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Smartphone apps have the potential to address some of the current issues facing service provision for young people's mental health by improving the scalability of evidence-based mental health interventions. However, very few apps have been successfully implemented, and consensus on implementation measurement is lacking. This review aims to determine the proportion of evidence-based mental health and well-being apps that have been successfully adopted and sustained in real-world settings. A secondary aim is to establish if key implementation determinants such as coproduction, acceptability, feasibility, appropriateness, and engagement contribute toward successful implementation and longevity. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, an electronic search of 5 databases in 2021 yielded 18,660 results. After full-text screening, 34 articles met the full eligibility criteria, providing data on 29 smartphone apps studied with individuals aged 15 to 25 years. Of 34 studies, only 10 (29%) studies were identified that were evaluating the effectiveness of 8 existing, commercially available mental health apps, and the remaining 24 (71%) studies reported the development and evaluation of 21 newly developed apps, of which 43% (9/21) were available, commercially or otherwise (eg, in mental health services), at the time of enquiry. Most studies addressed some implementation components including adoption, acceptability, appropriateness, feasibility, and engagement. Factors including high cost, funding constraints, and lengthy research processes impeded implementation. Without addressing common implementation drivers, there is considerable redundancy in the translation of mobile mental health research findings into practice. Studies should embed implementation strategies from the outset of the planned research, build collaborations with partners already working in the field (academic and commercial) to capitalize on existing interventions and platforms, and modify and evaluate them for local contexts or target problems and populations. PROSPERO CRD42021224365; https://tinyurl.com/4umpn85f.

User engagement is recognised as a critical and pervasive challenge that has limited the potential evidence base being developed for mental health apps. To understand young people's motivations for participating in a randomised controlled trial for a mental health app and the role of intrinsic (e.g. improving well-being) and extrinsic (e.g. financial incentives) drivers in engagement. Emotional Competence for Well-Being (ECoWeB) was a superiority parallel three-arm randomised cohort trial recruiting a cohort of 16-22 year-olds across the UK, Germany, Spain and Belgium, who, depending on risk, were allocated respectively to the PREVENT ( = 1262) versus PROMOTE ( = 2532) trials. We conducted in-depth semi-structured interviews in the UK ( = 18, mean age = 17.7, s.d. = 1.5) and Spain ( = 11, mean age 20.6, s.d. = 1.7) to explore participants' self-reported motivations and engagement. The trial was registered at ClinicalTrials.gov: NCT04148508. Across arms, 21% of participants never set up an account to access the app and approximately 50% did not complete the 3-month follow-up assessment. Engagement was not significantly higher in the intervention arm compared to the control arms across metrics. Qualitative findings demonstrated that although extrinsic factors alone may be enough to prompt someone to sign up to research, intrinsic drivers (e.g. finding the app useful) are needed to ensure longer-term engagement. Incentivising participation in clinical trials needs to be consistent with incentives that might be utilised at the point of dissemination and implementation to ensure that findings are replicated if that intervention is adopted at scale.

Digital interventions, including mobile apps, represent a promising means of providing effective mental health support to children and young people. Despite the increased availability of mental health apps, there is a significant gap for this age group, especially for children (aged 10-12 years). Research investigating the effectiveness and development process of child mental health apps is limited, and the field faces persistent issues in relation to low user uptake and engagement, which is assumed to be a result of limited user involvement in the design process. This study aims to present the development and design process of a new mental health app for children that targets their emotion regulation abilities. We describe the creation of a new interdisciplinary development framework to guide the design process and explain how each activity informed different app features. The first 2 stages of the framework used a variety of methods, including weekly classroom observations over a 6-month period (20 in total); public engagement events with the target group (N=21); synthesis of the existing evidence as part of a meta-analysis; a series of co-design and participatory workshops with young users (N=33), clinicians (N=7), researchers (N=12), app developers (N=1), and designers (N=2); and finally, testing of the first high-tech prototype (N=15). For the interdisciplinary framework, we drew on methods derived from the Medical Research Council framework for complex interventions, the patient-clinician framework, and the Druin cooperative inquiry. The classroom observations, public engagement events, and synthesis of the existing evidence informed the first key pillars of the app and wireframes. Subsequently, a series of workshops shaped and reshaped the content and app features, including games, psychoeducational films, and practice modules. On the basis of the prototype testing sessions, we made further adjustments to improve the app. Although mobile apps could be highly suitable to support children's mental health on a wider scale, there is little guidance on how these interventions could be designed and developed. The involvement of young users across different design activities is very valuable. We hope that our interdisciplinary framework and description of the used methods will be helpful to others who are hoping to develop mental health apps for children and young people.

Interest in youth perspectives on what constitutes an important outcome in the treatment of depression has been growing, but limited attention has been given to heterogeneity in outcome priorities, and minority viewpoints. These are important to consider for person-centred outcome tracking in clinical practice, or when conducting clinical trials targeting specific populations. This study used Q-methodology to identify outcome priority profiles among youth with lived experience of service use for depression. A purposive sample of 28 youth (aged 16–21 years) rank-ordered 35 outcome statements by importance and completed brief semi-structured interviews eliciting their sorting rationales. By-person principal component analysis was used to identify outcome priority profiles based on all Q-sort configurations. Priority profiles were described and interpreted with reference to the qualitative interview data. Four distinct outcome priority profiles were identified: “Relieving distress and experiencing a happier emotional state”; “Learning to cope with cyclical distressing emotional states”; “Understanding and processing distressing emotional states”; and “Reduced interference of ongoing distressing emotional states with daily life”. All four profiles prioritised improvements in mood and the ability to feel pleasure but differed in the level of importance assigned to learning coping skills, processing experiences, and the reduced interference of depression with life and identity. As part of a person-centered approach to care delivery, care providers should routinely engage young people in conversation and shared decision-making about the types of change they would like to prioritise and track during treatment, beyond a common core of consensus outcomes.

The primary aims of this thesis were to investigate the outcomes achieved by young people with anxiety and depression following treatment by specialist child and adolescent mental health services, the treatment outcome expectancies and illness belief models of young people, and how clinicians are currently managing outcome measurement and treatment outcome expectancies in practice. Study 1 consists of a systematic review and meta-analysis, which investigates the outcomes of routine specialist mental health care for young people with anxiety and depression. Results indicate that only approximately 38% of young people who access specialist mental health treatment show measurable improvement. Study 2 used qualitative methods to explore young people’s expectations of treatment outcomes and beliefs about their anxiety and depression, assessed across the dimensions outlined in the Self-Regulatory Model (Leventhal, Meyer, & Nerenz, 1980). Illness perceptions were multifactorial and highly idiosyncratic, suggesting the need to develop a valid and reliable tool to measure illness perceptions in this group. Study 3 aimed to address this by using mixed methods to develop modified, anxiety and depression specific versions of the revised illness perceptions questionnaire (IPQ-R) (Moss-Morris et al., 2002). Item development and modifications, along with the psychometric properties of the new measures, are reported. Overall, results suggest that the IPQ-Anxiety (IPQ-A) and IPQ-Depression (IPQ-D) are valid and reliable tools for measuring illness perceptions. Study 4 aimed to explore illness perceptions and mental health variables as predictors of treatment outcome expectancy among young people with a history of anxiety and depression. Young people’s cognitive representations of anxiety and depression differed across domains, highlighting that although the conditions co-occur, they are experienced and perceived independently. Results also indicated that greater treatment control beliefs and religious and spirituality beliefs were associated with more positive treatment outcome expectations in youth with history of both anxiety and depression. Study 5 used quantitative methods to investigate CAMHS professionals’ attitudes to routine outcome measurement (ROM) and the barriers to implementation in practice according to the theoretically derived dimensions and the Capability, Opportunity, and Motivation Model of Behaviour COM-B (COM-B) (Michie, Van Stralen, & West, 2011). ROM can serve as a useful clinical tool to monitor outcomes and manage expectations, providing both the practitioner and the young person with some degree of objective feedback about the degree of change. The findings of this study suggest that there are several psychological, motivational and structural barriers to usage, which map on to a number of intervention functions. Study 6 used a qualitative approach to better understand child and adolescent mental health practitioners’ views, feelings and experiences in relation to managing treatment when outcomes have not improved. This is the first study, to date, to utilise the COM-B Model within this context. Results highlight that practitioners face several key challenges in practice, including pervasive resource constraint and an obligation to manage ongoing risk. The results of this thesis can inform evidence-based communication between young people, families and practitioners to facilitate young people’s involvement in shared decision-making and choice regarding their own treatment.

Smartphone apps may provide an opportunity to deliver mental health resources and interventions in a scalable and cost-effective manner. However, young people from marginalized and underserved groups face numerous and unique challenges to accessing, engaging with, and benefiting from these apps. This study aims to better understand the acceptability (ie, perceived usefulness and satisfaction with an app) and feasibility (ie, the extent to which an app was successfully used) of mental health apps for underserved young people. A secondary aim was to establish whether adaptations can be made to increase the accessibility and inclusivity of apps for these groups. We conducted 2 sequential studies, consisting of a systematic literature review of mental health apps for underserved populations followed by a qualitative study with underserved young male participants (n=20; age: mean 19). Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, an electronic search of 5 databases was conducted in 2021. The search yielded 18,687 results, of which 14 articles met the eligibility criteria. The included studies comprised a range of groups, including those affected by homelessness, having physical health conditions, living in low- and middle-income countries, and those with sexual and gender minority identities. Establishing and maintaining user engagement was a pervasive challenge across mental health apps and populations, and dropout was a reported problem among nearly all the included studies. Positive subjective reports of usability, satisfaction, and acceptability were insufficient to determine users' objective engagement. Despite the significant amount of funding directed to the development of mental health apps, juxtaposed with only limited empirical evidence to support their effectiveness, few apps have been deliberately developed or adapted to meet the heterogeneous needs of marginalized and underserved young people. Before mental health apps are scaled up, a greater understanding is needed of the types of services that more at-risk young people and those in limited-resource settings prefer (eg, standard vs digital) followed by more rigorous and consistent demonstrations of acceptability, effectiveness, and cost-effectiveness. Adopting an iterative participatory approach by involving young people in the development and evaluation process is an essential step in enhancing the adoption of any intervention, including apps, in \"real-world\" settings and will support future implementation and sustainability efforts to ensure that marginalized and underserved groups are reached. PROSPERO CRD42021254241; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=254241.