Lina Gega

Research Background Young people with depression often feel low or irritable, and they may stop doing things they enjoy or find rewarding. Behavioural activation (BA) is a type of talking therapy. It aims to lift a young person’s mood by helping them take part in activities they enjoy and that matter to them. At the same time, BA aims to cut down on avoiding things, putting things off, going over the same negative thoughts and pulling away from other people, which are all common in depression. Research Aims ComBAT stands for Community based Behavioural Activation Training. It was a five year research programme that built and tested BA for young people aged 12-18 years with less severe depression. We tested whether BA helped depression more than usual care, and whether it gave better value for money. We also looked at what made BA easier or harder to deliver in health services and in the community, including schools, colleges and voluntary organisations. In these places, staff who are not mental health specialists often support young people with depression. What we did We ran a study with 260 young people across 22 sites: 12 schools and colleges, five NHS services and five voluntary organisations. We put each young person into one of two groups at random: one was offered BA, the other usual care. We trained community and NHS staff to deliver BA using a manual we wrote for this study, with five modules covered in 5-8 sessions. We measured symptoms of depression at the start of the study and again after 6 and 12 months. We also interviewed 48 young people (21 BA, 27 usual care) and 18 staff across different sites (7 BA, 5 usual care, 6 both). What we found BA was no better than usual care at reducing depression within a year. Usual care was an active, varied mix of support, such as counselling and help to challenge negative thoughts. Young people in both groups improved by a similar amount. The results were similar across different groups of young people. This included boys and girls, younger and older teenagers, and those with mild or moderate depression. Young people valued different things in each approach. With BA, they liked its clear structure, using the workbook as a guide, breaking the cycle of low mood and feeling a sense of achievement as they did more activities. In usual care, they valued the chance to get things off their chest and getting help with anxiety and overthinking. Young people in both groups went to a similar number of sessions: 6.5 on average for BA and 5.6 for usual care. We checked whether usual care used BA methods. This only happened in 4% of usual care sessions. Even so, young people in both groups took part in more enjoyable and useful activities by the same amount. BA and usual care had some common ingredients: both helped young people understand their problems, think about different solutions and build a relationship with the person who supported them. ComBAT was the first study to weigh the impact of BA on health and care costs against the extra health benefits it might bring for under 18s with depression. BA did not offer good value for money, because it cost more than usual care but worked no better. Running the BA sessions cost £460 per young person, whereas usual care cost £440. Setting up BA added another £760 per young person for training, supervision and manuals. This set-up cost was high because only 21 (16%) of the 132 staff we trained went on to deliver BA. Usual care did not have any set-up costs. In total, BA cost about £1,230 per young person, against £440 for usual care. Once we added up all the health, care and training costs, BA cost £580 more per young person than usual care. We can trust the results of ComBAT for several reasons. First, we recruited more young people than we planned: 260 against a target of 236. Our participants were a good match for the wider group of young people we wanted to reach. Second, the random split into BA or usual care worked as planned: the two groups were very similar in age, sex, ethnicity and how severe their depression was at the start. Third, young people stayed with the study to the end: we collected follow-up information from nearly 84% of them, and they went to around 88% of all planned therapy sessions, based on 1,583 session records. Fourth, staff delivered BA as planned, which we checked against audio recordings and written notes of sessions. Finally, we ran extra tests and reached the same answer. These tests allowed for missing information, adjusted for differences in follow-up times and included only those young people who completed their BA sessions as planned. What our findings mean Many young people with less severe depression can get substantial support from the services already on offer in the NHS, schools, colleges and voluntary organisations. Building on this support makes the best use of the skills and resources already in the community. We should offer training in a new therapy to those staff and services most likely to use it. How we involved young people, parents and professionals in the research A young person with lived experience of depression was a full member of the research team from the start of the project through to sharing the findings. We also set up three advisory groups, each with 6 to 8 members: one with young people, one with parents/carers and one with professionals. These groups helped us develop the intervention, training materials and study documents, including a questionnaire that gathered information from young people about the health and care services and support they used outside the study. The advisory groups also suggested ways to improve recruitment and helped us understand and interpret the experiences shared by young people and professionals in interviews.

Digital technologies are central to child and adolescent mental health research and intervention delivery. Online platforms expand access, reduce logistical barriers and create new opportunities for young people to engage directly with research and care. At the same time, digital methods introduce threats to research integrity and validity, particularly in randomised controlled trials and large observational studies relying on self‐selected samples. In this editorial, we argue that digital child and adolescent mental health research has missed opportunities and overlooked threats across three interconnected domains: young people's agency to participate in research and provide self‐reported data, representation of the populations targeted by digital interventions and inclusion of marginalised or underserved groups. We highlight how unusual patterns of participation – ranging from symptom misinterpretation to deliberate fraudulent enrolment – intersect with these domains and challenge a study's internal and external validity. Addressing these issues is essential for digitally enabled mental health research to translate into trustworthy and generalisable evidence.

Background: Physical activity is often associated with positive psychological wellbeing in adolescents, and there is evidence from randomised trials to support this. However, the effect sizes reported from intervention studies vary considerably. Moreover, physical activity is a ‘complex intervention’ and findings from trials may not generalise to naturalistic settings. Estimating causal effects from observational data is challenging, though provides an opportunity to add to the evidence base in this area. We used newer machine learning‐based causal inference methods to estimate (i) the causal effect of physical activity on psychological distress in young people (ii) variations in effects across subgroups (‘heterogeneous treatment effects’). Methods: Data from the Millennium Cohort Study were available for 9123 adolescents. Self‐reported days of moderate/vigorous activity was recorded at ages 14 and 17. Psychological distress was measured at age 17 using the Kessler‐6 scale. Directed acyclic graphs were co‐produced with a youth advisory group and individuals with lived experience to identify confounders. Average and heterogeneous treatment effects of physical activity at age 14 on psychological distress at age 17, as well as concurrently at age 17, were estimated using causal machine learning methods (targeted learning, causal forests). Results: We observed no overall impact of physical activity at age 14 on self‐reported distress scores at age 17 (0.11 points, −0.09 to 0.31, p = .28), although there was a modest impact of physical activity at 17 on concurrent distress (−0.39, −0.61 to −0.18, p < .001). Meeting government guidelines on physical activity levels benefited boys more than girls, but had relatively less positive impact on young people with special educational needs. Conclusions: Whilst no overall impact of physical activity levels on youth distress was observed, boys may particularly benefit from targeted interventions in this regard. Causal machine learning is a promising approach to rapidly generating evidence from observational data.

‘Bureaucracy’ is a loaded term in general practice. In October 2024, UK Secretary of State for Health and Social Care, Wes Streeting, announced a ‘red tape challenge’ to cut down on general practice bureaucracy at the RCGP annual conference. But is cutting down on bureaucracy the right starting point to bring about positive change in general practice administration?

Five articles in this issue's debate discuss whether we over‐pathologise young people's mental health. The articles highlight the paradox between inflating diagnoses in the community and under‐recognising mental health needs in health and social care settings. Co‐production with young people and their families when developing services, community‐based initiatives, and research projects is an important method for getting the balance right between increasing awareness and offering support for mental health problems at the earliest possible opportunity, without misinterpreting and mislabelling as ‘mental illness’ the emotions and behaviours of young people in response to challenging or changing life circumstances.

General anxiety is a common mental health condition across the world, with many barriers preventing people from accessing treatments. A growing body of evidence suggests that serious games offer appealing and effective solutions for anxiety. Despite their potential, an understanding of game design qualities and contextual game mechanics in game-based interventions are significantly under-explored, especially for general anxiety. Alternative and emerging game genres may offer new intervention approaches previously overlooked in digital mental health research. We use story-led exploration games, particularly the environmental storytelling walking simulator game genre, as an analytical template to understand new game design strategies and features that can potentially enable engaging and efficacious serious games as interventions for general anxiety. Using semi-structured interviews and thematic analysis, we summarize input from expert clinical participants who identified and evaluated several game design qualities towards developing walking simulators as potential serious game interventions.

Behavioural Activation (BA)—a brief therapy based on the scheduling of enjoyable, purposeful and rewarding activities—is an effective and cost-effective treatment for depression in adults that shows promise for children and adolescents. We provide an update on a previous systematic review of evidence on BA—delivered in-person, telephone, or online—for depression and comorbid anxiety in children and adolescents. We conducted systematic literature searches in 6 databases up to February 2024. We included all study designs evaluating BA with participants up to 18 years old with diagnosable depression, as established by a validated screening tool or diagnostic manual. We used the Moncrieff Scale and the Cochrane Risk of Bias tool to assess study quality. We summarised the findings of all study types with a narrative synthesis and of randomised controlled trials (RCTs) with a meta-analysis. Overall, 24 studies (6 RCTs, 18 pre-post evaluations, n = 2,758) met our inclusion criteria. A meta-analysis of 4 RCTs (n = 156) showed that BA has a small effect of 0.24 (Hedge’s adjusted g) in reducing depression symptoms compared to a waiting-list control, usual care and other therapies. Online and telephone-facilitated BA was shown to be feasible in 3 studies and effective in 1. Outcomes on comorbid anxiety were mixed. No economic evaluations met our inclusion criteria. BA shows sufficient promise as an intervention for reducing depression symptoms in children and adolescents to justify the need for further RCTs, providing that five conditions are met: studies are powered to detect a minimal clinically important difference; BA materials are fit-for-purpose to produce clinically meaningful change; follow-ups are longer than 6 months; primary outcomes are child-reported; and intervention costs, resource use and adverse events are reported.

Background: User involvement is widely accepted as key for designing effective applied games for health. This especially holds true for children and young people as target audiences, whose abilities, needs, and preferences can diverge substantially from those of adult designers and players. Nevertheless, there is little shared knowledge about how concretely children and young people have been involved in the design of applied games, let alone consensus guidance on how to do so effectively. Objective: The aim of this scoping review was to describe which user involvement methods have been used in the design of applied games with children and young people, how these methods were implemented, and in what roles children and young people were involved as well as what factors affected their involvement. Methods: We conducted a systematic literature search and selection across the ACM Digital Library, IEEE Xplore, Scopus, and Web of Science databases using State of the Art through Systematic Review software for screening, selection, and data extraction. We then conducted a qualitative content analysis on the extracted data using NVivo. Results: We retrieved 1085 records, of which 47 (4.33%) met the eligibility criteria. The chief involvement methods were participatory design (20/47, 43%) and co-design (16/47, 37%), spanning a wide range of 45 concrete activities with paper prototyping, group discussions, and playtesting being the most frequent. In only half of the studies (24/47, 51%), children and young people participated as true design partners. Our qualitative content analysis suggested 5 factors that affect their successful involvement: comprehension, cohesion, confidence, accessibility, and time constraints. Conclusions: Co-design, participatory design, and similar high-level labels that are currently used in the field gloss over very uneven degrees of participation in design and a wide variety of implementations that greatly affect actual user involvement. This field would benefit from more careful consideration and documentation of the reason of user involvement. Future research should explore concrete activities and configurations that can address the common challenges of involving children and young people, such as comprehension, cohesion, confidence, and accessibility.

Background: Up to 10% of children and young people have a specific phobia that can significantly affect their mental health, development and daily functioning. Cognitive–behavioural therapy-based interventions remain the dominant treatment, but limitations to their provision warrant investigation into low-intensity alternatives. One-session treatment is one such alternative that shares cognitive–behavioural therapy principles but has a shorter treatment period.Objective: This research investigated the non-inferiority of one-session treatment to cognitive–behavioural therapy for treating specific phobias in children and young people. The acceptability and cost-effectiveness of one-session treatment were examined.Design: A pragmatic, multicentre, non-inferiority randomised controlled trial, with embedded economic and qualitative evaluations.Settings: There were 26 sites, including 12 NHS trusts.Participants: Participants were aged 7–16 years and had a specific phobia defined in accordance with established international clinical criteria.Interventions: Participants were randomised 1 : 1 to receive one-session treatment or usual-care cognitive–behavioural therapy, and were stratified according to age and phobia severity. Outcome assessors remained blind to treatment allocation.Main outcome measures: The primary outcome measure was the Behavioural Avoidance Task at 6 months’ follow-up. Secondary outcomes included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children’s Anxiety and Depression Scale, a goal-based outcome measure, Child Health Utility 9D, EuroQol-5 Dimensions Youth version and resource usage. Treatment fidelity was assessed using the Cognitive Behaviour Therapy Scale for Children and Young People and the One-Session Treatment Rating Scale.Results: A total of 274 participants were recruited, with 268 participants randomised to one-session treatment (n = 134) or cognitive–behavioural therapy (n = 134). A total of 197 participants contributed some data, with 149 participants in the intention-to-treat analysis and 113 in the per-protocol analysis. Mean Behavioural Avoidance Task scores at 6 months were similar across treatment groups when both intention-to-treat and per-protocol analyses were applied [cognitive–behavioural therapy: 7.1 (intention to treat), 7.4 (per protocol); one-session treatment: 7.4 (intention to treat), 7.6 (per protocol); on the standardised scale adjusted mean difference for cognitive–behavioural therapy compared with one-session treatment –0.123, 95% confidence interval –0.449 to 0.202 (intention to treat), mean difference –0.204, 95% confidence interval –0.579 to 0.171 (per protocol)]. These findings were wholly below the standardised non-inferiority limit of 0.4, which suggests that one-session treatment is non-inferior to cognitive–behavioural therapy. No between-group differences in secondary outcome measures were found. The health economics evaluation suggested that, compared with cognitive–behavioural therapy, one-session treatment marginally decreased the mean service use costs and maintained similar mean quality-adjusted life-year improvement. Nested qualitative evaluation found one-session treatment to be considered acceptable by those who received it, their parents/guardians and clinicians. No adverse events occurred as a result of phobia treatment.Limitations: The COVID-19 pandemic meant that 48 children and young people could not complete the primary outcome measure. Service waiting times resulted in some participants not starting therapy before follow-up.Conclusions: One-session treatment for specific phobia in UK-based child mental health treatment centres is as clinically effective as multisession cognitive–behavioural therapy and highly likely to be cost-saving. Future work could involve improving the implementation of one-session treatment through training and commissioning of improved care pathways.Trial registration: This trial is registered as ISRCTN19883421.Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 26, No. 42. See the NIHR Journals Library website for further project information.