Examining the delivery of Smooth Sailing in Secondary Schools

Smooth Sailing is a web-based mental health service designed for secondary school students and administered by the Black Dog Institute. Smooth Sailing uses a website to register students, screen and monitor their mental health, allocate them to an appropriate level (or “step”) of care, engage them in youth-oriented evidence-based information and activities about mental health, depression, anxiety, and help-seeking, and connect them with a school counsellor when face-to-face support may be required. The service is delivered over a 12-week period in three classroom sessions spaced six weeks apart during which participating students complete several questionnaires. Between these classroom sessions, all participants are given access to an online learning platform called Bite Back during the first six-week period and complete a series of psychoeducation modules during the second six-week period. A member of the research team and/or a school staff member (e.g., teacher, school counsellor) will be present and available at each classroom session to discuss any questions or concerns and provide advice or assistance as required. Each school will be randomly allocated to receive the intervention in one of the following three arms: 1. Standard service: Smooth Sailing will be delivered over a 12-week period in three classroom sessions spaced six weeks apart (i.e., baseline, six weeks, and 12 weeks) and participating students will otherwise use the service in their own time. 2. Standard service with allocated class time: In addition to the standard service, participating students will be given two additional classroom sessions to use Smooth Sailing. 3. Standard service with financial incentive: In addition to the standard service, participating students will be given a financial incentive to use Smooth Sailing. Participants will be reimbursed $2.50 for completing the six- and 12-week classroom sessions and $3 for completing each of the five psychoeducation modules. Each participant can receive up to a total of $20 in reimbursements. Further details are provided below. 1. Service registration and initial screening: Students will complete service registration and screening questionnaires online using a compatible device (e.g., desktop computer, laptop, tablet, or smartphone) during the first of three classroom sessions. To register, students will be asked to go to the Smooth Sailing website using a school specific URL (provided on a slide or on a sheet of paper), read and understand the online consent form and Gillick Competency Test, register to the service by entering a valid, active, and accessible school-administered email address (or personal email address is school email unavailable) and create a password. Initial screening involves the completion of several questionnaires, including validated self-report measures of depression, anxiety, and help-seeking intentions and behaviours. This will take one class period or up to 45 minutes to complete. 2. Delivery of universal program Bite Back: After completing initial screening, all participating students will be given access to and asked to use the online learning platform Bite Back that aims to improve the mental health and wellbeing of young people aged 13 to 16 years. Bite Back provides a range of information, resources, strategies, activities, quizzes, stories, and multimedia related to positive psychology topics including gratitude, mindfulness, social connections, character strengths, and meaning and purpose. A key feature of the program is the Bite Back Mental Fitness Challenge, which contains six modules. Bite Back aligns with the mental health and wellbeing focus area of the National Health and Physical Education Curriculum for schools in Australia and has been shown in a RCT to reduce symptoms of psychopathology and increase wellbeing in young people. Each module takes approximately 10 minutes to complete and students will be asked to complete one module per week in their own time unless they are allocated to the additional class time arm. 3. Midpoint screening: At the 6-week time point, midway through delivery of the Smooth Sailing service and during the second classroom session, researchers will revisit the schools either in person or via an online platform. Participants will be asked to complete several questionnaires, including some of the questionnaires completed as part of the initial screening session via link that will be sent to the email address they registered with. This will take approximately 30 minutes to complete and will be completed during class time. 4. Step allocation and delivery of care: An algorithm based on the level of depression and anxiety symptoms indicated by the questionnaires completed as part of the initial and midpoint screening sessions automatically allocates each student to one of five symptom severity categories and one of three steps of care in accordance with the Australian Clinical Practice Guidelines for Clinical Depression (McDermott et al., 2010). The level of care, or intensity of care, is matched to the level (i.e., severity) of symptoms and increases cumulatively. Step One: Self-directed web-based psychoeducation. Participating students with nil to mild symptoms (i.e., symptom severity categories “0” and “1”) will be allocated to Step One comprising five 10-minute psychoeducation modules on i) general mental health, ii) depression, iii) anxiety, iv) seeking help for yourself, v) seeking help for a friend. Each of these modules provides youth-oriented information about mental health, depression, anxiety, and help-seeking. This content is complemented by youth-oriented graphics and hyperlinks to credible youth mental health services and websites. 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. Step Two: Self-directed web-based CBT. Participating students with moderate symptoms (i.e., symptom severity category “2”) will be allocated to Step Two and, in addition to having access to the five psychoeducation modules, will have access to a sixth module which provides information about a selection of publicly available, free, evidence-based online CBT programs. The online CBT module consists of a single webpage that outlines two evidence-based self-directed online CBT programs: i) MoodGym (Australian National University), ii) The BRAVE Program (University of Queensland), and iii) one relationships-focused program WeClick (Black Dog Institute). MoodGym is an interactive program that helps identify mental health symptoms and learn and practice skills for managing symptoms of depression and anxiety. BRAVE is an online CBT program that helps young people learn how to identify anxiety and stress, develop relaxation skills, and replace negative thinking with more positive thinking. WeClick is a relationships-focused program that helps young people learn skills and strategies to improve friendships and other relationships. Step Three: Face-to-face support from a school counsellor. Participating students with moderately severe to severe symptoms (i.e., symptom severity categories “3” and “4”) will be allocated to Step Three and, in addition to having access to all six Smooth Sailing modules, will be referred to a school counsellor for face-to-face support. Any participant who reports thoughts that they would be better off dead or harming themselves in some way will also be referred to a school counsellor for face-to-face support. Students will be asked to complete the modules and programs in their own time unless they are allocated to the additional class time arm. 5. Reminders and monitoring: Reminders will be sent to the registered email address (and mobile/cell phone number, if provided) of participating students to remind them to engage with the service. All participating students will receive three Bite Back program reminders (Day 8, 22 and 36) and three Smooth Sailing service reminders (Day 50, 64 and 78). Participating students in schools randomly allocated to the arm with a financial incentive will receive additional information about the financial incentive in the three Smooth Sailing service reminders. Following the 6-week assessment, participating students who are allocated to Step 2 and Step 3 (i.e., symptom severity categories “3” and “4”) will be asked to complete two monitoring assessments, spaced 14 days apart (Day 57 and 71). This consists of the PHQ-2 and GAD-2 and will be delivered via email or SMS and should take 2 minutes to complete. Participants are then reminded to use the program, with no symptom feedback given. These students will receive four reminders to complete the monitoring assessments (Day 59 and 61 for the first monitoring assessment and Day 73 and 75 for the second monitoring assessment). 6. Final screening: At the 12-week time point during the third classroom session, researchers will revisit the schools either in person or via an online platform. Participants will be asked to complete several questionnaires, including some of the questionnaires completed as part of the initial and midway screening sessions via link that will be sent to the email address they registered with. The final screening session will include a questionnaire to assess students’ satisfaction with Smooth Sailing. Participating students will have access to the Smooth Sailing modules for a further two-week period after the 12-week assessment. This will take approximately 30 minutes to complete and will be completed during class time. 7. School staff involved in delivering the service will be asked to complete a battery of questionnaires prior to service registration and baseline assessment and after the 12-week assessment. School staff will be invited to participate in a semi-structured phone interview to discuss their experiences.