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BACKGROUND As the demand for youth mental health care continues to rise, managing wait times and reducing treatment delays are key challenges to delivering timely and quality care. Clinical staging is a heuristic model for youth mental health that can stratify care allocation according to an individual’s risk of illness progression. The application of staging has been traditionally limited to trained clinicians, yet if digital technologies could be leveraged to apply clinical staging, then this could increase the scalability and utility of this model in services. OBJECTIVE The aim of this study is to validate a digital algorithm to accurately differentiate young people at lower and higher risk of developing mental disorders. METHODS The cohort comprised 131 young people, aged between 16 to 25 years, who presented to youth mental health services in Australia for the first time between November 2018 to March 2021. Clinical stages (either stage 1a or stage 1b+) were allocated independently by expert psychiatrists and compared to the digital algorithm based on a multidimensional self-report questionnaire. RESULTS Of the 131 participants, the mean (SD) age was 20.3 (2.4) years and 94 (71.8%) were female. Ninety-one percent of clinical stage ratings were concordant between the digital algorithm and the expert ratings with a substantial interrater agreement (κ=0.67, P CONCLUSIONS This novel digital algorithm is sufficiently robust to be used as an adjunctive decision support tool to stratify care and assist with demand management in youth mental health services. This work could transform care pathways and expedite care allocation for those in early stages of common anxiety and depressive disorders. Between 11% and 27% of young people presenting for care may be suitable for low intensity online or brief interventions, creating additional clinical capacity to be directed towards those who are in stage 1b+ for further assessment and intervention.

BACKGROUND As the demand for youth mental health care continues to rise, managing wait times and reducing treatment delays are key challenges to delivering timely and quality care. Clinical staging is a heuristic model for youth mental health that can stratify care allocation according to an individual’s risk of illness progression. The application of staging has been traditionally limited to trained clinicians, yet if digital technologies could be leveraged to apply clinical staging, then this could increase the scalability and utility of this model in services. OBJECTIVE The aim of this proof-of-concept study is to validate a digital algorithm to accurately differentiate young people at lower and higher risk of developing mental disorders. METHODS The cohort comprised 131 young people, aged between 16 to 25 years, who presented to youth mental health services in Australia for the first time between November 2018 to March 2021. Clinical stages (either stage 1a or stage 1b+) were allocated independently by expert psychiatrists and compared to the digital algorithm based on a multidimensional self-report questionnaire. RESULTS Of the 131 participants, the mean (SD) age was 20.3 (2.4) years and 94 (71.8%) were female. Ninety-one percent of clinical stage ratings were concordant between the digital algorithm and the expert ratings with a substantial interrater agreement (κ=0.67, P CONCLUSIONS This novel digital algorithm is sufficiently robust to be used as an adjunctive decision support tool to stratify care and assist with demand management in youth mental health services. This work could transform care pathways and expedite care allocation for those in early stages of common anxiety and depressive disorders. Between 11% and 27% of young people presenting for care may be suitable for low intensity online or brief interventions, creating additional clinical capacity to be directed towards those who are stage 1b+ for further assessment and intervention.

IntroductionThe susceptibility to suicidal behaviour has been linked to cognitive functioning deficits. Gamified assessments have emerged as a practical and engaging approach to assess these deficits, though their acceptability amongst young adults with suicidal thoughts is currently understudied.MethodsThirteen young Australian adults aged 18 to 25 years who experienced suicidal thoughts in the past year were recruited to evaluate the smartphone based CogGame app. Inductive thematic analysis was utilised to identify the themes obtained from the interviews. The relationships between cognitive functioning deficits and the severity of suicidal thoughts were explored by correlational analyses.ResultsAll participants found the GogGame app easy to learn to use and navigate. Positive experiences and high user satisfaction were reported with the use of CogGame app. Major areas for improvement include having clearer instructions and app information, adjusting the difficulty of the exercises, and addressing a few technical issues such as decreasing loading time. Higher levels of suicidal thoughts were found to be significantly associated with poorer visual learning performance on the CogGame app (p= .01).ConclusionPositive participant experiences with CogGame revealed the promising potential of gamified assessments to measure cognitive functioning in young adults with suicidal thoughts.

This paper presents a case study of an innovative direct-to-consumer preclinic triage system designed to reduce predicted peak demand for Australian mental health services as a result of COVID-19 and its associated socioeconomic consequences by guiding Australians to the right mental health care first time. Our innovative, digital health solution comprises two components: (1) a highly personalised and measurement-based model of care (Brain and Mind Centre model of care) that considers both the heterogeneity of mental disorders and other underlying comorbidities, as well as clinical staging; and (2) a health information technology (i.e. the InnoWell Platform). This digital health solution has been embedded as part of standard service delivery into a community-based intake service, thus resulting in a redesigned service model. The service model is currently being implemented as part of a pilot feasibility study, the marker of acceptability at the health professional and service level, and is now under active evaluation to determine its effect on outcomes for consumers, health professionals and the service. For the purposes of this paper, this model served as a prototype for the preclinic triage system that was conceptualised for national scalability at the primary health network level. When implemented at a national level, our direct-to-consumer preclinic triage system is expected to be an effective population health demand management strategy to address the rapidly emerging mental health demand crisis in Australia, and is aligned with the recent recommendation from the Productivity Commission to develop a sustainable national digital platform to facilitate the assessment and referral process to ensure access to mental health care matched to an individual’s level of need. What is known about the topic? Although there is increased recognition of the mental health demand crisis in Australia as a result of the COVID-19 pandemic, little has been done to ‘flatten’ the curve. The Australian Government committed additional funding to support the Better Access Pandemic Support measure; however, this approach to care fails to appreciate both the disparities in service availability across Australia and the gap fees that are prohibitive to some of those seeking help. Furthermore, the expansion of this program may only result in those in care remaining in care, thus further delaying access to those in need. What does this paper add? This paper describes a digital health solution, comprised of a highly personalised and measurement-based model of care coupled with a health information technology, that has been embedded as part of standard service delivery. Consumers seeking mental health care complete a multidimensional self-report assessment via the technology, the results of which are available in real-time and used to facilitate triage to pathways of care as indicated by the severity of the consumer’s illness and level of need to more effectively and efficiently allocate consumers to care. The redesigned service model is now under active evaluation to determine its effects on outcomes at consumer, health professional and service levels. What are the implications for practitioners? The redesigned local service model served as a prototype for our innovative direct-to-consumer preclinic triage system specifically designed to allocate consumers to self-management, ambulatory care or acute care based on clinical stage and level of need. It is our hypothesis that the preclinic triage system will be an effective population health demand management strategy. Importantly, the proposed preclinic triage system aligns with the recent recommendation from the Productivity Commission for the Australian Government to fund the development and sustained implementation of a digital platform to facilitate assessment and referral to evidence-based interventions matched to a consumer’s level of need.

An ongoing need exists for innovation in service delivery to ensure that mental health services deliver high-quality treatment and prevention in the population. This Special Article proposes the adoption of “staged care” as a population health–oriented service delivery model for packages of specialized services delivered largely in ambulatory care settings for individuals with common affective disorders. Staged care integrates measures of clinical need alongside clinical stage and personal choice to select hierarchically arranged service packages for individuals. Packages then vary according to the intensity, duration, and mix of treatment options. This Special Article describes five levels of care in staged care: self- or family-directed monitoring and management, low-intensity services, moderate-intensity services, high-intensity services, and acute and specialist community mental health services. The care environment, treatment team, and length of treatment are also described, and provisional criteria are specified for assigning individuals to different care levels on the basis of current clinical need and clinical stage. Staged care is presented as a model that guides treatment selection and health service delivery to ensure that the high-quality care aims of “right care first time” and prevention are achieved and optimal use of available resources is considered.

Background The World Economic Forum has recently highlighted substantial problems in mental health service provision and called for the rapid deployment of smarter, digitally-enhanced health services as a means to facilitate effective care coordination and address issues of demand. In mental health, the biggest enabler of digital solutions is the implementation of an effective model of care that is facilitated by integrated health information technologies (HITs); the latter ensuring the solution is easily accessible, scalable and sustainable. The University of Sydney’s Brain and Mind Centre (BMC) has developed an innovative digital health solution – delivered through the Youth Mental Health and Technology Program – which incorporates two components: 1) a highly personalised and measurement-based (data-driven) model of youth mental health care; and 2) an industrial grade HIT registered on the Australian Register of Therapeutic Goods. This paper describes a research protocol to evaluate the impact of implementing the BMC’s digital health solution into youth mental health services (i.e. headspace - a highly accessible, youth-friendly integrated service that responds to the mental health, physical health, alcohol or other substance use, and vocational concerns of young people aged 12 to 25 years) within urban and regional areas of Australia. Methods The digital health solution will be implemented into participating headspace centres using a naturalistic research design. Quantitative and qualitative data will be collected from headspace health professionals, service managers and administrators, as well as from lead agency and local Primary Health Network (PHN) staff, via service audits, Implementation Officer logs, online surveys, and semi-structured interviews, at baseline and then three-monthly intervals over the course of 12 months. Discussion At the time of publication, six headspace centres had been recruited to this study and had commenced implementation and impact evaluation. The first results are expected to be submitted for publication in 2021. This study will focus on the impact of implementing a digital health solution at both a service and staff level, and will evaluate digital readiness of service and staff adoption; quality, usability and acceptability of the solution by staff; staff self-reported clinical competency; overall impact on headspace centres as well as their lead agencies and local PHNs; and social return on investment.

UNSTRUCTURED Recent years have seen remarkable progress in our scientific understanding of early childhood social, emotional, and cognitive development, as well as our capacity to widely disseminate health information using digital technologies. Together, these scientific and technological advances offer exciting opportunities to deliver high-quality information about early childhood development (ECD) to parents and families globally, which may ultimately lead to greater knowledge and confidence among parents and better outcomes among children (particularly in lower-and-middle income countries). With these potential benefits in mind, we set out to design, develop, implement, and evaluate a new parenting app – “Thrive by Five” – that will be available in 30 countries, providing caregivers and families with evidence-based and culturally appropriate information about ECD, accompanied by sets of “collective actions” that go beyond mere “tips” for parenting practices. Here, we describe this ongoing global project and discuss the components of our scientific framework for developing and prototyping the app’s content. Specifically, we describe: (1) five domains used to organise the content and goals of the app’s information and associated practices; (2) five neurobiological systems that are relevant to ECD and can be “targeted” behaviourally to potentially influence social, emotional, and cognitive development; (3) our anthropological and cultural framework to learn about local contexts and appreciate decolonisation perspectives; and (4) our approach to tailor the app’s content to local contexts, involving collaboration with in-country partner organisations and local and international subject-matter experts in ECD, education, medicine, psychology, and anthropology, among others. Finally, we provide examples of content that has been incorporated in Thrive by Five’s global launch in Indonesia.

Objective This study utilised digital technology to assess the clinical needs of young people presenting for care at headspace centres across Australia. Method 1490 young people (12–25 years) who presented to one of 11 headspace services from four geographical locations (urban New South Wales, urban South Australia, regional New South Wales, and regional Queensland) completed a digital multidimensional assessment at initial presentation. Characteristics were compared between services and geographical locations. Results We identified major variation in the demographics, and the type and severity of needs across different services. Individuals from regional services were more likely to be younger, of Aboriginal and Torres Strait Islander origin, and present with psychotic-like symptoms and suicidality, while those in urban areas were more likely to have previously sought help and have problematic alcohol use. Further differences in age, distress, depressive symptoms, psychotic-like experiences, trauma, family history, alcohol use, education/employment engagement, and days out of role were identified between different urban sites. Conclusions The variability between services provides insight into the heterogeneity of youth mental health populations which has implications for appropriate early intervention and prevention service provisions. We propose that integrating digital technologies has the potential to provide insights for smarter service planning and evaluation.

Mediterranean diet interventions have demonstrated positive effects in the prevention and management of several chronic conditions in older adults. Understanding the effective components of behavioural interventions is essential for long-term health behaviour change and translating evidence-based interventions into practice. The aim of this scoping review is to provide an overview of the current Mediterranean diet interventions for older adults (≥55 years) and describe the behaviour change techniques used as part of the interventions. A scoping review systematically searched Medline, Embase, CINAHL, Web of Science, Scopus, and PsycINFO from inception until August 2022. Eligible studies were randomized and non-randomized experimental studies involving a Mediterranean or anti-inflammatory diet intervention in older adults (average age > 55 years). Screening was conducted independently by two authors, with discrepancies being resolved by the senior author. Behaviour change techniques were assessed using the Behaviour Change Technique Taxonomy (version 1), which details 93 hierarchical techniques grouped into 16 categories. From 2385 articles, 31 studies were included in the final synthesis. Ten behaviour change taxonomy groupings and 19 techniques were reported across the 31 interventions. The mean number of techniques used was 5, with a range from 2 to 9. Common techniques included instruction on how to perform the behaviour (n = 31), social support (n = 24), providing information from a credible source (n = 16), information about health consequences (n = 15), and adding objects to the environment (n = 12). Although behaviour change techniques are commonly reported across interventions, the use of the Behaviour Change Technique Taxonomy for intervention development is rare, and more than 80% of the available techniques are not being utilised. Integrating behaviour change techniques in the development and reporting of nutrition interventions for older adults is essential for effectively targeting behaviours in both research and practice.

Enhanced care coordination is essential to improving access to and navigation between youth mental health services. By facilitating better communication and coordination within and between youth mental health services, the goal is to guide young people quickly to the level of care they need and reduce instances of those receiving inappropriate care (too much or too little), or no care at all. Yet, it is often unclear how this goal can be achieved in a scalable way in local regions. We recommend using technology-enabled care coordination to facilitate streamlined transitions for young people across primary, secondary, more specialised or hospital-based care. First, we describe how technology-enabled care coordination could be achieved through two fundamental shifts in current service provisions; a model of care which puts the person at the centre of their care; and a technology infrastructure that facilitates this model. Second, we detail how dynamic simulation modelling can be used to rapidly test the operational features of implementation and the likely impacts of technology-enabled care coordination in a local service environment. Combined with traditional implementation research, dynamic simulation modelling can facilitate the transformation of real-world services. This work demonstrates the benefits of creating a smart health service infrastructure with embedded dynamic simulation modelling to improve operational efficiency and clinical outcomes through participatory and data driven health service planning.

Background Along with the proliferation of health information technologies (HITs), there is a growing need to understand the potential privacy risks associated with using such tools. Although privacy policies are designed to inform consumers, such policies have consistently been found to be confusing and lack transparency. Objective This study aims to present consumer preferences for accessing privacy information; develop and apply a privacy policy risk assessment tool to assess whether existing HITs meet the recommended privacy policy standards; and propose guidelines to assist health professionals and service providers with understanding the privacy risks associated with HITs, so that they can confidently promote their safe use as a part of care. Methods In phase 1, participatory design workshops were conducted with young people who were attending a participating headspace center, their supportive others, and health professionals and service providers from the centers. The findings were knowledge translated to determine participant preferences for the presentation and availability of privacy information and the functionality required to support its delivery. Phase 2 included the development of the 23-item privacy policy risk assessment tool, which incorporated material from international privacy literature and standards. This tool was then used to assess the privacy policies of 34 apps and e-tools. In phase 3, privacy guidelines, which were derived from learnings from a collaborative consultation process with key stakeholders, were developed to assist health professionals and service providers with understanding the privacy risks associated with incorporating HITs as a part of clinical care. Results When considering the use of HITs, the participatory design workshop participants indicated that they wanted privacy information to be easily accessible, transparent, and user-friendly to enable them to clearly understand what personal and health information will be collected and how these data will be shared and stored. The privacy policy review revealed consistently poor readability and transparency, which limited the utility of these documents as a source of information. Therefore, to enable informed consent, the privacy guidelines provided ensure that health professionals and consumers are fully aware of the potential for privacy risks in using HITs to support health and well-being. Conclusions A lack of transparency in privacy policies has the potential to undermine consumers’ ability to trust that the necessary measures are in place to secure and protect the privacy of their personal and health information, thus precluding their willingness to engage with HITs. The application of the privacy guidelines will improve the confidence of health professionals and service providers in the privacy of consumer data, thus enabling them to recommend HITs to provide or support care.

BACKGROUND Globally, there are fundamental shortcomings in mental health care systems, including restricted access, siloed services, interventions that are poorly matched to service users’ needs, underuse of personal outcome monitoring to track progress, exclusion of family and carers, and suboptimal experiences of care. Health information technologies (HITs) hold great potential to improve these aspects that underpin the enhanced quality of mental health care. OBJECTIVE Project Synergy aimed to co-design, implement, and evaluate novel HITs, as exemplified by the InnoWell Platform, to work with standard health care organizations. The goals were to deliver improved outcomes for specific populations under focus and support organizations to enact significant system-level reforms. METHODS Participating health care organizations included the following: Open Arms–Veterans & Families Counselling (in Sydney and Lismore, New South Wales [NSW]); NSW North Coast headspace centers for youth (Port Macquarie, Coffs Harbour, Grafton, Lismore, and Tweed Heads); the Butterfly Foundation’s National Helpline for eating disorders; Kildare Road Medical Centre for enhanced primary care; and Connect to Wellbeing North Coast NSW (administered by Neami National), for population-based intake and assessment. Service users, families and carers, health professionals, and administrators of services across Australia were actively engaged in the configuration of the InnoWell Platform to meet service needs, identify barriers to and facilitators of quality mental health care, and highlight potentially the best points in the service pathway to integrate the InnoWell Platform. The locally configured InnoWell Platform was then implemented within the respective services. A mixed methods approach, including surveys, semistructured interviews, and workshops, was used to evaluate the impact of the InnoWell Platform. A participatory systems modeling approach involving co-design with local stakeholders was also undertaken to simulate the likely impact of the platform in combination with other services being considered for implementation within the North Coast Primary Health Network to explore resulting impacts on mental health outcomes, including suicide prevention. RESULTS Despite overwhelming support for integrating digital health solutions into mental health service settings and promising impacts of the platform simulated under idealized implementation conditions, our results emphasized that successful implementation is dependent on health professional and service readiness for change, leadership at the local service level, the appropriateness and responsiveness of the technology for the target end users, and, critically, funding models being available to support implementation. The key places of interoperability of digital solutions and a willingness to use technology to coordinate health care system use were also highlighted. CONCLUSIONS Although the COVID-19 pandemic has resulted in the widespread acceptance of very basic digital health solutions, Project Synergy highlights the critical need to support equity of access to HITs, provide funding for digital infrastructure and digital mental health care, and actively promote the use of technology-enabled, coordinated systems of care.

Background Globally, there are fundamental shortcomings in mental health care systems, including restricted access, siloed services, interventions that are poorly matched to service users’ needs, underuse of personal outcome monitoring to track progress, exclusion of family and carers, and suboptimal experiences of care. Health information technologies (HITs) hold great potential to improve these aspects that underpin the enhanced quality of mental health care. Objective Project Synergy aimed to co-design, implement, and evaluate novel HITs, as exemplified by the InnoWell Platform, to work with standard health care organizations. The goals were to deliver improved outcomes for specific populations under focus and support organizations to enact significant system-level reforms. Methods Participating health care organizations included the following: Open Arms–Veterans & Families Counselling (in Sydney and Lismore, New South Wales [NSW]); NSW North Coast headspace centers for youth (Port Macquarie, Coffs Harbour, Grafton, Lismore, and Tweed Heads); the Butterfly Foundation’s National Helpline for eating disorders; Kildare Road Medical Centre for enhanced primary care; and Connect to Wellbeing North Coast NSW (administered by Neami National), for population-based intake and assessment. Service users, families and carers, health professionals, and administrators of services across Australia were actively engaged in the configuration of the InnoWell Platform to meet service needs, identify barriers to and facilitators of quality mental health care, and highlight potentially the best points in the service pathway to integrate the InnoWell Platform. The locally configured InnoWell Platform was then implemented within the respective services. A mixed methods approach, including surveys, semistructured interviews, and workshops, was used to evaluate the impact of the InnoWell Platform. A participatory systems modeling approach involving co-design with local stakeholders was also undertaken to simulate the likely impact of the platform in combination with other services being considered for implementation within the North Coast Primary Health Network to explore resulting impacts on mental health outcomes, including suicide prevention. Results Despite overwhelming support for integrating digital health solutions into mental health service settings and promising impacts of the platform simulated under idealized implementation conditions, our results emphasized that successful implementation is dependent on health professional and service readiness for change, leadership at the local service level, the appropriateness and responsiveness of the technology for the target end users, and, critically, funding models being available to support implementation. The key places of interoperability of digital solutions and a willingness to use technology to coordinate health care system use were also highlighted. Conclusions Although the COVID-19 pandemic has resulted in the widespread acceptance of very basic digital health solutions, Project Synergy highlights the critical need to support equity of access to HITs, provide funding for digital infrastructure and digital mental health care, and actively promote the use of technology-enabled, coordinated systems of care.

The thalamus is a key diencephalic structure involved in major depressive disorder (MDD). Studies have consistently revealed abnormalities in thalamic volumes in older adults with late-onset depression (LOD), however abnormalities in older adults with early-onset depression (EOD) have not yet been well-studied.Fifty-nine euthymic participants with a history of EOD and fifty-nine matched comparison participants without a lifetime history of depression underwent neuroimaging, medical and neuropsychological assessments. Thalamic volumes were compared between groups. To investigate the previously-proposed right hemispheric (RH) dominance theory of MDD, we explored the bilateral, right and left hemispheric (LH) thalamic volumes. Multiple regression analyses were used to evaluate between-group and within-group effects. Correlational analyses examined associations between group and cognitive performance.Relative to the comparison group, those with EOD had significantly larger bilateral, LH and RH thalamic volumes. Those with EOD, those who were younger, and those who had fewer years of education demonstrated larger bilateral and LH thalamic volumes. For RH thalamic volumes, those with EOD and those who were younger demonstrated larger RH thalamic volumes. EOD within-group models were also run to assess associations between relevant depression variables. The results showed that only age was significant for bilateral and RH thalamic volumes. For the LH thalamic volumes, the model was not significant. No significant correlations were found between cognitive performance and EOD groups.Older adults with a history of EOD showed significantly larger bilateral, RH and LH thalamic volumes. Further research is needed to delineate potential underlying mechanisms of this change.

An introduction (comprising background and problem statement): New health information technologies (HIT) are being rapidly developed to support the transformation of mental health services. The InnoWell Platform is a configurable and customisable digital tool that assists in assessment, monitoring and management of mental ill health and maintenance of wellbeing. Importantly, the InnoWell Platform is not just installed into a service, rather implementation is informed by participatory design methodologies, including service modelling to understand and map clinical pathways (both pre- and post-implementation), relationships to external mental health and social services, and key performance indicators related to safety and service quality.Theory/Methods: The InnoWell Platform is now being offered as part of standard clinical care in face-to-face and online mental health services across population groups, including young children and their families, young people, adults (including the veteran community) and older adults. During pre-implementation, at least two service modelling workshops are conducted to discover, evaluate and prototype clinical pathways (intake, assessment, treatment planning, treatment, progress monitoring, exit) which can be assessed against safety and service quality domains (i.e. accessibility, acceptability, workforce competence, efficiency, effectiveness, appropriateness and care continuity). The co-designed service models are updated quarterly to reflect changes related to implementation and impacts on workflows by role (i.e. health professional, service management or administration).Results: To date, service modelling workshops have been conducted in nine primary youth mental health services, a counselling service for veterans and their families, a helpline for individuals affected by eating disorders and negative body image issues, and a primary health network using ‘staged care’ principles across the lifespan. To ensure a comprehensive understanding of each service’s clinical pathway, participants included those with a lived experience (consumer and/or supportive other), health professionals, service management and administration. Key themes explored included: quality in mental health service provision; current clinical pathway(s) with an emphasis on access and delays in service provision; and, how the InnoWell Platform could enhance care and improve outcome monitoring.Discussion: New HITs, such as the InnoWell Platform, have the potential to realise significant improvements in Australian mental health service quality. Co-designed service models highlight potential points of consumer engagement with the Platform and impacts on service workflows to facilitate successful implementation.Conclusions (comprising key findings): A thorough understanding of a service’s clinical pathway is essential to determine at which point(s) the InnoWell Platform is best placed to drive person-centred, collaborative care; improve the efficiency and enhance the effectiveness of care provision; and monitor safety and service quality.Lessons learned: Iterative review of service models is required to track changes associated with embedding the Platform in the service as well as in response to service-level changes (i.e. revised intake procedures).Limitations: Currently, limited data is available in the Platform to evaluate safety and service quality indicators as they relate to points in the clinical pathways.Suggestions for future research: Monitoring changes in the service model in association with real-time metrics collected by the Platform will inform and guide service quality improvement.

BACKGROUND Along with the proliferation of health information technologies (HITs), there is a growing need to understand the potential privacy risks associated with using such tools. Although privacy policies are designed to inform consumers, such policies have consistently been found to be confusing and lack transparency. OBJECTIVE This study aims to present consumer preferences for accessing privacy information; develop and apply a privacy policy risk assessment tool to assess whether existing HITs meet the recommended privacy policy standards; and propose guidelines to assist health professionals and service providers with understanding the privacy risks associated with HITs, so that they can confidently promote their safe use as a part of care. METHODS In phase 1, participatory design workshops were conducted with young people who were attending a participating headspace center, their supportive others, and health professionals and service providers from the centers. The findings were knowledge translated to determine participant preferences for the presentation and availability of privacy information and the functionality required to support its delivery. Phase 2 included the development of the 23-item privacy policy risk assessment tool, which incorporated material from international privacy literature and standards. This tool was then used to assess the privacy policies of 34 apps and e-tools. In phase 3, privacy guidelines, which were derived from learnings from a collaborative consultation process with key stakeholders, were developed to assist health professionals and service providers with understanding the privacy risks associated with incorporating HITs as a part of clinical care. RESULTS When considering the use of HITs, the participatory design workshop participants indicated that they wanted privacy information to be easily accessible, transparent, and user-friendly to enable them to clearly understand what personal and health information will be collected and how these data will be shared and stored. The privacy policy review revealed consistently poor readability and transparency, which limited the utility of these documents as a source of information. Therefore, to enable informed consent, the privacy guidelines provided ensure that health professionals and consumers are fully aware of the potential for privacy risks in using HITs to support health and well-being. CONCLUSIONS A lack of transparency in privacy policies has the potential to undermine consumers’ ability to trust that the necessary measures are in place to secure and protect the privacy of their personal and health information, thus precluding their willingness to engage with HITs. The application of the privacy guidelines will improve the confidence of health professionals and service providers in the privacy of consumer data, thus enabling them to recommend HITs to provide or support care. CLINICALTRIAL

BACKGROUND As the global population ages, there is increased interest in developing strategies to promote health and well-being in later life, thus enabling continued productivity, social engagement, and independence. As older adults use technologies with greater frequency, proficiency, and confidence, health information technologies (HITs) now hold considerable potential as a means to enable broader access to tools and services for the purposes of screening, treatment, monitoring, and ongoing maintenance of health for this group. The InnoWell Platform is a digital tool co-designed with lived experience to facilitate better outcomes by enabling access to a comprehensive multidimensional assessment, the results of which are provided in real time to enable consumers to make informed decisions about clinical and nonclinical care options independently or in collaboration with a health professional. OBJECTIVE This study aims to evaluate the usability and acceptability of a prototype of the InnoWell Platform, co-designed and configured with and for older adults, using self-report surveys. METHODS Participants were adults 50 years and older who were invited to engage with the InnoWell Platform naturalistically (ie, at their own discretion) for a period of 90 days. In addition, they completed short web-based surveys at baseline regarding their background, health, and mental well-being. After 90 days, participants were asked to complete the System Usability Scale to evaluate the usability and acceptability of the prototyped InnoWell Platform, with the aim of informing the iterative redesign and development of this digital tool before implementation within a health service setting. RESULTS A total of 19 participants consented to participate in the study; however, only the data from the 16 participants (mean age 62.8 years, SD 7.5; range 50-72) who completed at least part of the survey at 90 days were included in the analyses. Participants generally reported low levels of psychological distress and good mental well-being. In relation to the InnoWell Platform, the usability scores were suboptimal. Although the InnoWell Platform was noted to be easy to use, participants had difficulty identifying the relevance of the tool for their personal circumstances. Ease of use, the comprehensive nature of the assessment tools, and the ability to track progress over time were favored features of the InnoWell Platform, whereas the need for greater personalization and improved mobile functionality were cited as areas for improvement. CONCLUSIONS HITs such as the InnoWell Platform have tremendous potential to improve access to cost-effective and low-intensity interventions at scale to improve and maintain mental health and well-being in later life. However, to promote adoption of and continued engagement with such tools, it is essential that these HITs are personalized and relevant for older adult end users, accounting for differences in background, clinical profiles, and levels of need.

Background Despite the widely acknowledged potential for health information technologies to improve the accessibility, quality and clinical safety of mental health care, implementation of such technologies in services is frequently unsuccessful due to varying consumer, health professional, and service-level factors. The objective of this co-design study was to use process mapping (i.e. service mapping) to illustrate the current consumer journey through primary mental health services, identify barriers to and facilitators of quality mental health care, and highlight potential points at which to integrate the technology-enabled solution to optimise the provision of care based on key service performance indicators. Methods Interactive, discussion-based workshops of up to six hours were conducted with representative stakeholders from each participating service, including health professionals, service managers and administrators from Open Arms – Veterans & Families Counselling Service (Sydney), a counselling service for veterans and their families, and five headspace centres in the North Coast Primary Health Network, primary youth mental health services. Service maps were drafted and refined in real time during the workshops. Through both group discussion and the use of post-it notes, participants worked together to evaluate performance indicators (e.g. safety) at each point in the consumer journey (e.g. intake) to indicate points of impact for the technology-enabled solution, reviewing and evaluating differing opinions in order to reach consensus. Results Participants (n=84 across participating services) created service maps illustrating the current consumer journey through the respective services and highlighting barriers to and facilitators of quality mental health care. By consensus, the technology-enabled solution as facilitated by the InnoWell Platform was noted to enable the early identification of risk, reduce or eliminate lengthy intake processes, enable routine outcome monitoring to revise treatment plans in relation to consumer response, and serve as a personal data record for consumers, driving person-centred, coordinated care. Conclusions Service mapping was shown to be an effective methodology to understand the consumer’s journey through a service and served to highlight how the co-designed technology-enabled solution can optimise service pathways to improve the accessibility, quality and clinical safety of care relative to key service performance indicators, facilitating the delivery of the right care.

BACKGROUND Australia’s mental health care system has long been fragmented and under-resourced, with services falling well short of demand. In response, the World Economic Forum has recently called for the rapid deployment of smarter, digitally enhanced health services to facilitate effective care coordination and address issues of demand. The University of Sydney’s Brain and Mind Centre (BMC) has developed an innovative digital health solution that incorporates 2 components: a highly personalized and measurement-based (data-driven) model of youth mental health care and a health information technology (HIT) registered on the Australian Register of Therapeutic Goods. Importantly, research into implementation of such solutions considers education and training of clinicians to be essential to adoption and optimization of use in standard clinical practice. The BMC’s Youth Mental Health and Technology Program has subsequently developed a comprehensive education and training program to accompany implementation of the digital health solution. OBJECTIVE This paper describes the protocol for an evaluation study to assess the effectiveness of the education and training program on the adoption and optimization of use of the digital health solution in service delivery. It also describes the proposed tools to assess the impact of training on knowledge and skills of mental health clinicians. METHODS The evaluation study will use the Kirkpatrick Evaluation Model as a framework with 4 levels of analysis: Reaction (to education and training), Learning (knowledge acquired), Behavior (practice change), and Results (client outcomes). Quantitative and qualitative data will be collected using a variety of tools, including evaluation forms, pre- and postknowledge questionnaires, skill development and behavior change scales, as well as a real-time clinical practice audit. RESULTS This project is funded by philanthropic funding from Future Generation Global. Ethics approval has been granted via Sydney Local Health District’s Human Research Ethics Committee. At the time of this publication, clinicians and their services were being recruited to this study. The first results are expected to be submitted for publication in 2021. CONCLUSIONS The education and training program teaches clinicians the necessary knowledge and skills to assess, monitor, and manage complex needs; mood and psychotic syndromes; and trajectories of youth mental ill-health using a HIT that facilitates a highly personalized and measurement-based model of care. The digital health solution may therefore guide clinicians to help young people recover low functioning associated with subthreshold diagnostic presentations and prevent progression to more serious mental ill-health. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/24697

Background Australia’s mental health care system has long been fragmented and under-resourced, with services falling well short of demand. In response, the World Economic Forum has recently called for the rapid deployment of smarter, digitally enhanced health services to facilitate effective care coordination and address issues of demand. The University of Sydney’s Brain and Mind Centre (BMC) has developed an innovative digital health solution that incorporates 2 components: a highly personalized and measurement-based (data-driven) model of youth mental health care and a health information technology (HIT) registered on the Australian Register of Therapeutic Goods. Importantly, research into implementation of such solutions considers education and training of clinicians to be essential to adoption and optimization of use in standard clinical practice. The BMC’s Youth Mental Health and Technology Program has subsequently developed a comprehensive education and training program to accompany implementation of the digital health solution. Objective This paper describes the protocol for an evaluation study to assess the effectiveness of the education and training program on the adoption and optimization of use of the digital health solution in service delivery. It also describes the proposed tools to assess the impact of training on knowledge and skills of mental health clinicians. Methods The evaluation study will use the Kirkpatrick Evaluation Model as a framework with 4 levels of analysis: Reaction (to education and training), Learning (knowledge acquired), Behavior (practice change), and Results (client outcomes). Quantitative and qualitative data will be collected using a variety of tools, including evaluation forms, pre- and postknowledge questionnaires, skill development and behavior change scales, as well as a real-time clinical practice audit. Results This project is funded by philanthropic funding from Future Generation Global. Ethics approval has been granted via Sydney Local Health District’s Human Research Ethics Committee. At the time of this publication, clinicians and their services were being recruited to this study. The first results are expected to be submitted for publication in 2021. Conclusions The education and training program teaches clinicians the necessary knowledge and skills to assess, monitor, and manage complex needs; mood and psychotic syndromes; and trajectories of youth mental ill-health using a HIT that facilitates a highly personalized and measurement-based model of care. The digital health solution may therefore guide clinicians to help young people recover low functioning associated with subthreshold diagnostic presentations and prevent progression to more serious mental ill-health. International Registered Report Identifier (IRRID) PRR1-10.2196/24697

Background Whilst apps and e-tools have tremendous potential as low-cost, scalable mental health intervention and prevention tools, it is essential that consumers and health professionals have a means by which to evaluate their quality and safety. Objective This study aimed to: 1) adapt the original Mobile App Rating Scale (MARS) in order to be appropriate for the evaluation of both mobile phone applications as well as e-tools; 2) test the reliability of the revised scale; and 3) develop a quality assurance protocol for identifying and rating new apps and e-tools to determine appropriateness for use in clinical practice. Methods The MARS was adapted to include items specific to health-related apps and e-tools, such as the availability of resources, strategies for self-management, and quality information. The 41 apps and e-tools in the standard youth configuration of the InnoWell Platform, a digital tool designed to support or enhance mental health service delivery, were independently rated by two expert raters using the A-MARS. Cronbach's alpha was used to calculate the internal consistency and interclass correlation coefficients were used to calculate interrater reliability. Results The A-MARS was shown to be a reliable scale with acceptable to excellent internal consistency and moderate to excellent interrater reliability across the subscales. Given the ever-increasing number of health information technologies on the market, a protocol to identify and rate new apps and e-tools for potential clinical use is presented. Conclusions Whilst the A-MARS is a useful tool to guide health professionals as they explore available apps and e-tools for potential clinical use, the training, time, and skill required to use it effectively may be prohibitive. As such, health professionals and services are likely to benefit from including a digital navigator as part of the care team to assist in selecting and rating apps and e-tools, increasing the usability of the data, and technology troubleshooting. When selecting, evaluating and/or recommending apps and e-tools to consumers, it is important to consider: 1) the availability of explicit strategies to set, monitor and review SMART goals; 2) the accessibility of credible, user friendly information and resources from reputable sources; 3) evidence of effectiveness; and 4) interoperability with other health information technologies., Highlights • The adapted Mobile Application Rating Scale (A-MARS) is a reliable scale to evaluate the quality of health-related apps and e-tools. • Important considerations include evidence of effectiveness as well as goal setting strategies and interoperability. • The A-MARS is appropriate for use by health professionals; however, they may require support from a digital navigator.

BACKGROUND Worldwide, the population is aging rapidly; therefore, there is a growing interest in strategies to support and maintain health and well-being in later life. Although familiarity with technology and digital literacy are increasing among this group, some older adults still lack confidence in their ability to use web-based technologies. In addition, age-related changes in cognition, vision, hearing, and perception may be barriers to adoption and highlight the need for digital tools developed specifically to meet the unique needs of older adults. OBJECTIVE The aim of this study is to understand the use of technology by older adults in general and identify the potential barriers to and facilitators of the adoption of health information technologies (HITs) to support the health and well-being of older adults to facilitate implementation and promote user uptake. In addition, this study aims to co-design and configure the InnoWell Platform, a digital tool designed to facilitate better outcomes for people seeking mental health services, to meet the needs of adults 50 years and older and their supportive others (eg, family members, caregivers) to ensure the accessibility, engagement, and appropriateness of the technology. METHODS Participants were adults 50 years and older and those who self-identified as a supportive other (eg, family member, caregiver). Participants were invited to participate in a 3-hour participatory design workshop using a variety of methods, including prompted discussion, creation of descriptive artifacts, and group-based development of user journeys. RESULTS Four participatory design workshops were conducted, including a total of 21 participants, each attending a single workshop. Technology use was prevalent, with a preference indicated for smartphones and computers. Factors facilitating the adoption of HITs included personalization of content and functionality to meet and be responsive to a consumer’s needs, access to up-to-date information from reputable sources, and integration with standard care practices to support the relationship with health professionals. Concerns regarding data privacy and security were the primary barriers to the use of technology to support mental health and well-being. CONCLUSIONS Although HITs have the potential to improve access to cost-effective and low-intensity interventions at scale for improving and maintaining mental health and well-being, several strategies may improve the uptake and efficacy of technologies by the older adult community, including the use of co-design methodologies to ensure usability, acceptability, and appropriateness of the technology; support in using and understanding the clinical applications of the technology by a digital navigator; and ready availability of education and training materials.

Background Worldwide, the population is aging rapidly; therefore, there is a growing interest in strategies to support and maintain health and well-being in later life. Although familiarity with technology and digital literacy are increasing among this group, some older adults still lack confidence in their ability to use web-based technologies. In addition, age-related changes in cognition, vision, hearing, and perception may be barriers to adoption and highlight the need for digital tools developed specifically to meet the unique needs of older adults. Objective The aim of this study is to understand the use of technology by older adults in general and identify the potential barriers to and facilitators of the adoption of health information technologies (HITs) to support the health and well-being of older adults to facilitate implementation and promote user uptake. In addition, this study aims to co-design and configure the InnoWell Platform, a digital tool designed to facilitate better outcomes for people seeking mental health services, to meet the needs of adults 50 years and older and their supportive others (eg, family members, caregivers) to ensure the accessibility, engagement, and appropriateness of the technology. Methods Participants were adults 50 years and older and those who self-identified as a supportive other (eg, family member, caregiver). Participants were invited to participate in a 3-hour participatory design workshop using a variety of methods, including prompted discussion, creation of descriptive artifacts, and group-based development of user journeys. Results Four participatory design workshops were conducted, including a total of 21 participants, each attending a single workshop. Technology use was prevalent, with a preference indicated for smartphones and computers. Factors facilitating the adoption of HITs included personalization of content and functionality to meet and be responsive to a consumer’s needs, access to up-to-date information from reputable sources, and integration with standard care practices to support the relationship with health professionals. Concerns regarding data privacy and security were the primary barriers to the use of technology to support mental health and well-being. Conclusions Although HITs have the potential to improve access to cost-effective and low-intensity interventions at scale for improving and maintaining mental health and well-being, several strategies may improve the uptake and efficacy of technologies by the older adult community, including the use of co-design methodologies to ensure usability, acceptability, and appropriateness of the technology; support in using and understanding the clinical applications of the technology by a digital navigator; and ready availability of education and training materials.

Study Objectives Cardiovascular autonomic dysfunction, as measured by short-term diurnal heart rate variability (HRV), has been reported in older adults with mild cognitive impairment (MCI). However, it is unclear whether this impairment also exists during sleep in this group. We, therefore, compared overnight HRV during sleep in older adults with MCI and those with subjective cognitive impairment (SCI). Methods Older adults (n = 210) underwent overnight polysomnography. Eligible participants were characterized as multi-domain MCI or SCI. The multi-domain MCI group was comprised of amnestic and non-amnestic subtypes. Power spectral analysis of HRV was conducted on the overnight electrocardiogram during non-rapid eye movement (NREM), rapid eye movement (REM), N1, N2, N3 sleep stages, and wake periods. High-frequency HRV (HF-HRV) was employed as the primary measure to estimate parasympathetic function. Results The MCI group showed reduced HF-HRV during NREM sleep (p = 0.018), but not during wake or REM sleep (p > 0.05) compared to the SCI group. Participants with aMCI compared to SCI had the most pronounced reduction in HF-HRV across all NREM sleep stages—N1, N2, and N3, but not during wake or REM sleep. The naMCI sub-group did not show any significant differences in HF-HRV during any sleep stage compared to SCI. Conclusions Our study showed that amnestic MCI participants had greater reductions in HF-HRV during NREM sleep, relative to those with SCI, suggesting potential vulnerability to sleep-related parasympathetic dysfunction. HF-HRV, especially during NREM sleep, may be an early biomarker for dementia detection.

Background Dementia prevalence is expected to increase substantially over the next few decades. Since there is currently no cure for dementia available, there is an urgent need for the early identification of individuals at high risk for dementia, so that primary and secondary prevention strategies can be implemented. Recently, the LIfestyle for BRAin health (LIBRA) index was developed as a new dementia risk algorithm. It specifically focuses on modifiable risk and protective factors that can be targeted in midlife. Objective The objective of this study was to evaluate the LIBRA index in relation to markers of cognitive functioning in a clinical, health-seeking sample of community-based older adults. Methods 484 participants (mean age 62.7 years) were recruited from the Healthy Brain Ageing Clinic at the Brain and Mind Centre, Sydney. Participants underwent comprehensive clinical and neuropsychological assessment and completed a self-report survey pack. Participants were rated via consensus as having either subjective cognitive complaints (SCC) or meeting criteria for mild cognitive impairment (MCI). The LIBRA score was calculated based on 11 available risk and protective factors. Results 65.4% of the sample met criteria for MCI. People with MCI showed a significantly higher LIBRA score compared to people with SCC. Furthermore, multiple cognitive domains, in particular executive functioning, were associated with a higher LIBRA score, with stronger correlations in people with MCI. Conclusion The LIBRA index might be a useful tool to determine lifestyle-attributable risk of cognitive decline in an older health-seeking population, including people with MCI.

Introduction Depression in older people is associated with changes in sleep, however associations between sleep architecture and cognition have not yet been delineated. We examined sleep architecture in older people with and without depressive symptoms, and relationships with neuropsychological performance. Methods Adults over 50 years underwent overnight polysomnography and memory and executive function tests. Depression and controls groups were defined by a Geriatric Depression Scale-15 cut off score of 6. Sleep architectural outcomes included amount of slow wave sleep (SWS), rapid eye movement (REM) sleep, REM onset latency (ROL), NREM slow wave activity (SWA, 0.5–4 Hz), N2 sleep spindle density and REM density. Results The sample comprised of 71 participants with depressive symptoms and 101 controls (mean age both groups = 64, mean GDS-15 dep= 9.3, con= 1.8). There were no significant group differences in time spent in SWS, REM, REM density or SWA. Those with depressive symptoms had later ROL (p=.008) and less N2 sleep spindles (p=.03) compared to controls. A differential association was observed with less SWS being associated with poor memory recall in the depression group only (z=.342, p=0.008). No associations between sleep and executive function performance were observed. Discussion The link between less time in SWS and poorer memory in those with depressive symptoms could suggest that SWS is particularly pertinent for cognition in depression or that both sleep and cognition mechanisms are influenced by depressive state. Further studies are needed to determine if changes in sleep are linked with underlying neurobiological changes.

BACKGROUND Health information technologies (HITs) are becoming increasingly recognized for their potential to provide innovative solutions to improve the delivery of mental health services and drive system reforms for better outcomes. OBJECTIVE This paper describes the baseline results of a study designed to systematically monitor and evaluate the impact of implementing an HIT, namely the InnoWell Platform, into Australian mental health services to facilitate the iterative refinement of the HIT and the service model in which it is embedded to meet the needs of consumers and their supportive others as well as health professionals and service providers. METHODS Data were collected via web-based surveys, semistructured interviews, and a workshop with staff from the mental health services implementing the InnoWell Platform to systematically monitor and evaluate its impact. Descriptive statistics, Fisher exact tests, and a reliability analysis were used to characterize the findings from the web-based surveys, including variability in the results between the services. Semistructured interviews were coded using a thematic analysis, and workshop data were coded using a basic content analysis. RESULTS Baseline data were collected from the staff of 3 primary youth mental health services (n=18), a counseling service for veterans and their families (n=23), and a helpline for consumers affected by eating disorders and negative body image issues (n=6). As reported via web-based surveys, staff members across the services consistently agreed or strongly agreed that there was benefit associated with using technology as part of their work (38/47, 81%) and that the InnoWell Platform had the potential to improve outcomes for consumers (27/45, 60%); however, there was less certainty as to whether their consumers’ capability to use technology aligned with how the InnoWell Platform would be used as part of their mental health care (11/45, 24% of the participants strongly disagreed or disagreed; 15/45, 33% were neutral; and 19/45, 42% strongly agreed or agreed). During the semistructured interviews (n=3) and workshop, participants consistently indicated that the InnoWell Platform was appropriate for their respective services; however, they questioned whether the services’ respective consumers had the digital literacy required to use the technology. Additional potential barriers to implementation included health professionals’ digital literacy and service readiness for change. CONCLUSIONS Despite agreement among participants that HITs have the potential to result in improved outcomes for consumers and services, service readiness for change (eg, existing technology infrastructure and the digital literacy of staff and consumers) was noted to potentially impact the success of implementation, with less than half (20/45, 44%) of the participants indicating that their service was ready to implement new technologies to enhance mental health care. Furthermore, participants reported mixed opinions as to whether it was their responsibility to recommend technology as part of standard care.

OBJECTIVE This study aimed to investigate the relationship between obesity and oxidative stress in older adults at risk for dementia. It also aimed to explore the influence of physical activity on the relationship between obesity and oxidative stress in this at risk cohort. METHODS Older adults at risk for dementia underwent comprehensive medical, neuropsychological, and psychiatric assessment. At risk was defined as participants with subjective or mild cognitive impairment. Glutathione was assessed by magnetic resonance spectroscopy in the left hippocampus and the anterior and posterior cingulate cortex. Body mass index (BMI) was calculated and classified as healthy (BMI