Investigating the feasibility and acceptability of Smooth Sailing: An online mental health service for depression and anxiety in high school students

Smooth Sailing is an online mental health service designed and administered by the Black Dog Institute. It is based on the principles of “stepped care” such that the intensity of the recommended interventions is matched to individuals’ symptom severity and individuals “step up” if they have not responded to treatment after a set period of time. Exposure to Smooth Sailing involves (more detail outlined in Phase 2 Clinical Trial Protocol in Attachments section of ANZCTR record): 1. Registration & Mental Health Assessment. In class time, participants are given a slip of paper with the service URL and their unique identification code. They then use a school or personal internet device to visit this website and undertake registration. Before registration commences, participants are asked to complete the Gillick Competency measure which consists of X questions to further confirm their understanding of the service and study requirements. Upon correct completion of this, participants are invited to create a personal profile (name, date of birth, email address, mobile phone number, and gender, history of mental health issues, and use of the internet for mental health information). Once a personal profile is created, four questionnaires were used to measure the presence of depression, anxiety, help-seeking attitudes and behaviours (see Appendix B in Attachments section of ANZCTR record). This takes approximately 30 minutes to complete. 2. Step allocation. Based on the answers inputted during registration, Smooth Sailing allocates each participant to one of five “steps”. This is automatic and based on a clinical algorithm which accounts for the severity levels of the anxiety and depression symptoms as reported by the participant on the Generalised Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire (PHQ-9). Each “step” matches a severity level and was based on clinical practice guidelines. The step allocations were: Nil/minimal (Step 0), Mild (Step 1), Moderate (Step 2), Moderately Severe (Step 3), and Severe (Step 4). 3. Delivery of tailored program. After step allocation, Smooth Sailing delivers a program of content that is tailored to each step. Steps 0 and 1 receive online psychoeducation. Step 2 receive online psychoeducation + online self-directed Cognitive Behavioural Therapy (CBT). Steps 3 and 4 receive online psychoeducation + online self-directed CBT + additional support from the School Counsellor. Any participant who was allocated to Step 3 or 4 triggered an electronic notification alert which was automatically sent to the school counsellor for further investigation. This allowed the school counsellor to facilitate a face-to-face session within 48 hours to provide the counselling or refer on to external services. The online psychoeducation consists of five modules on i) general mental health, ii) depression, iii) anxiety, iiii) seeking help for yourself, iv) seeking help for a friend. Each of these modules contains information about definitions of mental health terms, signs and symptoms, causes of mental health problems, what to do if needing help, and strategies and tips for what a young person can do immediately. Each module is complemented by animations and illustrations to depict key messages as well as hyperlinks to other credible youth mental health services and websites including Headspace, Reachout, Kids Helpline. This content was created specifically for this service, and was reviewed by clinicians. It is designed to be self-directed, such that the youth can read and return to it whenever they wish. The online CBT module consists of a single webpage that outlines two evidence-based self-directed online cognitive behavioural therapy programs: i) MoodGym (Australian National University) and ii) Brave Online (University of Queensland). MoodGym is an interactive self-help book which helps to learn and practise skills for managing symptoms of depression and anxiety. It consists of five modules alongside questionnaires, summaries and a personal workbook. BRAVE was developed for children and teenagers who experience Separation Anxiety Disorder, Social Phobia, Specific Phobia and Generalised Anxiety Disorder. This program helps young people to learn new ways to manage their anxiety and fears. It consists of 10 sessions and is effective for reducing social worries, anxiety about separating from loved ones, fears of specific objects or situation, worries about friendships, school performance or other everyday worries. 4. Monitoring and Feedback. At two points in the study (Day 15 and Day 22) participants received an automated 18-item “monitoring questionnaire” to assess how they were doing. This consisted of the Goldberg Depression and Anxiety Scales (answered using yes or no, see Appendix B in Attachments section of ANZCTR record) and was delivered via email or SMS. An automated thank you message was received alongside a reminder to use the program if participants completed this questionnaire. 5. Reassessment (Post-test/endpoint): At Day 43, researchers revisited the schools. Participants again logged onto the service using the same URL and unique ID codes and were delivered the final endpoint questionnaires. In theory, the results of these questionnaires would be used to determine whether a participant had responded to care or needed to be “stepped up”. In accordance with the Clinical Practice Guidelines for the Treatment of Depression in Young Adults, if a participant has not responded to their care within 43 days of their baseline allocation, they would be “stepped up” to the next level of care. Table 3 (in Phase 2 Clinical Trial Protocol in attachments section of the ANZCTR record) outlines the stepping matrix for depression and anxiety scores reported at 43 days. The matrix was designed such that a participant would not be stepped down, instead will either remain at the same step or step up. However, as the current trial ceased at 43 days, no stepping occurred during this trial. Instead, this trial was designed to provide the clinical data necessary to determine whether the steps are feasible for future trials. Throughout the trial, participants will be obligated to use Smooth Sailing at pre-test (for registration and baseline measure collection) and again at post-test (for reassessment and final endpoint collection) only. Completion of the monitoring questionnaires and use of the other components is entirely voluntary, and will be a measured as part of the study.