Roz Shafran

Objective: Increasing numbers of young people (YP) are seeking support for eating disorders, creating a growing unmet need for timely and accessible treatment. While guided self‐help (GSH) interventions have demonstrated effectiveness for other youth mental health difficulties, options for eating disorders remain limited. SPICE (Short Psychological Intervention for Children with Eating Disorders), a transdiagnostic CBT‐based GSH program, was developed to address this gap. This qualitative study explored participant perspectives on the mechanisms through which SPICE may support recovery. Method: SPICE comprises eight weekly modules supported by a 30‐min guided therapy session each week. Six female adolescents with eating disorders and their parents who completed SPICE participated in semi‐structured post‐intervention interviews. Data were analyzed using critical realist thematic analysis. Results: Four key putative mechanisms were identified: (1) Interpersonal support (from the guide and parents) as a catalyst for change and for keeping momentum going. (2) Increased knowledge of eating disorders and associated cognitive and behavioural factors leading to positive changes. (3) In vivo experiential learning as key to implementing specific strategies and taking ownership over change. (4) Context, that is, individual and systemic factors promoting and inhibiting change. Discussion: Interpersonal relationships were perceived to promote engagement and change. Participants reported that psychoeducation empowered them and their families, while experiential learning helped translate strategies into everyday practice. Flexible and tailored approaches were considered important for improving accessibility and effectiveness. Perceived barriers included complex module content, remote delivery, and competing commitments. Findings provide preliminary support for GSH interventions for eating disorders in YP and identify areas for refining future intervention.

UNSTRUCTURED Children and young people’s (CYPs) physical and mental health may cluster in heterogeneous ways, particularly during and after the COVID-19 pandemic. Using longitudinal data from 6,152 CYP in England, we applied a machine learning approach to characterise multidimensional health burden across four timepoints over 24-months (between 2020-2023), incorporating physical symptoms, fatigue, emotional/behavioural difficulties, wellbeing, quality of life, and healthcare use. After random-forest imputation and dimensionality reduction via a variational autoencoder, we used k-means to identify four clusters: (1) low burden (30.7%); (2) intermediate mental health burden (23.0%); (3) increasing physical and mental health burden (24.9%); and (4) persistent high burden (21.4%). The increasing and high burden clusters were older, predominantly female, and characterised by poorer pre-pandemic physical and mental health. Baseline SARS-CoV-2 status was only modestly associated with cluster membership. Findings demonstrate substantial heterogeneity in post-pandemic health trajectories and support targeted, person-centred prevention and service planning strategies.

Background: Anxiety and depression are among the most prevalent mental health problems affecting adolescents. Digital mental health interventions have emerged as promising means of addressing these challenges. Understanding adolescents’ experiences and perspectives, and incorporating them into intervention design, can enhance their relevance, engagement, and effectiveness, ensuring interventions meet young people’s needs. Objective: This qualitative study aimed to identify how adolescents aged 16-19 years engaged with 2 distinct interventions (Bite Back [Black Dog Institute] and Project YES [Youth Empowerment & Support; Lab for Scalable Mental Health and Koko]). It explored (1) barriers and facilitators to engagement, (2) young people’s preferred design features and content, and (3) perceptions of their potential usefulness and helpfulness. Methods: Adolescents aged 16-19 years living in the United Kingdom were eligible to take part and were recruited through a university and a charity using convenience sampling. The final sample comprised 22 participants aged 18-19 years. They were asked to use Bite Back and Project YES for 30 minutes each over a 2-week period. Following this, 1-hour semistructured online interviews were conducted between January and March 2025. Anonymized transcripts were managed in NVivo (version 14; Lumivero) and analyzed using a pragmatic, inductive thematic analysis. Results: Seven themes were identified that captured young people’s views on factors influencing engagement, preferred design features and content, and the perceived usefulness of digital mental health interventions. Participants’ views were shaped by whether the content felt age-appropriate, culturally relevant, and relatable, and by how clear and transparent the interventions were. Interactive, visually appealing, and tailored features were generally preferred. Although most participants found Bite Back helpful, useful elements were identified in both interventions. Conclusions: This study contributes to the growing understanding of how young people engage with digital mental health interventions by identifying a set of interconnected factors that influence young people’s experiences. It highlights the importance of designing interventions that align with young people’s stage of life, culture, and experiences. Even small age differences appeared to influence how relevant the interventions felt to the individual. Furthermore, involving young people in co-design and ensuring clear, accessible communication may support trust and engagement, ultimately enhancing the benefits of such interventions.

We examined the feasibility, acceptability and preliminary efficacy of Cognitive Behaviour Therapy for Perfectionism (CBT-P) for children delivered as an online 6-session guided parent-delivered intervention (GP-CBT-P). We conducted a two-arm randomised controlled trial comparing GP-CBT-P to waitlist for parents whose child was aged 7–12 and had elevated perfectionism. Primary outcomes were feasibility and acceptability; secondary outcomes were self-reported parental and child perfectionism, school satisfaction, happiness, stress, depressive symptoms, self-efficacy, and weight/shape concern. Assessment occurred at baseline (T1), 9- (T2, end of the intervention) and 18-weeks (T3) post-randomization. There were 89 enquiries over 14 months; 49 (54%) converted to randomisation (25 in GP-CBT-P, 24 in waitlist), and 60% of parents in the intervention group completed all 6 sessions. There were no differences between groups at baseline. Intent-to-treat analysis showed parents in GP-CBT-P had significantly lower levels of perfectionism at T2 and T3 than control (respective between groups effect sizes [ES] and 95% confidence intervals [CI] of 0.95 [0.37 to 1.53] and 0.65 [0.08 to 1.21]). Compared to control, children receiving GP-CBT-P reported significantly higher school satisfaction and academic self-efficacy, and lower stress, depression and weight/shape concerns; T3 ES ranged from 0.58 to 0.82. There were no significant differences between groups on child perfectionism. GP-CBT-P could benefit from strategies to enhance feasibility and acceptability given it promoted helpful change across parent and child self-reported outcomes. Reducing parental perfectionism may be a key driver of beneficial change in children. Further investigation with larger samples and longer-term follow-up is recommended.

Background: Cognitive–behavioural therapy is an effective treatment for depression. A key question is how to increase access. Engagement with cognitive–behavioural therapy-based computerised interventions is poor, and programmes are inflexible and impersonal. Innovative use of technology and integration of online materials could increase engagement and widen access. Objectives: To develop and evaluate a novel approach to delivering cognitive–behavioural therapy for depression integrating therapist-led sessions and online cognitive–behavioural therapy materials. Design and methods: The INTEgrated theRApist and online CbT for depression research programme comprised four work packages. The first developed the online therapy platform and materials, and training for therapists. This comprised a series of studies: a systematic review and network meta-analysis to compare the effectiveness of different types and components of cognitive–behavioural therapy; a Delphi study focused on the effective components of cognitive–behavioural therapy; a decision model to evaluate the cost-effectiveness of different formats of delivering cognitive–behavioural therapy; a survey of accredited cognitive–behavioural therapy therapists asking about their use and views of different resources used in cognitive–behavioural therapy; and iterative design work aimed at understanding the design requirements for the platform. The prototype platform was then evaluated in a pilot study, with subsequent final refinement. The second and third work packages evaluated the clinical and cost-effectiveness of the intervention compared with usual general practitioner care in a multicentre randomised controlled trial (with a parallel economic evaluation) over 12 months in primary care patients with depression. The fourth examined the intervention’s acceptability through a nested qualitative study of patients, therapists and supervisors. Setting: The randomised controlled trial was based in United Kingdom primary care in Bristol, London and York. Participants: Patients aged ≥ 18 years experiencing depressive symptoms in primary care were eligible for the randomised controlled trial. Interventions: In the randomised controlled trial, participants were individually randomised to: (1) integrated cognitive–behavioural therapy (in addition to usual general practitioner care); or (2) to continue with usual general practitioner care. Main outcome measures: The primary outcome for the randomised controlled trial was depressive symptoms measured using the Beck Depression Inventory, version 2 at 6 months post randomisation. Secondary outcomes included response and remission (based on Beck Depression Inventory, version 2 score), depressive symptoms (Patient Health Questionnaire-9), anxiety symptoms (Generalised Anxiety Disorder-7), function (Work and Social Adjustment Scale), quality of life (EuroQol-5 Dimensions, five-level version), and costs of interventions and wider services. Results: Work package 1: the network meta-analysis found no evidence of effect for any content components or combinations of components. There was uncertainty around estimates of cost-effectiveness for different treatment modalities and intensities. Effective components of cognitive–behavioural therapy were identified through the Delphi study, and resources used by therapists identified through a survey of United Kingdom cognitive–behavioural therapy practitioners. Key requirements of an online platform identified through iterative design work were: (1) overcoming depression-related barriers; (2) supporting engagement; (3) reinforcing learning and skill acquisition. In a pilot study with 18 primary care patients, patients said that the integrated approach made therapy more accessible. Therapists commented on the flexibility of the approach. Not all participants engaged with between-session tasks and some technical issues were experienced. Platform refinements were made prior to the randomised controlled trial. Work package 2: overall, 451 patients were recruited to the INTEgrated theRApist and online CbT for depression randomised controlled trial. Participants were predominantly female ( n = 313, 69%) and, on average, aged 39 years. The mean Beck Depression Inventory, version 2 score at baseline was 32.8, indicative of severe depression. Most had a history of depression (nearly half having had five or more prior episodes of depression), were taking antidepressants (70%) and the duration of the current episode of depression was ≥ 2 years for 51% of participants. In the intervention group, 14 individuals (6.2%) had no therapy sessions and 137 participants (60.9%) completed therapy (received at least 9 sessions or reached an agreed end of therapy with their therapist in fewer than 9 sessions). Including the above 14 individuals, 88 (39.1%) either withdrew from therapy ( n = 50) or were discharged for non-attendance ( n = 38). In total 334 patients (171 integrated cognitive–behavioural therapy; 163 usual care) were included in the primary analysis. The intervention group had a Beck Depression Inventory, version 2 score that was, on average, 4.4 points lower (less depressed) than the usual care group at 6 months [difference in means: −4.4 (95% confidence interval −7.0 to −1.9); p = 0.001]. In repeated-measures analyses using data from 6 and 12 months, individuals in the intervention group had a Beck Depression Inventory, version 2 score that was, on average, 3.8 points lower than those in the usual care group (95% confidence interval −6.1 to −1.5; p = 0.001). The intervention group had a twofold increased odds of response and remission, fewer symptoms of depression (Patient Health Questionnaire-9) and anxiety (Generalised Anxiety Disorder-7), and improved functioning (Work and Social Adjustment Scale). Work package 3: the mean costs of integrated cognitive–behavioural therapy were £987 (standard error £14) per participant. The mean costs of usual care were estimated at £382 (standard error £57) in usual care group and £193 (standard error £42) in intervention group. In the primary analyses, costs from the National Health Service/Personal Social Services perspective were £753 (standard error £77) per participant in the usual care group and £1754 (standard error £127) in the intervention group, with adjusted incremental costs of £1009 (95% confidence interval £737 to £1286). The mean quality-adjusted life-years were 0.554 (standard error 0.017) in the usual care group and 0.597 (standard error 0.017) in the intervention group, with adjusted incremental quality-adjusted life-years at 0.033 (95% confidence interval −0.002 to 0.059). The incremental cost-effectiveness ratio was £30,576 per quality-adjusted life-year gain. Complete-case analysis from the National Health Service/Personal Social Services perspective showed a slightly more favourable picture with an incremental cost-effectiveness ratio at £22,421. Work package 4: through interviews with trial participants and therapists, we found that the integrated approach helped patients manage their depression. Platform benefits included the opportunity to review transcripts and to support homework tasks. Typing allowed reflection and a focused discussion. Less could be covered than during an in-person session. Patients who did not complete therapy struggled with typing and found cognitive–behavioural therapy too demanding. Limitations: In the trial, the 6-month follow-up rate was slightly below the original target. Conclusions: Integrated cognitive–behavioural therapy is an effective and acceptable treatment for patients with depression. There was uncertainty around the cost-effectiveness of the intervention. This novel mode of delivery could increase the availability of cognitive–behavioural therapy and access for those who find it difficult to attend appointments in person. Future work: To examine whether effects are sustained long term and to understand which aspects of the platform lead to improvements. Study registration: This study is registered as ISRCTN14850613 (phase 2 pilot study) and ISRCTN13112900 (RCT). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0514-20012) and is published in full in Programme Grants for Applied Research ; Vol. 14, No. 13. See the NIHR Funding and Awards website for further award information.

Summary: It is time for evidence-based medicine to evolve and incorporate a fourth pillar of patient-level data. We describe what this pillar includes, how it integrates with existing pillars and its application to mental health treatment. We highlight key challenges and issue a ‘call to action’ for psychiatry and beyond.