations of the study are discussed.

Internationally, there is a wealth of research suggesting that many children and young people experience mental health problems. However, the evidence from low- and middle-income countries and developing nations is generally limited. This scoping review aimed to add to the body of evidence by providing an overview of the available research literature on children and young people's (CYP's) mental health in the English-speaking Caribbean region. Seven key online academic databases and grey literature sources were searched until January 2021. Records were screened against predefined criteria and suitable articles retrieved. Relevant information was then charted and summarized. All stages of the review were informed by expert consultations. Ninety-six articles from 7901 records met the inclusion criteria. Most of the studies were conducted in Jamaica, Trinidad and Tobago and Barbados while fewer studies reported findings from St Lucia, The Bahamas and St Kitts and Nevis. Research funding was not frequently reported, and participants were predominantly recruited in education settings. There was a substantial focus on depressive symptoms and behaviour problems. Little or no research was available for younger children (< 12), complex clinical cases or commonly under-represented groups. Four unique interventions were identified of which one intervention showed no significant impact on CYP. Among the commonly used outcome measures only the Jamaican Youth Checklist (teacher-reported), Beck Depression Inventory-II, Brief Screen for Depression, Trinidad and Tobago Youth Survey and Minnesota Multiphasic Personality Inventory had evidence for psychometric validity within this population. We discuss future directions, implications and recommendations for research, practice, policy and training., (© 2021. The Author(s).)

Background: Among the general public, there appears to be a growing need and interest in receiving digital mental health and well-being support. In response to this, mental health apps (MHapps) are becoming available for monitoring, managing, and promoting positive mental health and well-being. Thus far, evidence supports favorable outcomes when users engage with MHapps, yet there is a relative paucity of reviews on apps that support positive mental health and well-being., Objective: We aimed to systematically review the available research on MHapps that promote emotion regulation, positive mental health, and well-being in the general population aged 18-45 years. More specifically, the review aimed at providing a systematic description of the theoretical background and features of MHapps while evaluating any potential effectiveness., Methods: A comprehensive literature search of key databases, including MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL), was performed until January 2021. Studies were included if they described standalone mental health and well-being apps for adults without a formal mental health diagnosis. The quality of all studies was assessed against the Mixed Methods Appraisal Tool. In addition, the Cochrane Risk-of-Bias tool (RoB-2) was used to assess randomized control trials (RCTs). Data were extracted using a modified extraction form from the Cochrane Handbook of Systematic Reviews. A narrative synthesis and meta-analysis were then undertaken to address the review aims., Results: In total, 3156 abstracts were identified. Of these, 52 publications describing 48 MHapps met the inclusion criteria. Together, the studies evaluated interventions across 15 countries. Thirty-nine RCTs were identified suggesting some support for the role of individual MHapps in improving and promoting mental health and well-being. Regarding the pooled effect, MHapps, when compared to controls, showed a small effect for reducing mental health symptoms (k=19, Hedges g=-0.24, 95% CI -0.34 to -0.14; P<.001) and improving well-being (k=13, g=0.17, 95% CI 0.05-0.29, P=.004), and a medium effect for emotion regulation (k=6, g=0.49, 95% CI 0.23-0.74, P<.001). There is also a wide knowledge base of creative and innovative ways to engage users in techniques such as mood monitoring and guided exercises. Studies were generally assessed to contribute unclear or a high risk of bias, or to be of medium to low methodological quality., Conclusions: The emerging evidence for MHapps that promote positive mental health and well-being suggests promising outcomes. Despite a wide range of MHapps, few apps specifically promote emotion regulation. However, our findings may position emotion regulation as an important mechanism for inclusion in future MHapps. A fair proportion of the included studies were pilot or feasibility trials (k=17, 33%), and full-scale RCTs reported high attrition rates and nondiverse samples. Given the number and pace at which MHapps are being released, further robust research is warranted to inform the development and testing of evidence-based programs., (©Mia Eisenstadt, Shaun Liverpool, Elisa Infanti, Roberta Maria Ciuvat, Courtney Carlsson. Originally published in JMIR Mental Health (https://mental.jmir.org), 08.11.2021.)

Various health settings have advocated for involving patients and members of the public (PPI) in research as a means to increase quality and relevance of the produced knowledge. However, youth PPI has been an understudied area. This protocol paper describes a new project that aims to summarize what is known about PPI with young people in mental health research. In line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses Statement guidelines we will identify and appraise suitable articles and extract and synthesize relevant information including at least two reviewers at each stage of the process. Results will be presented in two systematic reviews that will describe (a) how youth PPI has been conducted (Review1) and (b) what impact youth PPI had on the subsequent research and on stakeholders (Review2). To our knowledge, this is the first set of reviews that uses a critical appraisal tool, which is co-developed with children and young people. Findings from this project will provide valuable insights and set out the key steps to adopting adequate PPI methods when involving children and young people in mental health research., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sales, Martins, Alves, Carletto, Conejo-Cerón, da Silva, Čuš, Edridge, Ferreira, Hancheva, Lima, Liverpool, Midgley, Moltrecht, Moreno-Peral, Morgan, Mortimer, Mota, Pietrabissa, Sousa, Ulberg and Edbrooke-Childs.)

Background: There is growing evidence suggesting that the emotional well-being of the public has been negatively affected in the past year. Consequently, demand for well-being support has increased. Although there is substantial empirical support for mental health apps that target diagnosed conditions, there is less research on emotional well-being apps. Among existing well-being apps, few studies have been conducted on apps that are based on lived experience and those that seek to enhance users' understanding of their emotional patterns. Thus, the acceptability of these novel apps requires further evaluation before upscaling., Objective: This evaluation aims to describe the acceptability, engagement, and preliminary outcomes of using an app (Paradym) designed to promote emotional well-being and positive mental health., Methods: This is a pre-post, mixed-methods, single-arm evaluation that is aggregated with digital analytics data. We anonymously collected real-world data on the demographics and well-being of the participants as well as the usability and acceptance of the app using validated questionnaires and open-ended questions. Participants tested the app for a minimum of 2 weeks before completing the follow-up measures. Google Analytics was used to record the level of app engagement. Chi-square and 2-tailed t tests were conducted to analyze quantitative data, and a thematic analysis approach was adopted for qualitative data., Results: A total of 115 participants completed baseline questionnaires, of which 79.1% (91/115) users downloaded the app. The sample was diverse in terms of ethnicity, including 43.4% (50/115) people who self-identified as belonging to minority ethnic groups. Most of the participants were female (78/115, 67.8%) and between the ages of 18 and 25 years (39/115, 33.9%). A total of 34 app users who completed questionnaires at baseline and follow-up provided valuable feedback to inform the future directions of Paradym. Favorable themes emerged describing the app's content, functionality, and underlying principles. Although usability feedback varied across items, a considerable number of participants (22/34, 64%) found that the app was easy to use. Google Analytics revealed that at least 79% (27/34) of people used the app daily. On the basis of preliminary observations, app users experience increased mental well-being. Post hoc analyses indicated that the reduction in depression scores (t 33 =-2.16) and the increase in the well-being measures (t 33 =2.87) were statistically significant. No adverse events were reported during the follow-up period., Conclusions: The findings of this evaluation are encouraging and document positive preliminary evidence for the Paradym app., (©Amelia Eisenstadt, Shaun Liverpool, Athina-Marina Metaxa, Roberta Maria Ciuvat, Courtney Carlsson. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.11.2021.)

Parents play a critical role in child and adolescent mental health care and treatment. With the increasing implementation of shared decision-making (SDM) across health settings, there is a growing need to understand the decision support interventions used to promote SDM in child and adolescent mental health services (CAMHS). The overall aim of this review is to identify and examine the existing decision support interventions available for parents. A broad search was conducted using the key concepts "shared decision-making", "parents" and "child and adolescent mental health". Five electronic databases were searched: PsycInfo, Embase, Medline, Web of Science and the Cochrane Library. In addition to these relevant databases, we searched the Ottawa's Inventory of Decision Aids, Children's Hospital of Eastern Ontario website, Google, Google Play and known CAMHS' websites. The search identified 23 interventions available for use with parents. These interventions targeted parents providing care for children with ADHD, ASD, emotional and behavioural problems including depression (EBD), self-harm or universal mental health care. Various modalities including face-to-face, digital and paper-based versions were adopted. The majority of the interventions were able to "present options" (87%) and "discuss the pros and cons" (83%) of treatment. Time, accessibility and appropriateness of the intervention emerged as factors influencing usage and implementation of interventions. Our findings suggest that SDM interventions involving parents have been implemented differently across various presenting mental health difficulties in CAMHS. This review brings awareness of existing parent-involved interventions and has implications for the development, implementation and usage of new interventions., (© 2020. The Author(s).)

Background and Objective: Shared decision making (SDM) has been associated with positive outcomes at child and adolescent mental health services (CAMHS). However, implementing SDM is sometimes challenging. Understanding the factors associated with parent/carer experience of SDM could provide empirical evidence to support targeted efforts to promote SDM. This study aimed to explore the frequency of parent/carer-reported experience of SDM and examine possible associations between SDM and clinician's perceptions of the (a) children's and young people's psychosocial difficulties, (b) additional complex problems, and (c) impact of the psychosocial difficulties. Methods: Secondary analysis was conducted on administrative data collected from CAMHS between 2011 and 2015. The sample was composed of 3,175 cases across 58 sites in England. Frequencies were recorded and associations were explored between clinician-reported measures and parent/carer-reported experiences of SDM using a two-level mixed-effect logistic regression analytic approach. Results: Almost 70% of parents/carers reported experiencing higher levels of SDM. Individual-level variables in model one revealed statistically significant ( p <0.05) associations suggesting Asian parents/carers (OR = 1.95, 95% CI [1.4, 2.73]) and parents/carers having children with learning difficulties (OR = 1.45, 95% CI [1.06, 1.97]) were more likely to report higher levels of SDM. However, having two parents/carers involved in the child's care and treatment decisions (OR = 0.3, 95% CI [0.21, 0.44]) and being a parent/carer of a child or young person experiencing conduct problems (OR = 0.78, 95% CI [0.63, 0.98]) were associated with lower levels of SDM. When adjusting for service level data (model two) the presence of conduct problems was the only variable found to be significant and predicted lower levels of SDM (OR = 0.29, 95% CI [0.52, 0.58]). Conclusion: Multilevel modelling of CAMHS administrative data may help identify potential influencing factors to SDM. The current findings may inform useful models to better predict and support SDM., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Liverpool, Hayes and Edbrooke-Childs.)

A large proportion of young people accessing specialist mental health services do so for a single session. The aim of the present study was to examine the characteristics of young people attending specialist mental health services for a single session and to examine associations between single session attendance and clinical characteristics. Secondary analysis of administrative data on N  = 23,300 young people (mean age = 12.73 years, 57% female, 64% White British) was conducted. The mean number of sessions attended was 4.33 and 46% (10,669) attended for a single session. Multilevel logistic regression analysis showed that younger children, Black young people (OR = 1.20, 95% CI = 1.01-1.43) or those whose ethnicity was not stated (OR = 1.25, 95% CI = 1.15-1.35), young people with peer relationship difficulties (OR = 1.11, 95% CI = 1.04-1.19) or low frequency problems (OR = 1.06, 95% CI = 0.99-1.14), and those with more complexity factors (OR = 1.07, 95% CI = 1.04-1.10) were more likely to attend services for a single session. The present study sets out research questions to prompt future research: (1) the experience of attending services for a single session, (2) identifying groups of single session attenders who do not require further support compared to those who are not able to sustain engagement with more sessions, and (3) whether new care pathways are needed for these groups who currently access specialist mental health services for a single session.

Background: Parents and caregivers are generally recognized by literature and the law as key to child and adolescent mental health decisions. Digital interventions are increasingly being used to support care and treatment in child and adolescent mental health services (CAMHS). However, evidence of the design and development process is generally not made available., Objective: In light of calls for more transparency, this paper aims to describe the development of an evidence-based, theoretically informed digital decision support intervention for parents and caregivers of young people accessing CAMHS., Methods: The intervention was developed in line with the UK Medical Research Council framework for developing complex interventions. The process incorporated the steps for developing patient decision aids, as follows: assessing need, assessing feasibility; defining objectives; identifying the framework of decision support; and selecting the methods, designs, and dissemination approach. We synthesized theory, research, international guidelines, and input from relevant stakeholders using an iterative design approach., Results: The development steps resulted in Power Up for Parents, a decision support intervention, with five key features (ie, decisions, goals, journey, support, and resources). The intervention aims to encourage discussion, allow parents to ask questions during sessions or seek further information between sessions, and allow service providers to tailor the shared decision-making process to accommodate the needs of the parent and child., Conclusions: We confirmed that it is possible to use input from end users-integrated with theory and evidence-to create digital interventions to be used in CAMHS. Key lessons with implications for practice, policy, and implementation science, along with preliminary findings, are presented., International Registered Report Identifier (irrid): RR2-10.2196/14571., (©Shaun Liverpool, Julian Edbrooke-Childs. Originally published in JMIR Formative Research (https://formative.jmir.org), 15.06.2021.)

Objective: Symptom improvement is often examined as an indicator of a good outcome of accessing mental health services. However, there is little evidence of whether symptom improvement is associated with other indicators of a good outcome, such as a mutual agreement to end treatment. The aim of this study was to examine whether young people accessing mental health services who meaningfully improved were more likely to mutually agree to end treatment. Methods: Multilevel multinomial regression analysis controlling for age, gender, ethnicity, and referral source was conducted on N = 8,995 episodes of care [Female = 5,469, 61%; mean Age = 13.66 (SD = 2.87) years] using anonymised administrative data from young people's mental health services. Results: Compared to young people with no change in mental health difficulties, those showing positive meaningful changes in mental health difficulties were less likely to have case closure due to non-mutual agreement (Odds Ratio or OR = 0.58, 95% Confidence Interval or CI = 0.50-0.61). Similarly, they were less likely to transfer (OR = 0.61, 95% CI = 0.49-0.74) or end treatment for other reasons (OR = 0.59, 95% CI = 0.50-0.70) than by case closure due to mutual agreement. Conclusion: The findings suggest that young people accessing mental health services whose symptoms meaningfully improve are more likely to mutually agree to end treatment, adding to the evidence that symptom improvement may be appropriate to examine as an indicator of a good outcome of accessing mental health services., Competing Interests: TB reports other funding from NHS England & NHS Improvement, outside the submitted work. JE-C reports grants from NHS England & NHS Improvement, outside the submitted work, and he was involved in the programme of service transformation that some of the data in the present manuscript draws on. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Edbrooke-Childs, Costa da Silva, Čuš, Liverpool, Pinheiro Mota, Pietrabissa, Bardsley, Sales, Ulberg, Jacob and Ferreira.)

Background: Interventions to involve parents in decisions regarding children's and young people's mental health are associated with positive outcomes. However, appropriately planning effectiveness studies is critical to ensure that meaningful evidence is collected. It is important to conduct pilot studies to evaluate the feasibility and acceptability of the intervention itself and the feasibility of the protocol to test effectiveness., Objective: This paper reports the findings from a feasibility and acceptability study of Power Up for Parents, an intervention to promote shared decision-making (SDM) and support parents and caregivers making decisions regarding children's and young people's mental health., Methods: A mixed method study design was adopted. In stage 1, health care professionals and parents provided feedback on acceptability, usefulness, and suggestions for further development. Stage 2 was a multicenter, 3-arm, individual, and cluster randomized controlled pilot feasibility trial with parents accessing services related to children's and young people's mental health. Outcome measures collected data on demographics, participation rates, SDM, satisfaction, and parents' anxiety. Qualitative data were analyzed using thematic analysis. Google Analytics estimates were used to report engagement with the prototype. Outcomes from both stages were tested against a published set of criteria for proceeding to a randomized controlled trial., Results: Despite evidence suggesting the acceptability of Power Up for Parents, the findings suggest that recruitment modifications are needed to enhance the feasibility of collecting follow-up data before scaling up to a fully powered randomized controlled trial. On the basis of the Go or No-Go criteria, only 50% (6/12) of the sites successfully recruited participants, and only 38% (16/42) of parents completed follow-up measures. Nonetheless, health care practitioners and parents generally accessed and used the intervention. Themes describing appearance and functionality, perceived need and general helpfulness, accessibility and appropriateness, and a wish list for improvement emerged, providing valuable information to inform future development and refinement of the intervention., Conclusions: Owing to the high attrition observed in the trial, proceeding directly to a full randomized controlled trial may not be feasible with this recruitment strategy. Nonetheless, with some minor adjustments and upgrades to the intervention, this pilot study provides a platform for future evaluations of Power Up for Parents., Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 39238984; http://www.isrctn.com/ISRCTN39238984., International Registered Report Identifier (irrid): RR2-10.2196/14571., (©Shaun Liverpool, Julian Edbrooke-Childs. Originally published in JMIR Formative Research (http://formative.jmir.org), 02.03.2021.)

Background: The majority of existing shared decision making (SDM) models are yet to explicitly account for emotion as an influencing factor to the SDM process. This study aimed to explore the role of parents' and carers' emotional experiences as a concept that has implications for SDM in children and young people's mental health (CYPMH) settings. Methods: A social constructivist grounded theory approach, analyzing data from focus groups ( n = 4) and semi-structured interviews ( n = 33) with parents and healthcare professionals, was undertaken. Participants were identified and selected at CYPMH sites and through social media platforms or in-person advertising as part of a larger feasibility trial. Interviews and focus groups were audio-recorded and transcribed verbatim. Thematic analysis moved from open to focused coding. Results: The majority of the sample consisted of mothers of adolescent girls. Healthcare professionals had an average of 7.54 (SD = 6.24) years of work experience in CYPMH outpatient capacities. Findings suggested that parents are "expected to, but not always able to" engage in SDM. Themes and subthemes described an affective-appraisal SDM process capturing: (1) views and experiences of SDM, (2) parents' emotional states, (3) the influence of emotions on SDM, and (4) key support systems accessed. The emerging affective-appraisal framework highlighted that negative emotional states hindered parents' active involvement in SDM, and positive emotions encouraged involvement in SDM. Conclusion: The current findings describe an SDM model specific to CYPMH. This new understanding contributes to addressing a possible theory to practice gap opening new challenges and opportunities for academic enquiry., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Liverpool, Hayes and Edbrooke-Childs.)

Background: There is a high prevalence of children and young people (CYP) experiencing mental health (MH) problems. Owing to accessibility, affordability, and scalability, an increasing number of digital health interventions (DHIs) have been developed and incorporated into MH treatment. Studies have shown the potential of DHIs to improve MH outcomes. However, the modes of delivery used to engage CYP in digital MH interventions may differ, with implications for the extent to which findings pertain to the level of engagement with the DHI. Knowledge of the various modalities could aid in the development of interventions that are acceptable and feasible., Objective: This review aimed to (1) identify modes of delivery used in CYP digital MH interventions, (2) explore influencing factors to usage and implementation, and (3) investigate ways in which the interventions have been evaluated and whether CYP engage in DHIs., Methods: A literature search was performed in the Cochrane Library, Excerpta Medica dataBASE (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), and PsycINFO databases using 3 key concepts "child and adolescent mental health," "digital intervention," and "engagement." Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least two reviewers. The selected articles were assessed for quality using the mixed methods appraisal tool, and data were extracted to address the review aims. Data aggregation and synthesis were conducted and presented as descriptive numerical summaries and a narrative synthesis, respectively., Results: This study identified 6 modes of delivery from 83 articles and 71 interventions for engaging CYP: (1) websites, (2) games and computer-assisted programs, (3) apps, (4) robots and digital devices, (5) virtual reality, and (6) mobile text messaging. Overall, 2 themes emerged highlighting intervention-specific and person-specific barriers and facilitators to CYP's engagement. These themes encompassed factors such as suitability, usability, and acceptability of the DHIs and motivation, capability, and opportunity for the CYP using DHIs. The literature highlighted that CYP prefer DHIs with features such as videos, limited text, ability to personalize, ability to connect with others, and options to receive text message reminders. The findings of this review suggest a high average retention rate of 79% in studies involving various DHIs., Conclusions: The development of DHIs is increasing and may be of interest to CYP, particularly in the area of MH treatment. With continuous technological advancements, it is important to know which modalities may increase engagement and help CYP who are facing MH problems. This review identified the existing modalities and highlighted the influencing factors from the perspective of CYP. This knowledge provides information that can be used to design and evaluate new interventions and offers important theoretical insights into how and why CYP engage in DHIs., (©Shaun Liverpool, Catarina Pinheiro Mota, Célia M D Sales, Anja Čuš, Sara Carletto, Camellia Hancheva, Sónia Sousa, Sonia Conejo Cerón, Patricia Moreno-Peral, Giada Pietrabissa, Bettina Moltrecht, Randi Ulberg, Nuno Ferreira, Julian Edbrooke-Childs. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 23.06.2020.)

Background: Shared decision making (SDM) is recognized as a person-centered approach to improving health care quality and outcomes. Few digital interventions to improve SDM have been tested in child and adolescent mental health (CAMH) settings. One such intervention is Power Up, a mobile phone app for young people (YP), which has shown some evidence of promise that YP who received Power Up reported greater levels of SDM. However, even though parents play a critical role in CAMH care and treatment, they often feel excluded from services., Objective: This protocol is for a pilot trial to determine the feasibility of a large-scale randomized trial to develop and evaluate a Web app called Power Up for Parents (PUfP) to support parents and promote involvement in CAMH decisions., Methods: A 2-stage process, consisting of the development stage and pilot-testing stage of the initial PUfP prototype, will be conducted. At the development stage, a qualitative study with parents and clinicians will be conducted. The interviews will aim to capture the experience of making CAMH decisions, preferences for involvement in SDM, and determine situations within which PUfP can be useful. At the pilot-testing stage, up to 90 parents and their clinicians will be invited to participate in the testing of the prototype. Parents will be randomly allocated to receive the intervention or be part of the control group. This study design will allow us to assess the acceptability and usefulness of PUfP in addition to examining the feasibility of a prospective randomized trial. Clinicians' perceptions of the prototype and how it has influenced parents' involvement in SDM will also be examined., Results: Recruitment began in January 2019 and is scheduled to last for 10 months. Interviews and baseline data collection are currently in progress. To date, 11 CAMH sites have been recruited to take part in the study. It is anticipated that data collection will be completed by October 2019., Conclusions: The lack of parents' involvement in CAMH care and treatment can lead to higher rates of dropout from care and lower adherence to therapeutic interventions. There are significant benefits to be gained globally if digital SDM interventions are adopted by parents and shown to be successful in CAMH settings., Trial Registration: ISRCTN Registry ISRCTN39238984; http://www.isrctn.com/ISRCTN39238984., International Registered Report Identifier (irrid): DERR1-10.2196/14571., (©Shaun Liverpool, Helen Webber, Rob Matthews, Miranda Wolpert, Julian Edbrooke-Childs. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 14.08.2019.)

Objective: To update the 1997 OMERACT-OARSI (Outcome Measures in Rheumatology-Osteoarthritis Research Society International) core domain set for clinical trials in hip and/or knee osteoarthritis (OA)., Methods: An initial review of the COMET database of core outcome sets (COS) was undertaken to identify all domains reported in previous COS including individuals with hip and/or knee OA. These were presented during 5 patient and health professionals/researcher meetings in 3 continents (Europe, Australasia, North America). A 3-round international Delphi survey was then undertaken among patients, healthcare professionals, researchers, and industry representatives to gain consensus on key domains to be included in a core domain set for hip and/or knee OA. Findings were presented and discussed in small groups at OMERACT 2018, where consensus was obtained in the final plenary., Results: Four previous COS were identified. Using these, and the patient and health professionals/researcher meetings, 50 potential domains formed the Delphi survey. There were 426 individuals from 25 different countries who contributed to the Delphi exercise. OMERACT 2018 delegates (n = 129) voted on candidate domains. Six domains gained agreement as mandatory to be measured and reported in all hip and/or knee OA clinical trials: pain, physical function, quality of life, and patient's global assessment of the target joint, in addition to the mandated core domain of adverse events including mortality. Joint structure was agreed as mandatory in specific circumstances, i.e., depending on the intervention., Conclusion: The updated core domain set for hip and/or knee OA has been agreed upon. Work will commence to determine which outcome measurement instrument should be recommended to cover each core domain.

Infection of sheep with Ehrlichia (Cytoecetes) phagocytophila, the causative agent of tick-borne fever (TBF), was characterised by a significant reduction in lymphocyte reactivity to the mitogens phytohaemagglutinin, concanavalin A, pokeweed mitogen and Escherichia coli lipopolysaccharide during the period of rickettsiaemia. The addition of the prostaglandin inhibitor, indomethacin, or the nitric oxide inhibitor, N(G)-monomethyl-L-arginine, had no significant effect on the suppressive effects of E. phagocytophila on lymphocyte reactivity to the mitogens. However, peripheral blood lymphocytes obtained from primed sheep proliferated in the presence of live or heat-inactivated E. phagocytophila. Antigen-specific proliferation was detected in lymphocytes samples obtained 11 to 21 days post-inoculation with E. phagocytophila.

Feline calicivirus (FCV) is a respiratory pathogen of cats that is capable of causing persistent infections. This study examined the evolution of a hypervariable region of the FCV capsid gene both during 90 passages in cell culture and during replication in persistently infected cats. This region of the capsid protein is known to contain neutralization epitopes and may be a target for immune evasion during virus persistence in the host. Sequence analysis showed that FCV exists as a quasispecies which evolved both in cell culture and in persistently infected cats. Changes involved both loss of sequence present in the infecting isolate and a gain of both synonymous and non-synonymous nucleotide substitutions to generate sequences not detected within earlier isolates. Overall, these changes led to a reduction in population heterogeneity over time. Where virus populations were highly homogeneous allowing a consensus sequence to be determined, evolution rates for the consensus sequence ranged from 0.10-1.07 substitutions per nucleotide per year. Marked changes in virus neutralization profiles were seen in isolates obtained sequentially from a persistently infected cat. This was not the case with cell culture passaged virus, suggesting that the individual amino acid changes found only in virus from persistently infected cats may significantly alter the antigenic profile of FCV, and may be the result of immune selection.

The effect of storage of whole blood of chicken and turkeys on the mitogen responses of lymphocytes to concanavalin A (con A) and pokeweed mitogen was investigated. It was found that, despite slight differences in optimum storage conditions with respect to mitogens, species and age of birds, blood could be stored for 24 h at 4 degrees C without significant reduction in the lymphoproliferative responses. However, even during the initial 24 h storage of blood at 4 degrees C, the levels of reduction in stimulation index (SI) values following con A stimulation, ranged from 27% for 3-4 week-old turkeys to 60% for 3-4 week-old white leghorn chickens.

The stretch modulus (stress/strain) of strips of ovine cervical tissue in vitro was measured at different stages of gestation. A decrease in stretch modulus implies softening of the tissue. There was a gradual but progressive reduction in the stretch modulus with advancing pregnancy between 30 and 140 days gestation with a marked increase between 140 days gestation and the onset of labour (P less than 0.005). After the first trimester, the uterine end of the cervix was usually more distensible than the vaginal end. No further reduction in the stretch modulus of the cervix occurred between labour and delivery of the fetus. The results of this study suggest that while there is some softening of the ovine cervix during pregnancy, most of the softening takes place immediately prior to the onset of labour and delivery of the fetus.