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Abstract Background Effective parenting can mediate the negative impact of complex humanitarian emergencies (CHEs) on child mental health, however many caregivers struggle to parent effectively in these settings. Parenting interventions have robust evidence in many settings, however research supporting their use in CHEs is limited. We describe the development of a caregiver group intervention delivered by non-specialist staff to support child mental health in CHEs. Methods A multi-phase, multi-method approach was employed: Phase 1: semi-structured interviews, analysed inductively, with specialist mental health staff in CHEs on needs and challenges in providing mental healthcare to children and caregivers. Phase 2: initial intervention development informed by Phase 1 and evidence-based theoretical approaches and psychological therapies. Phase 3: expert review of draft intervention. Phase 4: semi-structured interviews, analysed inductively, with non-specialist staff in Papua New Guinea (PNG) to evaluate relevance, comprehensibility, and applicability of the intervention. Phase 5: cultural adaptation of the intervention prior to implementation in Northern Iraq. Different operational partners and research sites were employed at different phases of development to increase diversity of inputs and support the overall vision of an intervention that addressed common mental health difficulties and underlying factors to support children and caregivers across CHEs. Results Mental health staff in CHEs identified a significant need for interventions to support parenting and address child mental health needs. A caregiver group intervention was developed consisting of six two-hour sessions, delivered weekly by non-specialist staff, and targeting parent knowledge and skills and parent stress. Expert consultation identified aspects of the intervention to emphasise or simplify, resulting in a refined intervention with ensured clinical quality. Non-specialist staff in PNG confirmed the intervention relevance to a vulnerable population in a humanitarian setting, and the manual was determined suitable for non-specialist facilitators. Mental health literacy, stigma and cultural views (masculinity, family privacy) were identified as challenges to address. A multi-stage method of cultural adaptation in Iraq ensured the clinical and cultural accuracy, relevance, and acceptability of the intervention. Initial adaptations to the language and metaphors used in the intervention resulted in high cultural appropriateness during pilot testing. Prioritising the recruitment and engagement of male caregivers is critical. Conclusions A caregiver intervention to support child mental health in CHEs is available. It’s development using multi-method, co-design processes will ensure its relevance and acceptability to target populations. Further research to evaluate the effectiveness and long-term effectiveness of the intervention is warranted.

Abstract Background The acquisition of knowledge and use of skills from digital mental health interventions (DMHIs) are considered important for effectiveness. However, our understanding of user experiences implementing skills learned from these interventions is limited, particularly outside of research trials. This qualitative study aimed to investigate how community users learn and apply knowledge and skills from DMHIs based on cognitive behavioural therapy (CBT) in daily life. The study also examined factors influencing the selection and use of skills and explored perceived changes in mental health resulting from the intervention. Methods Thirteen adults aged 26 to 66 years (10 females) were recruited using social media advertising and participated in semi-structured interviews by telephone or videoconference. All participants were living in Australia and had used a digital CBT program within the past 3 months. Interviews lasted on average 45 min. Transcripts were analysed using theoretical thematic analysis. Results Participants demonstrated high levels of program engagement. Findings were organised into three topics with six major themes. Participants reported that their chosen intervention reinforced existing knowledge and fostered new skills and insights (Topic 1, Theme 1: knowledge consolidation). Most described actively applying skills (Topic 1, Theme 2: active approach to skill enactment), although the extent of learning and range of skills enacted varied across participants. Influences on skill selection included the perceived relevance of intervention strategies to the user’s needs and personal characteristics (Topic 2, Theme 1: relevance of intervention strategies), as well as the perceived or experienced effectiveness of those strategies (Topic 2, Theme 2: perceived and experienced benefit). Challenges to ongoing skill enactment included time scarcity, prioritisation difficulties, and lack of motivation (Topic 2, Theme 3: navigating time constraints and low motivation). Improvements in mental health were generally modest and attributed mainly to participants’ proactive efforts (Topic 3, Theme 1: perceived changes). Conclusions DMHIs may reinforce existing understanding of psychotherapeutic strategies, offer new knowledge, and encourage the application of skills in everyday life among community users who actively engage with these interventions. Future research should prioritise personalising DMHIs and investigating methods to optimise the acquisition, retention, and sustained application of knowledge and skills.

ABSTRACT Background Applied research using co‐creation methods is rarely described or evaluated in detail. Practical evidence of co‐creation processes and collaboration effectiveness is needed to better understand its complex and dynamic nature. Methods Using a case study design and survey method, we assessed processes of co‐implementation and co‐evaluation grounded in our own experiences from the Co‐Creating Safe Spaces project. We examine these in the context of a published systematic framework designed to improve clarity about co‐creation processes and report on how co‐creation was experienced by collaborative partners. Results Our study showed the interconnectedness between co‐implementation and co‐evaluation processes and the importance of aligning research with program processes to ensure it is responsive to emergent local needs and problems. Given relatively low levels of researcher embeddedness across sites, service champions played a pivotal role in data collection. Survey findings indicated strong support for a healthy collaboration with some concerns expressed over individual partner's areas of responsibility and ability to deliver on commitments. Conclusion Co‐creation can be a very robust approach to translational research but is a complex endeavour. Ongoing reflexivity and attention to relational aspects support genuine collaboration and provide a foundation for addressing challenges. Patient or Public Contribution People with lived experience of emotional distress and/or suicidal crisis, including researchers from both academic and non‐research backgrounds, service managers, peer workers, carers and advocates, were involved in this research and authored this paper.

Abstract Background Mental disorders are common in childhood, but many young people do not receive adequate professional support. Help-seeking interventions may bridge this treatment gap, however, there is limited research on interventions for primary-school children. This study aims to evaluate the effectiveness of an emotion literacy program at increasing literacy, reducing stigma, and promoting help-seeking in children aged 8–10 years. Methods and analysis A two-arm pragmatic cluster-controlled trial will compare Thriving Minds, an emotion literacy program for middle primary school children, to a wait-list control condition. Children aged 8–10 years will be recruited from approximately 12 schools (6 intervention schools/6 wait-list control) to participate in Thriving Minds via direct invitation by the program delivery service. Allocation to the intervention condition will be pragmatically, by school. Children will receive the intervention over two 50-minute sessions, across two weeks. Using story books and interactive discussion, the program aims to develop children’s knowledge of their own and other’s emotional experiences and emotion regulation strategies (self-care and help-seeking). The primary outcome is help-seeking intentions. Secondary outcomes include help-seeking knowledge, attitudes, and behaviours, emotion knowledge and attitudes, and stigma. Children will complete surveys at pre-intervention, post-intervention (one week after the program) and 12-week follow-up. Additional satisfaction data will be collected from teachers in intervention schools via surveys (post-intervention and 3-month follow-up) and semi-structured interviews (after follow-up), and selected children via focus groups (12-week follow-up). Analyses will compare changes in help-seeking intentions relative to the waitlist control condition using mixed-model repeated-measures analyses to account for clustering within schools. Discussion With demonstrated effectiveness, this universal emotion literacy program for promoting help-seeking for mental health could be more widely delivered in Australian primary schools, providing a valuable new resource, contributing to the mental health of young people by improving help-seeking for early mental health difficulties. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12623000910606 Registered on 24 August 2023.

Abstract Background The factors that influence transition from suicidal ideation to a suicide attempt or remission of suicidal thoughts are poorly understood. Despite an abundance of research on risk factors for suicidal ideation, no large-scale longitudinal population-based studies have specifically recruited people with suicidal ideation to examine the mechanisms underlying critical transitions to either suicide attempt or recovery from suicidal ideation. Without longitudinal data on the psychological, behavioural, and social determinants of suicide attempt and the remission of suicidal ideation, we are unlikely to see major gains in the prevention of suicide. Aim The LifeTrack Project is a population-based longitudinal cohort study that aims to identify key modifiable risk and protective factors that predict the transition from suicidal ideation to suicide attempt or remission of suicidal ideation. We will assess theory-informed risk and protective factors using validated and efficient measures to identify distinct trajectories reflecting changes in severity of suicidal ideation and transition to suicide attempt over three years. Methods A three-year prospective population-based longitudinal cohort study will be conducted with adults from the general Australian population who initially report suicidal ideation (n = 842). Eligibility criteria include recent suicidal ideation (past 30 days), aged 18 years or older, living in Australia and fluent in English. Those with a suicide attempt in past 30 days or who are unable to participate in a long-term study will be excluded. Participants will be asked to complete online assessments related to psychopathology, cognition, psychological factors, social factors, mental health treatment use, and environmental exposures at baseline and every six months during this three-year period. One week of daily measurement bursts (ecological momentary assessments) at yearly intervals will also capture short-term fluctuations in suicidal ideation, perceived burdensomeness, thwarted belongingness, capability for suicide, and distress. Conclusion This study is intended to identify potential targets for novel and tailored therapies for people experiencing suicidal ideation and improve targeting of suicide prevention programs. Even modest improvements in current treatments may lead to important reductions in suicide attempts and deaths. Study Registration Australian New Zealand Clinical Trials Registry identifier: ACTRN12623000433606.

Abstract Background When COVID-19 spread to Australia in January 2020, many communities were already in a state of emergency from the Black Summer bushfires. Studies of adolescent mental health have typically focused on the effects of COVID-19 in isolation. Few studies have examined the impact of COVID-19 and other co-occurring disasters, such as the Black Summer bushfires in Australia, on adolescent mental health. Methods We conducted a cross-sectional survey to examine the impact of COVID-19 and the Black Summer bushfires on the mental health of Australian adolescents. Participants (N = 5866; mean age 13.61 years) answered self-report questionnaires about COVID-19 diagnosis/quarantine (being diagnosed with and/or quarantined because of COVID-19) and personal exposure to bushfire harm (being physically injured, evacuated from home and/or having possessions destroyed). Validated standardised scales were used to assess depression, psychological distress, anxiety, insomnia, and suicidal ideation. Trauma related to COVID-19 and the bushfires was also assessed. The survey was completed in two large school-based cohorts between October 2020 and November 2021. Results Exposure to COVID-19 diagnosis/quarantine was associated with increased probability of elevated trauma. Exposure to personal harm by the bushfires was associated with increased probability of elevated insomnia, suicidal ideation, and trauma. There were no interactive effects between disasters on adolescent mental health. Effects between personal risk factors and disasters were generally additive or sub-additive. Conclusions Adolescent mental health responses to community-level disasters are multi-faceted. Complex psychosocial factors associated with mental ill health may be relevant irrespective of disaster. Future research is needed to investigate synergistic effects of disasters on young mental health.

Background: Hopelessness is an important risk factor for depression and suicide. However, few suitable measures exist for use in the general population, limiting research testing aetiological models. The present study aimed to develop and validate a new measure of hopelessness using a community-based sample. Method: Twenty-nine candidate items underwent refinement via three sequential stages– (1) feedback from 15 experts, (2) scale development (N = 218), and (3) scale validation (N = 218)—resulting in the final 5-item scale, the Hopelessness Inventory-5 (HI-5). Results: EFA and CFA supported the unidimensionality of the new HI-5 scale, with excellent fit indices (SRMR=0.02, RMSEA=0.06, CFI=0.99, TLI=0.97). High Cronbach's alpha (0.92) indicated that the scale was internally consistent. Bivariate correlations with related constructs supported both convergent and divergent validity. Comparing information curves of the HI-5 and a shortened BHS indicated that the HI-5 provided more information across a wider range of the latent trait. Limitations: The HI-5 was not validated against the original BHS. The sampling method may have led to limited hopelessness scores in the very high range and overrepresentation of females. Conclusions: The HI-5 is a brief, succinctly-worded, and freely available scale, developed using expert feedback and validated in a community sample. It is intended to facilitate the advancement of research and theory that include hopelessness as a key risk factor for mental ill health in the general population.

Background: Little attention has been paid to the experiences of families and carers supporting and accessing support for individuals in the period preceding and following their death by suicide. For many families and carers who have experienced loss and been subjected to a series of unhelpful or harmful encounters with health and emergency services, there is a desire to share their stories so that their experiences might contribute to the improvement of practices and policies. Methods: We conducted qualitative interviews with 17 participants supporting and accessing support for individuals who died by suicide in the Australian Capital Territory, Australia. Interviews and thematic analysis were guided by the theoretical frameworks of trauma-informed and restorative practice. Results: Key barriers for those seeking to access support were the difficulties experienced upon entering the health system, inadequate care pathways for ensuring continuity of care, and the lack of trauma-informed, holistic care. Participants described how concerns over their loved one's welfare were minimized by health professionals, and how ineffective communication strategies and the hierarchies of power and control evident in many health care settings were experienced as exclusionary and disempowering. These results provide compelling evidence that emergency services and health workforces require new strategies for effective management and care of people experiencing suicidal distress, their families, and carers. Conclusions: Results support the view that trauma-informed and restorative approaches provide promising strategies for addressing issues of disconnected, fragmented, and exclusionary health care and medico-legal investigative practices, as well as to help resolve conflict and prevent harm.

Abstract Background Family and kinship networks are a key aspect of culture for Aboriginal and Torres Strait Islander peoples from Australia. They are intrinsically connected to good health and wellbeing, and cultural knowledge exchange. However, despite the known importance of family and kinship networks in Aboriginal and Torres Strait Islander cultures, and the move towards family-centred approaches in healthcare service provision, there is no validated, national measure of family functioning for Aboriginal and Torres Strait Islander peoples. A valid tool to measure family functioning is necessary in order to better understand what fosters good family functioning, and to inform and develop programs and healthcare interventions. Methods Mayi Kuwayu: the National Study of Aboriginal and Torres Strait Islander Wellbeing is a longitudinal cohort study of Aboriginal and Torres Strait Islander adults aged 16 years and over. An existing family functioning scale was modified for use in the Mayi Kuwayu Study to measure family functioning at the national Aboriginal and Torres Strait Islander population level. This study used a national sample of Aboriginal and Torres Strait Islander adults (N = 8705, ≥16 years) for the psychometric assessment of the modified Mayi Kuwayu Study Family Functioning Measure. This involved face validity, acceptability, internal consistency/reliability, construct validity, and convergent and divergent validity testing. Results Participants in this study were 8705 Aboriginal and Torres Strait Islander peoples, with a mean age of 48 years, who primarily live in regional Australia (47.3%). The Mayi Kuwayu Family Functioning Measure demonstrated face validity for family functioning and had good internal consistency/reliability (Cronbach’s alpha > 0.90). Construct validity results were mixed, with an indication of uni-dimensionality (with one component explaining 59.5% of variance), but some item redundancy and inconsistency in responding patterns among groups of respondents. Balancing psychometric properties with Aboriginal and Torres Strait Islander expert and end-user feedback of the measure indicate that the full scale should be retained. Finally, the measure demonstrated strong convergent and divergent validity, with prevalence ratios exhibiting dose-response relationships between family functioning and conceptually related outcomes (convergent validity) and conceptually unrelated outcomes (divergent validity). Conclusion The Mayi Kuwayu Family Functioning Measure is a valid measure of family functioning in the Aboriginal and Torres Strait Islander adult population.

Abstract Objectives The Future Proofing Study (FPS) was established to examine factors associated with the onset and course of mental health conditions during adolescence. This paper describes the design, methods, and baseline characteristics of the FPS cohort. Methods The FPS is an Australian school‐based prospective cohort study with an embedded cluster‐randomized controlled trial examining the effects of digital prevention programs on mental health. Data sources include self‐report questionnaires, cognitive functioning, linkage to health and education records, and smartphone sensor data. Participants are assessed annually for 5 years. Results The baseline cohort (N = 6388, M = 13.9 years) is broadly representative of the Australian adolescent population. The clinical profile of participants is comparable to other population estimates. Overall, 15.1% of the cohort met the clinical threshold for depression, 18.6% for anxiety, 31.6% for psychological distress, and 4.9% for suicidal ideation. These rates were significantly higher in adolescents who identified as female, gender diverse, sexuality diverse, or Aboriginal and/or Torres Strait Islander (all ps

Abstract Background The COVID-19 outbreak has spread to almost every country around the world and caused more than 3 million deaths. The pandemic has triggered enormous disruption in people’s daily lives with profound impacts globally. This has also been the case in Australia, despite the country’s comparative low mortality and physical morbidity due to the virus. This scoping review aims to provide a broad summary of the research activity focused on mental health during the first 10 months of the pandemic in Australia. Results A search of the Australian literature was conducted between August-November 2020 to capture published scientific papers, online reports and pre-prints, as well as gaps in research activities. The search identified 228 unique records in total. Twelve general population and 30 subpopulation group studies were included in the review. Conclusions Few studies were able to confidently report changes in mental health driven by the COVID-19 context (at the population or sub-group level) due to a lack of pre-COVID comparative data and non-representative sampling. Never-the-less, in aggregate, the findings show an increase in poor mental health over the early period of 2020. Results suggest that young people, those with pre-existing mental health conditions, and the financially disadvantaged, experienced greater declines in mental health. The need for rapid research appears to have left some groups under-researched (e.g. Culturally and Linguistically Diverse populations and Indigenous peoples were not studied), and some research methods under-employed (e.g. there was a lack of qualitative and mixed-methods studies). There is a need for further reviews as the follow-up results of longitudinal studies emerge and understandings of the impact of the pandemic are refined.

COVID-19 has disrupted the normative social order, particularly for young adults. Their deteriorating mental health over 2020 has been associated with the economic and social conditions during the COVID-19 lockdowns. We conducted 19 semi-structured interviews with young adults aged 8 and 29 most of whom lived in Victoria, Australia. The interviews explored participants' experiences and responses to COVID-19, covering areas such as disrupted everyday practices and future plans, impacts on their physical and mental health, and interactions with community and services. Young adults were concerned about loss of social connectedness, their mental health and the complex interplay of issues such as employment, income, education and housing. They developed routines to protect their physical and mental health while in lockdown and some made the most of new opportunities. However, the pandemic may have had a profound effect by disrupting some young adults’ plans for the future, thus contributing to a sense of ontological insecurity.

Background: Complex humanitarian emergencies have a significant negative impact on the prevalence and severity of child mental health. The capacity of primary caregivers to provide care to their children is often adversely affected. There is a lack of evidence-based interventions to guide primary caregivers. This study assessed the feasibility and acceptability of implementing and evaluating a caregiver group counselling intervention, and provided an indication of its potential benefits. Methods: A single arm pilot study was conducted in Northern Iraq. Primary caregivers of a child aged 8–12 years with concern about their child's mental health attended the caregiver group intervention. Quantitative and qualitative outcome measures were completed by caregivers and children at pre-intervention, post-intervention, and 12-week follow-up. Results: The intervention was found to be feasible and acceptable to implement. Twelve participants were recruited, of which ten started the intervention and eight completed the intervention. All eight participants reported finding the intervention helpful. Evaluation of the intervention was found to be feasible and acceptable. Indicative results showed potential improvements across child and caregiver mental health. Limitations: Limitations are that the small sample size limits the range of perspectives, lack of control group means observed changes could be due to factors other than the intervention, and potential bias exists due to self-completed fidelity monitoring and possible response bias. Conclusions: The caregiver group intervention was feasible and acceptable to implement and evaluate in a humanitarian setting, and showed potential to positively impact child and caregiver mental health, warranting further research on its effectiveness.

Abstract Background COVID-19 lockdowns have resulted in school closures worldwide, requiring curriculum to be delivered to children remotely (home schooling). Qualitative evidence is needed to provide important context to the positive and negative impacts of home schooling and inform strategies to support caregivers and children as the pandemic continues. This study aimed to explore the experiences of home schooling caregivers at multiple time-points during the pandemic. Methods Data were obtained from a longitudinal survey of a representative Australian sample conducted over 8 waves during 2020 and 2021. Participants who had home schooled at least one child during COVID-19 completed open-ended questions at Wave 4 (May 2020; n = 176), Wave 7 (June 2020; n = 145), and Wave 8 (March 2021; n = 57). Participants were asked to describe what they found positive and challenging about home schooling (Wave 4), what they would do differently if they home schooled their children again (Wave 7), and the longer-term impacts of home schooling on caregivers and children (Wave 8). Results 91% of participants at Wave 4 reported at least one positive and/or negative aspect of home schooling. At Wave 8, 32% and 29% of participants reported no long-term positive or negative impacts of home schooling respectively. Using a qualitative content analysis approach, six themes were developed from the data, encompassing the impacts of home schooling on parents, and the perceived impacts on children. Impacts on parents included connecting with children, managing the work-life-school balance, and the challenge of home schooling when parents are not teachers. Perceived impacts on children included: quieter and safer learning at home, and the negatives of managing schoolwork load and social isolation. At Wave 7, 56 participants (44%) identified at least one thing they would do differently. Conclusions Despite some participants reporting positive experiences associated with home schooling, it remains challenging for many parents and their children. Supports for parents and children engaged in home schooling should provide clear and flexible guidance on how to balance schoolwork with other competing demands, assist parents who lack confidence in supporting their children’s remote learning, and address risks associated with social isolation.

Abstract Background The COVID-19 pandemic has been highly disruptive, with the closure of schools causing sudden shifts for students, educators and parents/caregivers to remote learning from home (home-schooling). Limited research has focused on home-schooling during the COVID-19 pandemic, with most research to date being descriptive in nature. The aim of the current study was to comprehensively quantify the psychosocial impacts of home-schooling on parents and other caregivers, and identify factors associated with better outcomes. Methods A nationally representative sample of 1,296 Australian adults was recruited at the beginning of Australian COVID-19 restrictions in late-March 2020, and followed up every two weeks. Data for the current study were drawn from waves two and three. Surveys assessed psychosocial outcomes of psychological distress, work and social impairment, and wellbeing, as well as a range of home-schooling factors. Results Parents and caregivers who were home-schooling during the COVID-19 pandemic experienced significantly higher levels of psychological distress and work/social impairment compared to those who were not home-schooling or had no school-aged children. A current mental health diagnosis or lower levels of perceived support from their child’s school negatively affected levels of psychological distress, work and social impairment, and wellbeing in parents and caregivers involved in home-schooling. Conclusions The mental health impacts of home-schooling were high and may rise as periods of home-schooling increase in frequency and duration. Recognising and acknowledging the challenges of home-schooling is important, and should be included in psychosocial assessments of wellbeing during periods of school closure. Emotional and instrumental support is needed for those involved in home-schooling, as perceived levels of support is associated with improved outcomes. Proactive planning by schools to support parents may promote better outcomes and improved home-schooling experiences for students.

BackgroundThe mental health impacts of the COVID-19 pandemic remain a public health concern. High quality synthesis of extensive global literature is needed to quantify this impact and identify factors associated with adverse outcomes.MethodsWe conducted a rigorous umbrella review with meta-review and present (a) pooled prevalence of probable depression, anxiety, stress, psychological distress, and post-traumatic stress, (b) standardised mean difference in probable depression and anxiety pre-versus-during the pandemic period, and (c) comprehensive narrative synthesis of factors associated with poorer outcomes. Databases searched included Scopus, Embase, PsycINFO, and MEDLINE dated to March 2022. Eligibility criteria included systematic reviews and/or meta-analyses, published post-November 2019, reporting data in English on mental health outcomes during the COVID-19 pandemic.FindingsThree hundred and thirty-eight systematic reviews were included, 158 of which incorporated meta-analyses. Meta-review prevalence of anxiety symptoms ranged from 24.4% (95%CI: 18–31%, I2: 99.98%) for general populations to 41.1% (95%CI: 23–61%, I2: 99.65%) in vulnerable populations. Prevalence of depressive symptoms ranged from 22.9% (95%CI: 17–30%, I2: 99.99%) for general populations to 32.5% (95%CI: 17–52%, I2: 99.35) in vulnerable populations. Prevalence of stress, psychological distress and PTSD/PTSS symptoms were 39.1% (95%CI: 34–44%; I2: 99.91%), 44.2% (95%CI: 32–58%; I2: 99.95%), and 18.8% (95%CI: 15–23%; I2: 99.87%), respectively. Meta-review comparing pre-COVID-19 to during COVID-19 prevalence of probable depression and probable anxiety revealed standard mean differences of 0.20 (95%CI = 0.07–0.33) and 0.29 (95%CI = 0.12–0.45), respectively.ConclusionThis is the first meta-review to synthesise the longitudinal mental health impacts of the pandemic. Findings show that probable depression and anxiety were significantly higher than pre-COVID-19, and provide some evidence that that adolescents, pregnant and postpartum people, and those hospitalised with COVID-19 experienced heightened adverse mental health. Policymakers can modify future pandemic responses accordingly to mitigate the impact of such measures on public mental health.

Abstract Objective The evidence base for suicide prevention programs in Australian schools is limited. The aim of this study was to examine the impact of a universal, mental health promotion and suicide prevention program—Youth Aware of Mental Health (YAM)—on suicidal ideation, mental health, and help-seeking in Australian secondary school students from baseline to post-intervention and 6-month follow up. Methods Using a single-arm design, the YAM program was delivered to Year 9 students (13–16 years) in secondary schools located within four regions across New South Wales, Australia. A structured self-report questionnaire using validated scales was administered at each time point. Linear mixed-effects modelling was used to examine differences in suicidal ideation scores across time, while accounting for random effects of individual schools. Results Suicidal ideation reduced significantly from baseline to post, and from baseline to follow-up (p

Introduction: Implementation of evidence-based programs in school settings can be challenging, undermining the benefits these programs deliver for children. The primary aim of this study is to assess whether an enhanced implementation intervention increases adoption of the PAX Good Behaviour Game in New South Wales (NSW) primary schools in Australia. A secondary outcome is to investigate the impact of the PAX Good Behaviour Game on children's mental health in the Australian context. Methods and analysis: The study uses a cluster randomised hybrid type 3 effectiveness-implementation design and will involve 40 NSW primary schools. Randomisation will occur at the school level. All NSW primary schools trained in the PAX Good Behaviour Game are eligible for participation. The intervention is a multicomponent implementation strategy that has been iteratively co-designed by our research team and local stakeholders. Intervention schools will have access to eight implementation support strategies in addition to the training received as usual delivery to build knowledge and skills. Research staff will assess implementation and effectiveness outcomes using self-report online surveys with teachers and support staff at baseline, 6-weeks, 6-months and 12-months follow up. Semi-structured interviews with teachers and support staff will be used to examine which implementation strategies worked for whom and under what conditions. Discussion: If successful, this study will highlight effective strategies schools or education departments can use internationally to improve their translation of evidence-based programs into routine practices. This will lead to better outcomes for children and young people.

Abstract Background It is well established that racism is a fundamental contributor to poor health and inequities. There is consistent evidence of high exposure to discrimination among Aboriginal and Torres Strait Islander (Indigenous Australian) peoples, but impacts have not been fully quantified, in part due to limited measurement tools. We aim to validate instruments developed to measure interpersonal discrimination. Methods Instruments were discussed at five focus groups and with experts, and field tested in developing Mayi Kuwayu: The National Study of Aboriginal and Torres Strait Islander Wellbeing. Data from 7501 baseline survey participants were analysed. Acceptability was assessed according to extent of missingness, construct validity using exploratory and confirmatory factor analysis, and reliability using Cronbach’s alpha. Associations between each instrument and outcomes conceptually understood to be closely (community-level racism) or less closely (family wellbeing) related were quantified to test convergent and discriminant validity. Results An 8-item instrument captures experiences of discrimination in everyday life and a 4-item instrument experiences in healthcare, each followed by a global attribution item. Item missingness was 2.2–3.7%. Half (55.4%) of participants reported experiencing any everyday discrimination, with 65.7% attributing the discrimination to Indigeneity; healthcare discrimination figures were 34.1% and 51.1%. Items were consistent with two distinct instruments, differentiating respondents with varying experiences of discrimination. Scales demonstrated very good reliability and convergent and divergent validity. Conclusion These brief instruments demonstrate face validity and robust psychometric properties in measuring Aboriginal and Torres Strait Islander adults’ experiences of interpersonal discrimination in everyday life and in healthcare. They can be used to quantify population-level experiences of discrimination, and associated wellbeing consequences, and monitor change.

Abstract Background People who are at elevated risk of suicide stand to benefit from internet-based interventions; however, research in this area is likely impacted by a range of ethical and practical challenges. The aim of this study was to examine the ethical issues and practical barriers associated with clinical studies of internet-based interventions for suicide prevention. Method This was a mixed-methods study involving two phases. First, a systematic search was conducted to identify studies evaluating internet-based interventions for people at risk of suicide, and information pertaining to safety protocols and exclusion criteria was extracted. Second, investigators on the included studies were invited to complete an online survey comprising open-ended and forced-choice responses. Quantitative and qualitative methods were used to analyse the data. Results The literature search identified 18 eligible studies, of which three excluded participants based on severity of suicide risk. Half of the 15 suicide researchers who participated in the survey had experienced problems obtaining ethics approval, and none had encountered adverse events attributed to their intervention. Survey respondents noted the difficulty of managing risk in online environments and the limitations associated with implementing safety protocols, although some also reported increased confidence resulting from the ethical review process. Respondents recommended researchers pursue a collaborative relationship with their research ethics committees. Conclusion There is a balance to be achieved between the need to minimise the risk of adverse events whilst also ensuring interventions are being validated on populations who may be most likely to use and benefit from them (i.e., those who prefer anonymity). Further research is required to obtain the views of research ethics committees and research participants on these issues. Dialogue between researchers and ethics committees is necessary to address the need to ensure safety while also advancing the timely development of effective interventions in this critical area.

Abstract Background Despite increasing investment in suicide prevention, Australian suicide rates have increased steadily in the past decade. In response to growing evidence for multicomponent intervention models for reducing suicide, the LifeSpan model has been developed as the first multicomponent, evidence-based, system-wide approach to suicide prevention in Australia. The LifeSpan model consists of nine evidence-based strategies. These include indicated, selective and universal interventions which are delivered simultaneously to community and healthcare systems over a 2-year implementation period. This study will evaluate the effectiveness of the LifeSpan model in reducing suicide attempts and suicide deaths in four geographically defined regions in New South Wales, Australia. Methods We outline the protocol for a stepped-wedge, cluster randomized controlled trial. Following a 6-month transition phase, the trial sites will move to the 2-year active implementation phase in 4-monthly intervals with evaluation extending a minimum of 24 months after establishment of the full active period. Analysis will be undertaken of the change attributable to the invention across the four sites. The primary outcome for the study is the rate of attempted suicide in the regions involved. Rate of suicide deaths within each site is a secondary outcome. Discussion If proven effective, the LifeSpan model for suicide prevention could be more widely delivered in Australian communities, providing a valuable new approach to tackle rising suicide rates. LifeSpan has the potential to significantly contribute to the mental health of Australians by improving help-seeking for suicide, facilitating early detection, and improving aftercare to reduce re-attempts. The findings from this research should also contribute to the evidence base for multilevel suicide prevention programs internationally. Trial registration Australia New Zealand Clinical Trials Register, ID: ACTRN12617000457347 . Prospectively registered on 28 March 2017. https://www.anzctr.org.au/TrialSearch.aspx#&&conditionCode=&dateOfRegistrationFrom=&interventionDescription=&interventionCodeOperator=OR&primarySponsorType=&gender=&distance=&postcode=&pageSize=20&ageGroup=&recruitmentCountryOperator=OR Protocol Version: 1.0, 31 May 2019.

The aim of the current study was to explore awareness and perceived helpfulness of mental health peer workers in Australia, and factors associated with knowledge and perceptions. As part of a broader longitudinal study of mental health in the COVID-19 pandemic, a survey of a nationally representative sample of N ​= ​812 Australians was conducted in June 2020. Investigation of peer work comprised two areas: 1) whether they had accessed or were aware of peer workers; and 2) perceived helpfulness of peer workers. Only participants who indicated awareness of peer workers were asked about helpfulness. Seventy-five participants (9.2%) reported accessing a peer worker, but over half the sample were not aware they existed (n ​= ​448). Mean helpfulness ratings indicated that participants believed peer work is somewhat or very helpful. In multivariate logistic regression analyses, age was associated with both greater awareness and perceived helpfulness; awareness was also associated with social impairment, and helpfulness with positive social support. Awareness of peer workers across the general community is limited, but peer workers are viewed favourably. Particularly in the context of increased need for mental support due to COVID-19, this suggests an opportunity to increase the workforce with an acceptable addition to clinical support.

Despite growing research on the associations between environmental conditions and mental health, no previous study has collected both quantitative indicators of farm-scale ecology and validated measures of farmer mental health. We assessed whether on-farm factors of engaging in natural resource management (NRM), the environmental state of the farm, or perceived financial challenges were associated with mental health and wellbeing in farmers. A cross-sectional survey was conducted in an established cohort of farmers for whom ecological monitoring data were collected, with data linkage to vegetation and biodiversity indicators. Participants were 63 farmers residing or working in the Box-gum grassy woodlands ecological region of eastern Australia. Primary outcome measures were symptoms of depression, anxiety, life satisfaction and wellbeing. Based on both zero-order correlations and regression models, financial struggle or financial worry were associated with poorer mental health and wellbeing outcomes, as was younger age. There were no direct associations of vegetation cover, avian biodiversity or NRM engagement with mental health or wellbeing. There remain considerable challenges in quantifying the effects of farm ecology on mental health outcomes. Further investigation of the potential social and financial benefits of natural asset management may be warranted.

We examine how prior mental health predicts hopes and how hopes predict subsequent mental health, testing hypotheses in a longitudinal study with an Australian nation-wide adult sample regarding mental health consequences of the COVID-19 outbreak during its initial stage. Quota sampling was used to select a sample representative of the adult Australian population in terms of age groups, gender, and geographical location. Mental health measures were selected to include those with the best psychometric properties. Hypotheses were tested using generalized linear models with random intercepts, with the type of GLM determined by the nature of the dependent variable. Greater anxiety, depression, distress, and loneliness predict less hope, but impaired quality of life and stress positively predict hopes of gaining new skills. Distress and loneliness predict hopes for social connectedness and an improved society, suggesting that predictors of hope depend on what is hoped for. These findings suggest the need for more nuanced theories of hope. Greater hopes for societal improvement predict lower anxiety, depression, distress, and impaired quality of life, but greater hopes for skills and better mental health predict higher levels of these covariates. Moreover, when relevant prior psychological states are more intense, the impact of hope state declines. These findings indicate that the consequences of hope are heterogeneous, and suggest a possible explanation for the seemingly inconsistent therapeutic effectiveness of raising hope.

The 2019–20 bushfires that raged in eastern Australia were an overwhelming natural disaster leading to lives lost or upended, and communities destroyed. For almost a month, Canberra, Australia's capital city in the Australian Capital Territory (ACT), was obscured by smoke from fires which threatened the outer suburbs. While smoke itself is experientially different from many natural disasters, it nevertheless poses a significant public health threat. As the impact of extended bushfire smoke in an urban setting is relatively unexplored we aimed to capture the individual and community-level experiences of the event and their importance for community and social functioning. We responded rapidly by conducting semi-structured interviews with a range of Canberra residents who, due to their personal or social circumstances, were potentially vulnerable to the effects of the smoke. Three major themes emerging from the narratives depicted disruption to daily life, physical and psychological effects, and shifting social connectedness. This study highlighted the ambiguous yet impactful nature of a bushfire smoke event, and identified four simple key messages that may be critically relevant to policy making in preparation for similar smoke events in the future.

Introduction Safe spaces are an alternative to emergency departments, which are often unable to provide optimum care for people experiencing emotional distress and/or suicidal crisis. At present, there are several different safe space models being trialled in Australia. However, research examining the effectiveness of safe space models, especially in community settings, is rare. In this paper, we present a protocol for a study in which we will investigate the implementation, effectiveness, and sustainability of safe space models as genuine alternatives for people who might usually present to the emergency department or choose not to access help due to past negative experiences. Material and methods We will use a mixed methods, co-designed study design, conducted according to the principles of community-based participatory research to obtain deep insights into the benefits of different safe space models, potential challenges, and facilitators of effective practice. We developed the study plan and evaluation framework using the RE-AIM framework, and this will be used to assess key outcomes related to reach, effectiveness, adoption, implementation, and maintenance. Data collection will comprise quantitative measures on access, use, satisfaction, (cost) effectiveness, distress, and suicidal ideation; and qualitative assessments of service implementation, experience, feasibility, acceptability, community awareness, and the fidelity of the models to service co-design. Data will be collected and analysed concurrently throughout the trial period of the initiatives. Discussion This study will enable an extensive investigation of safe spaces that will inform local delivery and provide a broader understanding of the key features of safe spaces as acceptable and effective alternatives to hospital-based care for people experiencing emotional distress and/or suicidal crisis. This study will also contribute to a growing body of research on the role and benefits of peer support and provide critical new knowledge on the successes and challenges of service co-design to inform future practice.

IntroductionThe majority of people who die by suicide have never seen a mental health professional or been diagnosed with a mental illness. To date, this majority group has largely been ignored, with most existing research focusing on predictors of suicide such as past suicide attempts. Identifying the characteristics of people who die by suicide without receiving services, often with a fatal first attempt, is crucial to reduce suicide rates through guiding improvements to service pathways and “just in time” interventions.MethodsIn this systematic review, PsycInfo, PubMed, CINAHL, and Web of Science were searched for peer-reviewed articles published from 1980 to 1st March 2021. Included studies examined predictors of non-receipt of formal mental health services among people who died by suicide. Data were extracted from published reports and the quality of included studies was assessed using a modified version of the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies. This review was registered with PROSPERO, CRD 42021226543.ResultsSixty-seven studies met inclusion criteria, with sample sizes ranging from 39 to 193,152 individuals. Male sex, younger or older age, and rural location were consistently associated with non-receipt of mental health services. People not receiving mental health services were also less likely to have a psychiatric diagnosis, past suicidal behavior or contact with general health services, and more likely to use violent means of suicide. There was some evidence that minority ethnicity and psychosocial stressors were associated with service non-receipt.ConclusionPeople who die by suicide without receiving mental health services are likely to have diverse profiles, indicating the need for multifaceted approaches to effectively support people at risk of suicide. Identifying the needs and preferences of individuals who are at risk of suicide is crucial in developing new support pathways and services, and improving the quality of existing services.Systematic Review Registrationhttp://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021226543.

Background: The aim of this study was to assess the effects of loneliness, belongingness and other modifiable factors on psychological distress and wellbeing and whether the effects of COVID-19 modulated these relationships. Methods: The current study reported on 1217 participants aged 18 years or older who completed an online survey from 28 to 31 March 2020. Survey measures included demographic characteristics; exposure to COVID-19; impact of COVID-19 on employment, finance, and work and social adjustment; loneliness, thwarted belongingness, and health behavior changes as modifiable factors. Outcome measures were psychological distress and wellbeing. Results: Linear regression models revealed that COVID-19 related work and social adjustment difficulties, financial distress, loneliness, thwarted belongingness, eating a less healthy diet poorer sleep and being female were all associated with increased psychological distress and reduced wellbeing (p

The 2019–20 bushfire season in south-eastern Australia was one of the most severe in recorded history. Bushfire smoke-related air pollution reached hazardous levels in major metropolitan areas, including the Australian Capital Territory (ACT), for prolonged periods of time. Bushfire smoke directly challenges human health through effects on respiratory and cardiac function, but can also indirectly affect health, wellbeing and quality of life. Few studies have examined the specific health effects of bushfire smoke, separate from direct effects of fire, and looked beyond physical health symptoms to consider effects on mental health and lifestyle in Australian communities. This paper describes an assessment of the health impacts of this prolonged exposure to hazardous levels of bushfire smoke in the ACT and surrounding area during the 2019–20 bushfire season. An online survey captured information on demographics, health (physical and mental health, sleep) and medical advice seeking from 2,084 adult participants (40% male, median age 45 years). Almost all participants (97%) experienced at least one physical health symptom that they attributed to smoke, most commonly eye or throat irritation, and cough. Over half of responders self-reported symptoms of anxiety and/or feeling depressed and approximately half reported poorer sleep. Women reported all symptoms more frequently than men. Participants with existing medical conditions or poorer self-rated health, parents and those directly affected by fire (in either the current or previous fire seasons) also experienced poorer physical, mental health and/or sleep symptoms. Approximately 17% of people sought advice from a medical health practitioner, most commonly a general practitioner, to manage their symptoms. This study demonstrated that prolonged exposure to bushfire smoke can have substantial effects on health. Holistic approaches to understanding, preventing and mitigating the effects of smoke, not just on physical health but on mental health, and the intersection of these, is important. Improved public health messaging is needed to address uncertainty about how individuals can protect their and their families health for future events. This should be informed by identifying subgroups of the population, such as those with existing health conditions, parents, or those directly exposed to fire who may be at a greater risk.

Existing evidence suggests that suicide stigma and suicide literacy may influence outcomes for people experiencing suicidal thoughts. The current study investigated suicide stigma and suicide literacy in a Japanese community sample (N ​= ​217), with comparison to published data and evaluation of correlates of suicide stigma and literacy. Japanese participants had significantly higher levels of suicide stigma and lower levels of suicide literacy than those in Australia and Germany. Greater self-reliance was associated with increased stigma. Younger age, less education, greater suicide exposure and greater social support were associated with increased suicide literacy. Implications for suicide prevention activities in Japan are discussed.

Abstract Background Depression frequently first emerges during adolescence, and one in five young people will experience an episode of depression by the age of 18 years. Despite advances in treatment, there has been limited progress in addressing the burden at a population level. Accordingly, there has been growing interest in prevention approaches as an additional pathway to address depression. Depression can be prevented using evidence-based psychological programmes. However, barriers to implementing and accessing these programmes remain, typically reflecting a requirement for delivery by clinical experts and high associated delivery costs. Digital technologies, specifically smartphones, are now considered a key strategy to overcome the barriers inhibiting access to mental health programmes. The Future Proofing Study is a large-scale school-based trial investigating whether cognitive behaviour therapies (CBT) delivered by smartphone application can prevent depression. Methods A randomised controlled trial targeting up to 10,000 Year 8 Australian secondary school students will be conducted. In Stage I, schools will be randomised at the cluster level either to receive the CBT intervention app (SPARX) or to a non-active control group comparator. The primary outcome will be symptoms of depression, and secondary outcomes include psychological distress, anxiety and insomnia. At the 12-month follow-up, participants in the intervention arm with elevated depressive symptoms will participate in an individual-level randomised controlled trial (Stage II) and be randomised to receive a second CBT app which targets sleep difficulties (Sleep Ninja) or a control condition. Assessments will occur post intervention (both trial stages) and at 6, 12, 24, 36, 48 and 60 months post baseline. Primary analyses will use an intention-to-treat approach and compare changes in symptoms from baseline to follow-up relative to the control group using mixed-effect models. Discussion This is the first trial testing the effectiveness of smartphone apps delivered to school students to prevent depression at scale. Results from this trial will provide much-needed insight into the feasibility of this approach. They stand to inform policy and commission decisions concerning if and how such programmes should be deployed in school-based settings in Australia and beyond. Trial registration Australian and New Zealand Clinical Trial Registry, ACTRN12619000855123. Registered on 31 May 2019. Clinical Trial Notification Scheme (CTN), CT-2019-CTN-02110-1-v1. Registered on 30 June 2019.

Background: Low engagement with self-guided online programs limits the potential of these programs to provide effective and low-cost treatment of mild to moderate depression and anxiety at scale. Identifying factors that increase uptake and adherence in self-guided online programs may facilitate the development of targeted implementation strategies to increase engagement with these programs in the community. Using data from a randomized controlled trial of a self-guided online program for depression and anxiety, the aim of this study was to identify predictors of the acceptability of internet-based psychological programs, and engagement (uptake and adherence) with the online program tested in the trial. Methods: A total of 556 community members with elevated symptoms of depression or anxiety were recruited via social media into the two active conditions of a three-arm randomized controlled trial. This trial tested the effectiveness of a 7-week self-guided online program for depression and anxiety called myCompass 2, delivered with or without an Engagement-Facilitation Intervention. Predictors of uptake (accessing at least one therapeutic module of the program), adherence (modules completed), and acceptability of internet-based psychological programs (Unified Theory of Acceptance and Use of Technology, UTAUT scale) were examined, including demographics, mental health status, help-seeking attitudes, stigma, acceptability of internet programs, and personality factors. Results: Logistic regression demonstrated that higher levels of conscientiousness (OR = 1.06, p = .026, 95% CI =1.01–1.12), and acceptability of internet-based psychological programs (OR = 1.09, p = .005, 95% CI =1.03–1.16) predicted greater uptake, and that failing to complete a module was predicted by lower levels of acceptability (OR = 0.88, p = .027, 95% CI =0.78–0.99). Linear regression showed that higher levels of agreeableness (t = 4.66, p

Background The COVID-19 pandemic has seen an increase in depression and anxiety among those with and without a history of mental illness. Commonly used forms of psychological therapy improve mental health by teaching psychotherapeutic strategies that assist people to better manage their symptoms and cope with life stressors. Minimal research to date has explored their application or value in managing mental health during significant broad-scale public health crises. Aims To determine which psychotherapeutic strategies people who have previously received therapy use to manage their distress during the COVID-19 pandemic, and whether the use and perceived helpfulness of these strategies has an effect on symptoms of depression and anxiety. Method Data (N = 857) was drawn from multiple waves of a representative longitudinal study of the effects of COVID-19 on the mental health of Australian adults, which includes measures of anxiety, depression and experiences with psychotherapy and psychotherapeutic strategies. Results Previous engagement in therapy with psychotherapeutic strategies had a protective effect on depressive but not anxiety symptoms. Common and helpful strategies used by respondents were exercise, mindfulness and breathing exercises. Using mindfulness and perceiving it to be helpful was associated with lower levels of depression and anxiety symptoms. No other strategies were associated with improved mental health. Conclusions Prior knowledge of psychotherapeutic strategies may play a role in managing mental health during unprecedented public health events such as a global pandemic. There may be value in promoting these techniques more widely in the community to manage general distress during such times.

There is minimal knowledge about the impact of large-scale epidemics on community mental health, particularly during the acute phase. This gap in knowledge means we are critically ill-equipped to support communities as they face the unprecedented COVID-19 pandemic. This study aimed to provide data urgently needed to inform government policy and resource allocation now and in other future crises. The study was the first to survey a representative sample from the Australian population at the early acute phase of the COVID-19 pandemic. Depression, anxiety, and psychological wellbeing were measured with well-validated scales (PHQ-9, GAD-7, WHO-5). Using linear regression, we tested for associations between mental health and exposure to COVID-19, impacts of COVID-19 on work and social functioning, and socio-demographic factors. Depression and anxiety symptoms were substantively elevated relative to usual population data, including for individuals with no existing mental health diagnosis. Exposure to COVID-19 had minimal association with mental health outcomes. Recent exposure to the Australian bushfires was also unrelated to depression and anxiety, although bushfire smoke exposure correlated with reduced psychological wellbeing. In contrast, pandemic-induced impairments in work and social functioning were strongly associated with elevated depression and anxiety symptoms, as well as decreased psychological wellbeing. Financial distress due to the pandemic, rather than job loss per se, was also a key correlate of poorer mental health. These findings suggest that minimizing disruption to work and social functioning, and increasing access to mental health services in the community, are important policy goals to minimize pandemic-related impacts on mental health and wellbeing. Innovative and creative strategies are needed to meet these community needs while continuing to enact vital public health strategies to control the spread of COVID-19.

BackgroundThere are few very brief measures that accurately identify multiple common mental disorders.AimsThe aim of this study was to develop and assess the psychometric properties of a new composite measure to screen for five common mental disorders.MethodTwo cross-sectional psychometric surveys were used to develop (n = 3175) and validate (n = 3620) the new measure, the Rapid Measurement Toolkit-20 (RMT20) against diagnostic criteria. The RMT20 was tested against a DSM-5 clinical checklist for major depression, generalised anxiety disorder, panic disorder, social anxiety disorder and post-traumatic stress disorder, with comparison with two measures of general psychological distress: the Kessler-10 and Distress Questionnaire-5.ResultsThe area under the curve for the RMT20 was significantly greater than for the distress measures, ranging from 0.86 to 0.92 across the five disorders. Sensitivity and specificity at prescribed cut-points were excellent, with sensitivity ranging from 0.85 to 0.93 and specificity ranging from 0.73 to 0.83 across the five disorders.ConclusionsThe RMT20 outperformed two established scales assessing general psychological distress, is free to use and has low respondent burden. The measure is well-suited to clinical screening, internet-based screening and large-scale epidemiological surveys.

Introduction: Suicide is the second leading cause of death for the university aged population globally. A significant proportion of students with suicidal ideation or behaviours do not seek professional help. Few primary suicide prevention programs have specifically targeted help seeking for suicidal ideation or behaviours among university students. Methods: This study reported the development and pilot test of a brief, two-module online psychoeducational program (ProHelp) that aimed to encourage help seeking for suicidal ideation and behaviours among university students. The program consists of two five-minute modules that address the risk factors and warning signs of suicide, stigmatising attitudes, and perceived barriers to help seeking. 156 Chinese university students and 101 Australian university students were recruited to evaluate the effectiveness of this program at post-test and one-month follow-up. Participants were randomly assigned to the psychoeducational program or an attention control program. Results: Of the Chinese and Australian students who were randomised into the study, around 50% completed the two­day post­test survey, and 30% completed the one-month follow­up survey. Although no significant difference was found between the control and experimental group on professional help-seeking beliefs and intentions, both groups' help-seeking attitudes increased during the study (p=0.003 for the post­test survey, and p=0.008 for the follow­up survey). The experimental group in both countries demonstrated a significant improvement in suicide literacy at the post-test survey (p=0.015) compared to control. Qualitative feedback indicated that the ProHelp program was user-friendly, clear, and helpful. Conclusions: This study provides initial evidence that a brief online psychoeducational program could enhance university students' suicide literacy in both China and Australia. It also suggests that increasing suicide literacy might not be sufficient to improve students' help seeking, although effect sizes indicated that this low­intensity online approach shows promise in encouraging more positive beliefs towards help seeking and preparedness to help individuals with suicidal ideation among young people. Keywords: Suicide prevention, Psychoeducational program, University students, Help seeking

Purpose: Online mental health programs can be effective in reducing symptoms of depression, anxiety disorders, substance use and suicidal ideation. However, most existing e-mental health programs focus on a single domain of mental health, neglecting comorbidity. Furthermore, few programs are tailored to the symptom patterns of the individual user. FitMindKit was designed to overcome the gaps of existing e-mental health programs, providing tailored, transdiagnostic therapeutic content to address a range of comorbid mental health symptoms. A trial was conducted to test the program's efficacy. Methods: Australian adults with elevated symptoms of depression, anxiety, suicidal ideation and/or substance use were recruited through social media, with n=194 randomised into a fully-automated trial of a 10-day brief intervention. Participants were randomly allocated to receive FitMindKit tailored to their symptoms, an untailored generic version of FitMindKit, or an attention control. Results: Mixed model repeated measures ANOVA indicated that participants in both FitMindKit and the attention control had significant reductions in symptom composite scores. Effects were not significantly greater in the FitMindKit program relative to control, either at post-test or 3-month follow-up. No effects were detected for specific decreases in depression, generalized anxiety, social anxiety, panic, suicidal ideation or alcohol/substance use. There were no significant differences between the tailored and static versions in effectiveness or adherence. Participants in the tailored and static conditions were more satisfied than in the control condition, with some evidence favouring the tailored condition. High attrition reduced power to find effects. Conclusions: FitMindKit provides a model for addressing comorbid mental health symptoms in an online program, using automated tailoring to symptom patterns. Modifications to the program are recommended, along with the need for larger trials to test the effects of tailoring on mental health outcomes. Keywords: Comorbidity, Depression, Anxiety, Substance use, Suicidal ideation, Tailored interventions

Abstract Background Young men are consistently less likely to seek help for mental health problems than their female peers. This is particularly concerning given the high rates of suicide among male adolescents. The school system has been identified as an ideal setting for the implementation of prevention and early intervention programs for young people. The current trial aims to determine the effectiveness of the Silence is Deadly program in increasing positive help-seeking intentions for mental health problems and suicide among male secondary school students. Methods This study is a two-arm, cluster-randomised, controlled trial that will compare the Silence is Deadly program to a wait-list control condition. Eight Australian high schools will be recruited to the trial, with male students in grades 11 and 12 (16 to 18 years of age) targeted for participation. The program is an innovative male-tailored suicide prevention intervention, comprising a presentation that emphasises role-modelling and legitimises help-seeking for personal and emotional problems, and a brief video that features celebrity athletes who counter existing male norms around help-seeking and encourage communication about personal and emotional issues. The program also includes a discussion of how to help a friend in distress and ends with a question and answer session. The primary outcome measure for the current study is help-seeking intentions. Secondary outcomes include help-seeking behaviour, help-seeking attitudes, help-seeking stigma, mental health symptoms, and suicidal ideation. Data will be collected pre-intervention, post-intervention, and at 3-month follow-up. Primary analyses will compare changes in help-seeking intentions for the intervention condition relative to the wait-list control condition using mixed-effects repeated-measures analyses that account for clustering within schools. Discussion If proven to be effective, this targeted help-seeking intervention for adolescent males, which is currently only delivered in one jurisdiction, could be more widely delivered in Australian high schools. The Silence is Deadly program has the potential to significantly contribute to the mental health of young men in Australia by improving help-seeking for suicidality and mental health problems, allowing this population to better access treatment and support sooner. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12617000658314 . Registered on 8 May 2017.

The social media platform Twitter has been used by individuals to communicate suicidal thoughts and intentions. Currently, the nature and rate of reply to this type of Twitter content is unknown. This brief report aimed to understand how Twitter users respond to suicide-related content as compared to non-suicide related content. Using a dataset of suicide and non-suicide related posts, replies, retweets and likes were analysed and compared. The content of the first replies to suicide-related posts were also reviewed. When compared to non-suicide related posts, those that were suicide-related received a significantly greater number of replies, with fewer retweets and likes. The rate of reply to the suicide-related posts was also significantly faster than that of the non-suicide related posts, with the average reply occurring within 1 h. Thematic analysis revealed that 62% of the first replies to suicidal posts were of a potentially helpful nature (e.g. discouraging suicide, caring, or clarifying), while 23% were dismissive or encouraging of the suicide. These findings indicate that Twitter users respond differently to suicidal content. Further research is needed to determine the effects of the replies on suicidal intentions or ideations, and whether this platform can be used to intervene, increase help-seeking, or provide anti-stigma campaigns. Keywords: Suicide, Prevention, Twitter, Social media, Mental health

Background: Transdiagnostic online interventions have the potential to overcome help seeking barriers, address symptom comorbidity, and increase accessibility to evidence-based treatments. However, there is currently a lack of high quality studies examining brief transdiagnostic interventions, as well as research examining optimal methods for screening and providing members of the community with access to these interventions. This randomised controlled trial will compare a brief, video-based transdiagnostic online intervention (FitMindKit) to an attention matched control condition (HealthWatch). Aims: The aims of the study are to (1) examine the efficacy of FitMindKit in reducing depression symptoms, anxiety symptoms, suicidal ideation, and disability relative to HealthWatch and (2) compare uptake of the program via the Internet with uptake via general practices and pharmacies (methods used in a parallel implementation study). Methods: A two-arm randomised controlled trial will be conducted with adults residing in the Australian Capital Territory, Australia. Participants will be recruited online via social media advertisements, screened, and randomised to receive one of two four-week programs: FitMindKit (12-module psychotherapeutic intervention) or HealthWatch (12-module program providing general health information). Participants will be assessed at baseline and 4 weeks post-baseline. Results: Findings from the trial will provide important knowledge regarding the utility and optimal implementation of brief transdiagnostic interventions for depression and anxiety in the community. Conclusions: This trial has strong potential to increase access to evidence-based treatments in the community by directly addressing several factors that impede this access, such as symptom comorbidity and a lack of knowledge regarding optimal implementation pathways. Trial registration: This trial is registered with the Australian New Zealand Clinical Trials Registry (number ACTRN12618001688279). Keywords: Depression, Anxiety, Transdiagnostic, Randomised controlled trial, Internet, Implementation

Recruiting participants is a challenge for many health, medical and psychosocial research projects. One tool more frequently being used to improve recruitment is the social networking website Facebook. A systematic review was conducted to identify studies that have used Facebook to recruit participants of all ages, to any psychosocial, health or medical research. 110 unique studies that used Facebook as a recruitment source were included in the review. The majority of studies used a cross-sectional design (80%) and addressed a physical health or disease issue (57%). Half (49%) of the included studies reported specific details of the Facebook recruitment process. Researchers paid between $1.36 and $110 per completing participants (Mean = $17.48, SD = $23.06). Among studies that examined the representativeness of their sample, the majority concluded (86%) their Facebook-recruited samples were similarly representative of samples recruited via traditional methods. These results indicate that Facebook is an effective and cost-efficient recruitment method. Researchers should consider their target group, advertisement wording, offering incentives and no-cost methods of recruitment when considering Facebook as a recruitment source. It is hoped this review will assist researchers to make decisions regarding the use of Facebook as a recruitment tool in future research.

Background Community-based screening for mental health problems may increase service use through feedback to individuals about their severity of symptoms and provision of contacts for appropriate services. Aims The effect of symptom feedback on service use was assessed. Secondary outcomes included symptom change and study attrition. Method Using online recruitment, 2773 participants completed a comprehensive survey including screening for depression (n=1366) or social anxiety (n=1407). Across these two versions, approximately half (n=1342) of the participants were then randomly allocated to receive tailored feedback. Participants were reassessed after 3 months (Australian New Zealand Clinical Trials Registry ANZCTR12614000324617). Results A negative effect of providing social anxiety feedback to individuals was observed, with significant reductions in professional service use. Greater attrition and lower intentions to seek help were also observed after feedback. Conclusions Online mental health screening with feedback is not effective for promoting professional service use. Alternative models of online screening require further investigation.

Twitter is increasingly investigated as a means of detecting mental health status, including depression and suicidality, in the population. However, validated and reliable methods are not yet fully established. This study aimed to examine whether the level of concern for a suicide-related post on Twitter could be determined based solely on the content of the post, as judged by human coders and then replicated by machine learning. From 18th February 2014 to 23rd April 2014, Twitter was monitored for a series of suicide-related phrases and terms using the public Application Program Interface (API). Matching tweets were stored in a data annotation tool developed by the Commonwealth Scientific and Industrial Research Organisation (CSIRO). During this time, 14,701 suicide-related tweets were collected: 14% were randomly (n = 2000) selected and divided into two equal sets (Set A and B) for coding by human researchers. Overall, 14% of suicide-related tweets were classified as ‘strongly concerning’, with the majority coded as ‘possibly concerning’ (56%) and the remainder (29%) considered ‘safe to ignore’. The overall agreement rate among the human coders was 76% (average κ = 0.55). Machine learning processes were subsequently applied to assess whether a ‘strongly concerning’ tweet could be identified automatically. The computer classifier correctly identified 80% of ‘strongly concerning’ tweets and showed increasing gains in accuracy; however, future improvements are necessary as a plateau was not reached as the amount of data increased. The current study demonstrated that it is possible to distinguish the level of concern among suicide-related tweets, using both human coders and an automatic machine classifier. Importantly, the machine classifier replicated the accuracy of the human coders. The findings confirmed that Twitter is used by individuals to express suicidality and that such posts evoked a level of concern that warranted further investigation. However, the predictive power for actual suicidal behaviour is not yet known and the findings do not directly identify targets for intervention.