School based mental health intervention for young people: development and feasibility study of a digital information prescription intervention.

There is overwhelming evidence that the foundation of lifelong mental health begins in childhood and adolescence. Currently, more than half of young people will, by the age of 21, have experienced mental health difficulties [3,4]. This is of concern since mental health difficulties in adolescence typically persist into adulthood [5]. The cost of poor mental health to the young person, their families, and the healthcare system is extensive [6]. In the UK, the need for specialist mental health services far outweighs resources, and only a quarter of those referred to specialist services will be seen [7]. Young people and families are often left to cope with mental health difficulties on their own. This project aligns with strategic shifts in national and international policy [8,9] to promote mental health through public health initiatives and with recommendations for early intervention when mental health difficulties arise [5]. In regional (Leeds) plans for implementing the NHS England and Department of Health's Future in Mind strategy [8], young people say that "We want it to be easy to find information about mental health and well-being so we can help ourselves" and "We want to be able to get help quickly and easily when we ask for it" [10]. This project therefore adopts a public health approach to examine the potential of information prescription to help young people with early signs of mental health difficulties get the information they need to help themselves. Information prescription involves the prescription of evidence-based, personalised information and guidance, at the right time, to help people understand their experiences, and equip them with knowledge, strategies and motivation to improve their well-being. Studies with adults show high levels of user satisfaction with self-help information interventions for physical and mental health conditions [11, 12], but the potential of self-help information prescription to help the mental health of young people is unexplored. There is currently no information prescription intervention for young people's mental health that can be delivered in schools. We will develop and feasibility test a digital information prescription intervention suitable for delivery by trained staff in schools to 14-18 year olds who are experiencing mild-moderate (but non-clinical) mental health difficulties and who are in the help-seeking stage [13]. A sister intervention for parents/carers will be developed as they currently report feeling insufficiently equipped to help. The primary aim of the intervention is to halt the progression of early mental health difficulties and to help the young person resume a productive and enjoyable life by developing their knowledge, understanding and resources to improve their mental health. Our project adopts a recovery approach, stressing the first person view of the service user, including personal views of what recovery and good mental health means [14].Our early phase study will work closely with YP with mental health difficulties, parents of YP with difficulties, school staff and mental health professionals to identify their support and information needs, before building an information repository relevant to the six most common mental health difficulties experienced by young people in local schools, and which would be suitable for early intervention via information prescription in school. We will convert this repository into a secure, interactive, multi-media platform, suitable for web and app based access, with monitoring potential, delivered via trained school staff. The project will also co-design school based implementation and training materials as well as safety and evaluation protocols to ensure that any young person whose need escalates will receive help quickly. We will use the study outcomes to co-design a trial comparing the effectiveness of the intervention with other early intervention approaches for young peoples' mental health.

YP aged 12-18y have the highest incidence and prevalence of mental illness across the lifespan [3,4]. Public health approaches to mental ill health are strongly advocated nationally and internationally [16, 17]. Indicated prevention interventions can reduce the incidence of new cases of mental disorder; these target individuals showing early signs of poor mental health and they aim to avoid progression to a fully-fledged disorder [15]. Although UK schools have responsibility for supporting YPs mental health, they are without a well-evidenced, sustainable early intervention programme. We will develop and feasibility test a digital information prescription intervention for delivery in secondary schools to indicated YP aged 14-18y, along with a sister intervention for parents. Information prescription encourages people to act on accurate, personalised information and guidance about their difficulties, and covers the affective, cognitive and behavioural determinants of good mental health [18,19]. An early phase study is required as existing information prescription interventions for adult mental health [e.g.11,12] are unsuitable and unworkable for delivery in schools to YP. Adopting a comprehensively co-design process with YP, parents, schools and other stakeholders, we will generate intervention content and the technical and software delivery platform, along with training materials and key design features including theoretical frameworks, implementation model, recruitment criteria, user defined outcomes, prototype journey, risk management protocol, referral pathways, change measurement and feasibility and acceptability benchmarks. We will assess information standards and communication power of intervention content before a feasibility and acceptability study in four pilot sites, where we will also test candidate outcome measures for the main study, alongside an exploratory health economics assessment. Outcomes will inform the design of an RCT.

A clear and meaningful pathway to impact in this project is facilitated by the centrality of user perspectives, its attention to the complexities of schools as implementation contexts, and in the comprehensive co-design and testing of resources with users and stakeholders. We will realise project impacts through our co-design process, our communication strategy, targeted impact events and by applying for a Knowledge Exchange Fellowship (University of Leeds Social Sciences Impact Acceleration Fund) early in the life of the project. We anticipate both short- and long-term impacts for the following beneficiaries:

(i) YP, parents and schools: YP will benefit from involvement in our co-design process (e.g. new experiences and skills, mental health information, value in contributing to research) and by participation in the intervention, where we anticipate improvements to quality of life. Parents will benefit from contributing to co-design (e.g. meeting other parents, influencing action) and also from intervention participation (e.g. accessing new resources). Schools will benefit from shaping the intervention for suitable delivery in schools and by access to new resources to support YP's wellbeing.

(ii) Mental Health Stakeholders: Public health commissioners need cost-effective, sustainable, evidence-base interventions that can operate as both preventive and early intervention for mental health. This project will deliver important early indicators of the potential of information prescription as a public health initiative with young people. We will inform local commissioners of the project and will share final outcomes with them. The project is supported by Leeds South and East CCG and, through RG, we have direct input to the Future in Mind: Leeds Local Transformation Plan (Programme Board) which the CCG lead. We will use the project outcomes to influence the agenda there for public mental heath interventions with young people (e.g. the value in testing low intensity, resilience building, early interventions; and the creative deployment of co-designed digital technologies). There may be additional longer-term impacts through the sharing of good practice with other UK regional transformation plans.

(iii) Digital Technologies and Information Prescription: The innovative use of information prescription through interactive, multi-media for young people will have national interest. We will host a one day national conference targeting non-academic stakeholders to showcase the new resource and to raise awareness of the potential of information prescription for recovery of good mental health.
(iv) Public Mental Health Practice & Policy: Current UK policy highlights schools' responsibilities for the health and wellbeing of children and young people, yet there is a significant absence of support for schools to deliver public mental health work, and more broadly, there are tensions and challenges facing the nature and ownership of public mental health initiatives. We will contribute to and extend these discussions via a multi-stakeholder event examining key issues facing public mental health for YP and the changing landscape for schools as key sites for public mental health work. A post-event report will published online with email shots to key stakeholders.

Across these domains and with the third sector, we will aim to establish new relationships likely to be important for a future definitive trial and to create a step-change in way information prescription may be used and deployed for mental health. Success in our Pathways to Impact will be indicated by: number of users reached through the project; feedback from the steering group and participants; website hits; number and kind of attendees at impact events; number of new collaborative partnerships established; the number of new organisations /stakeholders to whom we communicate the work; and the number of successful publications in both academic and non-academic outlets.