Susan H. Spence

Background: Self-directed digital mental health programs can increase access to evidence-based interventions for child anxiety. However, there has been little comprehensive investigation of real-world dissemination, especially using implementation science approaches. Objective: This study aimed to describe and comprehensively assess the implementation of the BRAVE Self-Help program for child and adolescent anxiety in Australia over a 10-year period, including implementation strategies during establishment and sustainability phases and implementation-effectiveness outcomes. Methods: This study was a large, open implementation-effectiveness trial involving Australian child and adolescent participants in the BRAVE Self-Help Program, conducted between January 1, 2015, and December 31, 2024. Implementation strategies were reported descriptively across program establishment and sustainability phases. Implementation and effectiveness outcomes were reported across 10 years, in line with the implementation outcomes framework (IOF) and taxonomy of implementation outcomes for digital interventions. Metrics included adoption, penetration, appropriateness, fidelity, feasibility, acceptability, and effectiveness. Results: Over the 10-year period, the BRAVE Self-Help program had 53,726 users, including 28,700 children (mean age 9.36, SD 1.40 years) and 25,026 adolescents (mean age 14.15, SD 1.62 years). Data revealed a wide variety of user characteristics in terms of age, gender, geographical location, baseline severity, and referral sources (community, health, and education settings). Improvement in anxiety symptoms from first to last interaction with the program was observed for participants in general, particularly among those with elevated anxiety at program registration ( P <.001; Cohen d =0.54). Of all users completing the registration assessment, 38.72% (20,026/51,721) completed 3 or more of the 10 sessions, with consistent moderate to high satisfaction rates across all sessions. Conclusions: This study demonstrated that a self-help digital program for child and adolescent anxiety can be successfully disseminated nationally, and that it is feasible, acceptable, and effective for many young people. During a span of 10 years, the BRAVE Self-Help program for child and adolescent anxiety offered evidence-based support to more than 50,000 families. Notably, although progress through sessions was low for some young people, significant improvements could be made in as few as 3 sessions, and decisions to stop treatment occurred for many reasons, including treatment success.

BACKGROUND Digital mental health interventions (DMHIs) offer a promising means of extending care for children and adolescents, yet their integration into routine clinical services remains inconsistent. Understanding implementation from the perspective of mental health professionals (MHPs) is critical to bridging the gap between efficacy and real-world uptake. OBJECTIVE This study examined the perspectives of MHPs working with children and young people to identify key implementation considerations for the development and adoption of DMHIs. METHODS Nineteen focus groups were conducted with 50 mental health clinicians (including psychologists, social workers, and counsellors) from a range of service settings between May 2020 and May 2021. Data were analyzed using a mixed deductive-inductive thematic approach informed by the interview domains. RESULTS MHPs were cautiously optimistic about DMHIs, viewing them as most valuable when implemented as supplementary rather than replacement tools. Key perceived uses included waitlist support, screening and assessment, between-session engagement, and flexible treatment pathways. However, MHPs consistently emphasized the need to preserve clinical judgement and oversight across all stages of DMHI use. Risk management, duty of care, and privacy and confidentiality were identified as critical prerequisites for implementation. CONCLUSIONS Successful DMHI implementation in child and adolescent mental health services requires flexible, clinician-centered integration approaches, robust risk management protocols, and clear organizational frameworks delineating clinician responsibility. These findings have direct implications for the implementation planning, rollout, and governance of DMHIs in youth mental health settings.

BACKGROUND Self-directed digital mental health services can increase access to evidence-based interventions for child anxiety. However, there has been little comprehensive investigation of real-world dissemination especially utilizing implementation science approaches. OBJECTIVE To describe and comprehensively assess implementation of the BRAVE Self-Help program for child and adolescent anxiety in Australia over a 10-year period, including implementation strategies during establishment and sustainability phases and implementation-effectiveness outcomes. METHODS This study was a large, open implementation-effectiveness trial with Australian child and adolescent participants of the BRAVE Self-Help Program, collected between January 1, 2015, and December 31, 2024. Implementation strategies were reported descriptively across program establishment and sustainability phases. Implementation and effectiveness outcomes were reported across 10 years, in line with the Implementation Outcomes Framework (IOF) and taxonomy of implementation outcomes for digital interventions. Metrics include Adoption, Penetration, Appropriateness, Fidelity, Feasibility, Acceptability and Effectiveness. RESULTS Examples of implementation strategies included targeted promotion and education strategies across academic, professional and community settings, a focus on geographical areas with low service accessibility, provision of easy-to-access resources and support for common challenges, targeting education contexts, and continuous data-driven and user-informed improvement. Over the 10-year period, the BRAVE Self-Help program had 53,726 users, including 28,700 children (mean 9.36, SD 1.40 years) and 25,026 adolescents (mean 14.15, SD 1.62 years). Data revealed a wide variety of user characteristics in terms of age, gender, geographical location, baseline severity, and referral sources (community, health and education settings). Improvement in anxiety symptoms from first to last interaction with the program was observed for participants in general, particularly among those with elevated anxiety at program registration (P <.001, Cohen d=0.54). Of all users completing the registration assessment, 38.72% (20,026/51,721) completed 3 or more of the 10 sessions, with consistent moderate to high satisfaction rates across all sessions. CONCLUSIONS This study demonstrated that a self-help digital program for child and adolescent anxiety can be successfully disseminated nationally, and that it is feasible, acceptable and effective for many young people. During a span of 10 years, the BRAVE Self-Help program for child and adolescent anxiety offered evidence-based support to more than 50,000 families. Notably, although progress through sessions was low for some young people, significant improvements can be made in as few as three sessions, and decisions to stop treatment may occur for many reasons, including treatment success.

BACKGROUND The integration of digital mental health interventions (DMHIs) into mainstream mental health services can reduce access barriers for young people and enhance client outcomes. To support effective implementation of DMHIs into routine care, it is vital to understand the factors supporting their uptake. OBJECTIVE This study aimed to better understand how Australian mental health professionals currently use DMHIs in their personal and professional practice, and how they select effective, evidence-based interventions. METHODS An overview of a proposed DMHI platform for children and adolescents was disseminated to mental health professionals from hospital, community, education and crisis support hotline settings. Participants (n=87) then completed a mixed methods survey, exploring relevant domains of the Consolidated Framework for Implementation Research. Quantitative data (electronic-therapy attitudes and process questionnaire, bespoke items) were summarised descriptively and compared between organisation types. Open-ended questions were examined via qualitative content analysis. RESULTS Survey results indicate strong support for DMHIs; 78% of participants incorporated DMHIs into clinical practice, and 86% had recommended DMHIs to friends, family and colleagues. Common reasons for recommending DMHIs to clients were utility for monitoring symptoms, providing support, and offering another source of information. When selecting DMHIs, the minority of participants independently sought out research evidence. More often, participants relied on endorsements from their workplace and trusted third parties, the source of the intervention, or self-assessment of intervention quality. Assessing client and family needs, preferences and feedback was the most common strategy for determining if interventions were effective for young people. CONCLUSIONS While DMHIs are commonly used and recommended by mental health professionals, there is variation in how practitioners assess and select appropriate and effective interventions. Findings highlight the importance of strategically communicating evidence of intervention efficacy. Disseminating evidence via commonly accessed platforms may support improved evidence-informed decision making when selecting DMHIs in clinical practice.

Background: Digital mental health (dMH) interventions offer the ability to reach many more adolescents with anxiety than face-to-face therapy. While efficacious dMH interventions are available for adolescents, premature dropout and low engagement are common, especially if delivered on a self-help basis without any form of therapist guidance. This is concerning, given that higher engagement, in terms of the number of sessions completed, has been repeatedly associated with improved clinical outcomes. The reasons for poor adolescent engagement in dMH programs are unclear. A clear understanding of when and why disengagement occurs is important in order to seek to improve engagement rates. Contemporary models consider engagement as multifaceted, comprising both “use” (eg, amount of content completed, frequency of use, duration spent logged into the dMH program, and depth of use, such as word or character count) and “user experience” (eg, interest and satisfaction in the program and affect and attention whilst engaging in the program). Objective: This study investigated the role of demographic and early engagement (EE) factors, specifically program use, in predicting overall program engagement and continued engagement, respectively, in a self-directed, internet-based cognitive behavioral therapy program for adolescent anxiety, namely, BRAVE Self-Help. It examined multiple measures of program use, including task completion, homework completion, and depth of response (character count of responses typed into program tasks). It also examined the moderating role of baseline anxiety severity. Methods: Data collected between July 2014 and May 2020 from 2850 adolescents aged 12 to 18 years who participated in BRAVE Self-Help were analyzed via a series of moderated regressions. Results: Results showed that EE (in terms of program use) was associated with continued engagement, demonstrated by early tasks (tasks completed in the first two sessions; R²=0.035; P<.001) and early depth (characters written in the first two sessions; R²=0.08; P<.001) predicting continued depth of program response (total character count of responses typed into all program tasks from sessions 3 to 10). Demographic factors and anxiety severity did not directly impact adolescents’ engagement in BRAVE Self-Help. Conclusions: These findings highlight the need to investigate ways to (1) enhance EE and (2) better understand how to measure and capture all aspects of program engagement.

Background: Self-guided internet-delivered cognitive behavioral therapy (ICBT) achieves greater reach than ICBT delivered with therapist guidance, but demonstrates poorer engagement and fewer clinical benefits. Alternative models of care are required that promote engagement and are effective, accessible, and scalable. Objective: This randomized trial evaluated whether a stepped care approach to ICBT using therapist guidance via videoconferencing for the step-up component (ICBT-SC[VC]) is noninferior to ICBT with full therapist delivery by videoconferencing (ICBT-TG[VC]) for child and adolescent anxiety. Methods: Participants included 137 Australian children and adolescents aged 7 to 17 years (male: n=61, 44.5%) with a primary anxiety disorder who were recruited from participants presenting to the BRAVE Online website. This noninferiority randomized trial compared ICBT-SC[VC] to an ICBT-TG[VC] program, with assessments conducted at baseline, 12 weeks, and 9 months after treatment commencement. All ICBT-TG[VC] participants received therapist guidance (videoconferencing) after each session for all 10 sessions. All ICBT-SC[VC] participants completed the first 5 sessions online without therapist guidance. If they demonstrated response to treatment after 5 sessions (defined as reductions in anxiety symptoms to the nonclinical range), they continued sessions without therapist guidance. If they did not respond, participants were stepped up to receive supplemental therapist guidance (videoconferencing) for the remaining sessions. The measures included a clinical diagnostic interview (Anxiety Disorders Interview Schedule) with clinician-rated severity rating as the primary outcome and parent- and child-reported web-based surveys assessing anxiety and anxiety-related interference (secondary outcomes). Results: Although there were no substantial differences between the treatment conditions on primary and most secondary outcome measures, the noninferiority of ICBT-SC[VC] compared to ICBT-TG[VC] could not be determined. Significant clinical benefits were evident for participants in both treatments, although this was significantly higher for the ICBT-TG[VC] participants. Of the 89 participants (38 in ICBT-SC[VC] and 51 in ICBT-TG[VC]) who remained in the study, 26 (68%) in ICBT-SC[VC] and 45 (88%) in ICBT-TG[VC] were free of their primary anxiety diagnosis by the 9-month follow-up. For the intention-to-treat sample (N=137), 41% (27/66) ICBT-SC[VC], and 69% (49/71) ICBT-TG[VC] participants were free of their primary anxiety diagnosis. Therapy compliance was lower for the ICBT-SC[VC] participants (mean 7.39, SD 3.44 sessions) than for the ICBT-TG[VC] participants (mean 8.73, SD 3.08 sessions), although treatment satisfaction was moderate to high in both conditions. Conclusions: This study provided further support for the benefits of low-intensity ICBT for children and adolescents with a primary anxiety disorder and highlighted the excellent treatment outcomes that can be achieved through therapist-guided ICBT delivered via videoconferencing. Although noninferiority of the stepped care adaptive approach could not be determined, it was acceptable to families, produced good outcomes, and could assist in increasing access to evidence-based care. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618001418268; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001418268

Background: Difficulties identifying anxiety disorders in primary‐school aged children present significant barriers to timely access to support and intervention. This study aimed to develop a brief assessment tool that can identify children with anxiety disorders in community settings, with a high level of sensitivity and specificity.Methods: Children (aged 8–11 years), and their parents/carers and teachers from 19 primary/junior schools in England each completed a pool of questionnaire items that assessed child anxiety symptoms and associated impact. Diagnostic assessments (Anxiety Disorder Interview Schedule for Children: Child and Parent interviews) were administered by independent assessors to determine the presence/absence of anxiety disorders in children. We created alternative candidate brief child‐, parent‐, teacher‐report questionnaires consisting of the ‘best’ items selected from the wider pool of completed items. We used exploratory factor analysis to reduce the item pool, and multivariable backward elimination logistic regression to identify items that were the strongest predictors of the presence/absence of an anxiety disorder.Results: Parents/carers of 646 children provided consent; child/parent/teacher‐report questionnaires were collected for 582/646/565 children respectively; and diagnostic outcome data were collected for 463 children. None of the brief child‐ nor teacher‐report questionnaires achieved acceptable sensitivity/specificity (<75%). Parent‐report questionnaires including between 2 and 9 items that assess anxiety symptoms and/or associated impact achieved acceptable sensitivity and specificity (≥75%).Conclusions: The two‐item parent‐report measure that assesses distress and impairment associated with anxiety brings the advantage of brevity and has the potential to be used in community settings to improve identification of children with anxiety disorders.

UNSTRUCTURED Digital mental health (dMH) interventions offer the ability to reach many more adolescents with anxiety than traditional, face-to-face therapy. While efficacious dMH interventions are available, premature dropout and low engagement is common if delivered on a self-help basis without any form of therapist guidance, and it is unclear who is most likely to complete and benefit from such interventions. This study investigated the role of demographic and early engagement factors in predicting overall program engagement and continued engagement respectively, in a self-directed, internet-based Cognitive Behavioral Therapy program for adolescent anxiety, namely BRAVE Self-Help. It examined multiple measures of engagement, including task completion, homework completion, and depth of engagement. It also examined the moderating role of baseline anxiety severity. Data from 2850 adolescents aged between 12 and 18-years-old who participated in BRAVE Self-Help were analysed via a series of moderated regressions. Results showed that early engagement was associated with continued engagement, demonstrated by early tasks (tasks completed in the first two sessions; R2=.035, P=<.001) and early depth (characters written in the first two sessions; R2=.08, P=<.001) predicting continued program depth (character count from sessions 3 to 10). Demographic factors and anxiety severity did not directly impact adolescents’ engagement in BRAVE Self-Help. These findings highlight the need to investigate ways to 1) enhance early engagement, and 2) better understand how to fully measure and capture all aspects of program engagement.

BACKGROUND Self-guided internet-delivered cognitive behavioral therapy (ICBT) achieves greater reach than ICBT delivered with therapist guidance, but demonstrates poorer engagement and fewer clinical benefits. Alternative models of care are required that promote engagement and are effective, accessible, and scalable. OBJECTIVE This randomized trial evaluated whether a stepped care approach to ICBT using therapist guidance via videoconferencing for the step-up component (ICBT-SC[VC]) is noninferior to ICBT with full therapist delivery by videoconferencing (ICBT-TG[VC]) for child and adolescent anxiety. METHODS Participants included 137 Australian children and adolescents aged 7 to 17 years (male: n=61, 44.5%) with a primary anxiety disorder who were recruited from participants presenting to the BRAVE Online website. This noninferiority randomized trial compared ICBT-SC[VC] to an ICBT-TG[VC] program, with assessments conducted at baseline, 12 weeks, and 9 months after treatment commencement. All ICBT-TG[VC] participants received therapist guidance (videoconferencing) after each session for all 10 sessions. All ICBT-SC[VC] participants completed the first 5 sessions online without therapist guidance. If they demonstrated response to treatment after 5 sessions (defined as reductions in anxiety symptoms to the nonclinical range), they continued sessions without therapist guidance. If they did not respond, participants were stepped up to receive supplemental therapist guidance (videoconferencing) for the remaining sessions. The measures included a clinical diagnostic interview (Anxiety Disorders Interview Schedule) with clinician-rated severity rating as the primary outcome and parent- and child-reported web-based surveys assessing anxiety and anxiety-related interference (secondary outcomes). RESULTS Although there were no substantial differences between the treatment conditions on primary and most secondary outcome measures, the noninferiority of ICBT-SC[VC] compared to ICBT-TG[VC] could not be determined. Significant clinical benefits were evident for participants in both treatments, although this was significantly higher for the ICBT-TG[VC] participants. Of the 89 participants (38 in ICBT-SC[VC] and 51 in ICBT-TG[VC]) who remained in the study, 26 (68%) in ICBT-SC[VC] and 45 (88%) in ICBT-TG[VC] were free of their primary anxiety diagnosis by the 9-month follow-up. For the intention-to-treat sample (N=137), 41% (27/66) ICBT-SC[VC], and 69% (49/71) ICBT-TG[VC] participants were free of their primary anxiety diagnosis. Therapy compliance was lower for the ICBT-SC[VC] participants (mean 7.39, SD 3.44 sessions) than for the ICBT-TG[VC] participants (mean 8.73, SD 3.08 sessions), although treatment satisfaction was moderate to high in both conditions. CONCLUSIONS This study provided further support for the benefits of low-intensity ICBT for children and adolescents with a primary anxiety disorder and highlighted the excellent treatment outcomes that can be achieved through therapist-guided ICBT delivered via videoconferencing. Although noninferiority of the stepped care adaptive approach could not be determined, it was acceptable to families, produced good outcomes, and could assist in increasing access to evidence-based care. CLINICALTRIAL Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618001418268; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001418268

Introduction: Although there have been assumptions about the link between eco-emotions and suicidality, there is currently no systematic evidence. Therefore, the aim of this review is to systematically examine empirical literature analysing the link between eco-emotions and suicidal ideation and behaviours, both fatal and non-fatal. Methods: The review protocol was pre-registered in PROSPERO [CRD42022352379] and the PRISMA checklist was followed. Searches were conducted in six electronic databases (Scopus (Elsevier), Medline (PubMed), Web of Science, ProQuest, CINAHL and Embase) for peer-reviewed English language literature published from 1 January 2000 until 16 September 2023. Screening of titles, abstracts and full texts was conducted independently by two reviewers and any discrepancies were resolved in consultation with a senior researcher. The Johanna Briggs Institute’s quality appraisal tools were used for quality assessment. Results: Search results revealed 559 records. After removal of duplicates, 424 articles were screened. After title and abstract screening, 28 articles were included for full text screening. Only one paper satisfied the inclusion criteria. A cross-sectional online knowledge, attitudes, and practice (KAP) survey among practicing mental health professionals across the State of Minnesota analysed the impact of climate change on their work and clients. Although the study did not specifically focus on suicidality, it reported that 22% of practicing mental health professionals had seen evidence of suicidal ideation or attempts in their clients as an outcome of climate change. Conclusion: There is a lack of research on the association between eco-emotions and suicidality. Considering advancing climate change research, our review emphasizes an urgent need to conduct high level research to analyse the association between eco-emotions and suicidality and consider its potential implications. What is already known on this topic?: There’s a recognized and growing concern about the impact of climate change on mental health, particularly the emergence of eco-emotions such as eco-anxiety, eco-grief, and solastalgia. While studies have linked higher temperatures and natural disasters to suicidality, research specifically examining the association between eco-emotions and suicidal ideation and behaviours is lacking. What this study adds?: This systematic literature review revealed a stark scarcity of research connecting eco-emotions with suicidal ideation and behaviours. Only one paper met the inclusion criteria of the review. This scarcity underscores the urgent need for more comprehensive studies exploring the potential connection between eco-emotions and suicidality at an individual level. How this study might affect research, practice, or policy?: The limited findings from this review highlight the pressing need for more in-depth research to determine and understand the association between eco-emotions and suicidal ideation and behaviours. It emphasizes the necessity for interdisciplinary research for a multi-faceted approach addressing mental health impacts of climate change and its underlying causes, calling for informed engagement, mental health support, and policy actions to mitigate eco-grief and anxiety related to climate change impacts.