LEARNING OBJECTIVES

After reading this article you will be able to:

• • identify digital programmes developed and evaluated to prevent and manage depression and anxiety in adolescents

• • understand the underlying psychological theories and technological approaches utilised, and how technologies might be developed, evaluated and accessed in health, education and other settings

• • appreciate the potential benefits, challenges and future developments in this field.

Depression and anxiety are common in adolescents, but most individuals requiring support do not receive any formal help (Potter Reference Potter, Mars and Eyre2012; Neufeld Reference Neufeld, Dunn and Jones2017). The reasons for the high levels of unmet clinical need in adolescent depression and anxiety are complex. However, one way of improving access to evidence-based resources and interventions is via digital mental health technologies. Indeed, digital mental health has been identified as a key area of future clinical practice, in particular for preventing and treating adolescent depression and anxiety (Brent Reference Brent, Maalouf, Thapar, Pine, Leckman, Scott and Snowling2015). Digital mental health technologies include resources and interventions that are delivered via devices such as computers, tablets or smartphones to support and improve mental health. Digital technologies have been highlighted as particularly valuable given their potential to improve reach and to ease access to psychotherapy, at a relatively low cost (Stasiak Reference Stasiak, Hatcher and Frampton2016).

Digital technologies can vary in design (e.g. website-based or delivered via apps) and can include a range of digital elements (e.g. games, online activities and chatbots) to help personalise and better meet the range of needs and preferences of users. Some of these technologies are supported by contact with a healthcare provider or other professional. At one end of the human support continuum, this can include a service that is delivered by a clinician digitally in ‘real time’ (e.g. therapy provided via videoconferencing). At the other end of the continuum, resources and interventions are ‘pure self-help’ and therefore involve no human support to an individual user.

Most young people in high-income countries have access to the internet and mobile technologies. For instance, in the UK only 12% (n = 700 000) of those aged between 11 and 18 years reported having no access to the internet at home from a computer or tablet (Office for National Statistics 2019), and by the end of 2020 around 94% of homes had internet access (Ofcom 2021). Many young people in low- and middle-income countries (LMICs) can also access the internet, where there might be a lack of alternative face-to-face approaches (Naslund Reference Naslund, Aschbrenner and Araya2017). More recently, there has been increased interest in implementing remote assessments as well as technologies in a range of settings – especially because of the effects of the COVID-19 pandemic on adolescent mental health, at a time when services are under particular pressure (Ford Reference Ford, John and Gunnell2021; Newlove-Delgado Reference Newlove-Delgado, McManus and Sadler2021).

There is growing evidence to support the use of some technologies in preventing and treating adolescent anxiety and depression (Reyes-Portillo Reference Reyes-Portillo, Mufson and Greenhill2014; Stasiak Reference Stasiak, Hatcher and Frampton2016; Hollis Reference Hollis, Falconer and Martin2017; Grist Reference Grist, Croker and Denne2019), and the National Institute for Health and Care Excellent (NICE) guidelines for the identification and management of depression in children and young people recommend digital cognitive–behavioural therapy (CBT) in the management of mild depression (NICE 2019).

This review article is written with both practitioners and researchers in mind, especially those interested in child and adolescent mental health and novel resources and interventions. The overarching aim is to provide a clinical overview of digital mental health technologies to support the prevention and treatment of depression and anxiety in adolescents.

Review method

Relevant articles were identified through online searches of two databases (Medline and PsycInfo via Ovid) with no restriction regarding publication dates up until March 2021. The key search terms used were: ‘teen*’ or ‘young’ or ‘youth’ or ‘adolescen*’ or ‘child*’ or ‘paediatric’ or ‘pediatric’ AND ‘internet’ or ‘social media’ or ‘telemedicine’ or ‘cellular phone’ or ‘mobile phone’ or ‘smartphone app*’ or ‘mobile app*’ or ‘digital’ or ‘web-based’ or ‘website*’ or ‘ehealth’ or ‘e-health’ or ‘mhealth’ or ‘m-health’ or ‘online’ or ‘computer*’ AND ‘depress*’ or ‘mood’ or ‘anxiety’. We also searched reviews, guidelines and reference lists.

Studies were included if they:

• • were articles with information on the evaluation of digital technologies to prevent and manage depression and anxiety (diagnosis or symptoms) in adolescents (primarily aged 13 to 18 years old); and

• • were papers published in English in a peer-reviewed journal.

Papers were excluded if the technologies were developed for adults or primarily for physical health and well-being, or were diagnostic, screening, monitoring, communication or data management digital tools.

The titles and abstracts were screened (via Mendeley) by F.H., S.S.A., B.W. and R.B.J. (n = 5503 papers). Then the full texts of the studies on the included digital technologies (n = 33 technologies) were read in more detail and the relevant information was summarised. Key papers on the evaluation of each technology were cited. Key authors were contacted for further information, especially on how to access each technology. As this was an educational and descriptive review, and not a formal systematic literature review, an inclusive and pragmatic approach was taken in summarising the relevant papers. We have supplemented the key findings from the literature with our own reflections as practitioners or researchers working in the field.

General characteristics of the identified digital technologies

The 33 identified digital technologies are presented in Table 1. Most of them target depression symptoms alone or together with anxiety symptoms, but a few are for anxiety only. Many are designed to be used in different contexts, including clinical and community settings, whereas others are designed to be integrated into specific settings, such as schools. The majority of the technologies are based, at least in part, on the principles of CBT, and many are informed by a combination of psychological or other theories, including positive psychology and interpersonal psychotherapy (IPT). NICE (2019) guidelines cite three digital CBT programmes for mild depression – specifically SPARX (Merry Reference Merry, Stasiak and Shepherd2012), Stressbusters (Wright Reference Wright, Tindall and Hargate2020) and Grasp the Opportunity (Ip Reference Ip, Chim and Chan2016) – and these three are described in later sections.

TABLE 1 Digital technologies to support adolescents with depression and anxiety

ASD, autism spectrum disorder; CBT, cognitive–behavioural therapy; CYP, children and young people; GP, general practitioner; iCBT, internet-based cognitive–behavioural therapy; iPDT, internet-based psychodynamic psychotherapy; IPT, interpersonal psychotherapy; RCT, randomised controlled trial; TAU, treatment as usual; v., versus (compared with).

A range of digital elements are used in technologies that aim to help ensure the programme is relevant, personalised, flexible and engaging for the user. These include interactive exercises, gamification, avatars, video clips, animations, social media components, user messaging and chatbots. Many of the programmes include several of these elements, and they are categorised here primarily in terms of the digital approach taken. Some are developed to be used independently as ‘stand-alone’ technologies (unguided), whereas others are supported by practitioners (guided). Most technologies had elements of co-design with potential users in their development, particularly those produced in recent years (Bevan Jones Reference Bevan Jones, Stallard and Agha2020a).

In summarising the technologies, we have prioritised the programmes that have been evaluated via randomised controlled trials (RCTs), and we include other programmes with emerging evidence, in particular where there has been feasibility testing. Most technologies identified in our search are not yet available outside of research projects. However, we also refer to available technologies that did not meet the inclusion criteria. We discuss the overall effectiveness and challenges (including accessibility) of technologies later. Further information on each technology (e.g. screenshots) can be found on the websites and papers cited in Table 1 and by contacting the authors and developers. All programme characteristics (e.g. health difficulties targeted, settings, therapeutic and technological approaches, effectiveness, availability) can be considered when selecting which technologies meet the needs and preferences of young people in specific contexts.

Technological approaches and underlying psychological theories

Serious games, gamification and avatars

‘Serious games’ are a form of ‘applied games’ and are in essence computerised games designed for ‘serious’ purposes, for example to improve mental health outcomes. ‘Gamification’ in digital technologies refers to gaming elements used to enhance an intervention's appeal, outside of a fully bespoke ‘serious game’. Both serious games and gamification have been highlighted as ways to potentially increase the impact of mental health interventions (Fleming Reference Fleming, Bavin and Stasiak2017).

SPARX, The Journey, SPARX-R and Rainbow SPARX

SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) is CBT in serious game format developed in New Zealand (Merry Reference Merry, Stasiak and Shepherd2012) (Fig. 1(a)). The user chooses an avatar and travels through seven provinces in the SPARX fantasy world dominated by GNATs (Gloomy Negative Automatic Thoughts). The user undertakes a series of challenges to restore balance and interacts with a ‘guide’, who puts the game into context. SPARX was informed by an earlier CBT intervention, The Journey (Stasiak Reference Stasiak, Fleming and Lucassen2014), which was a prototype serious game intervention, also developed in New Zealand. SPARX has been evaluated in primary care (Merry Reference Merry, Cargo and Christie2012), and subsequently refined and tested with school students in Australia using SPARX-R, the resiliency version (Perry Reference Perry, Werner-Seidler and Calear2017), and refined for sexual minority youth using Rainbow SPARX (Lucassen Reference Lucassen, Merry and Hatcher2015).

FIG 1 Examples of screenshots and characters from digital technologies. (a) SPARX (Merry Reference Merry, Cargo and Christie2012). (b) MoodHwb (Bevan Jones Reference Bevan Jones, Thapar and Rice2020b).

Pesky gNATs and Mindful gNATs

Pesky gNATs (a wordplay on ‘negative automatic thoughts’) is a computer game to support CBT for anxiety and low mood. This was originally designed for children and can be played during face-to-face therapy sessions with a practitioner. Users navigate a three-dimensional world and meet characters who introduce CBT concepts using audio, animation and video, and can learn behavioural activation, relaxation and mindfulness skills. There is online training for therapists, and evaluations include a naturalistic deployment study (van der Meulen Reference van der Meulen, McCashin and O'Reilly2019). Mindful gNATs is a related gamified programme with more focus on mindfulness training (Tunney Reference Tunney, Cooney and Coyle2017).

Overall benefits and effectiveness of digital technologies

Systematic reviews of digital technologies for adolescents (e.g. Hollis Reference Hollis, Falconer and Martin2017) have shown that there is more support for technologies for depression and anxiety than for other problems, such as neurodevelopmental difficulties. Reviews suggest that digital CBT interventions are particularly promising (Grist Reference Grist, Croker and Denne2019) and, as noted earlier, NICE guidelines have cited three digital CBT technologies (SPARX, Stressbusters, Grasp the Opportunity) for mild depression (NICE 2019).

Of the 33 technologies identified in our review (summarised in Table 1), 18 were evaluated via effectiveness RCTs. Nine of these were developed for depression, six for depression and anxiety, and three for anxiety alone. Most of these studies showed an improvement in mental health outcomes (e.g. symptoms, disorders) at least in the short term, in those using the technologies (compared with controls), or the technologies performed at least as well as face-to-face approaches. The studies showed that digital technologies can also help with other mental health-related outcomes, including knowledge, stigma and help-seeking behaviour.

Other potential benefits of digital technologies include the increase in reach and access to therapies at relatively low cost, flexibility of use and increased personal choice (Table 2). It is also possible to tailor programmes to address diversity in the user group. Furthermore, digital programmes can help young people to communicate and connect with practitioners and each other, and to reduce feelings of isolation, using devices and media that they use in their daily lives.

TABLE 2 Potential benefits and challenges of digital mental health technologies for adolescents

CBT, cognitive–behavioural therapy; IPT, interpersonal psychotherapy.

Potential challenges of digital technologies

Although the studies are promising, there are several key challenges in this field, including methodological limitations (Hollis Reference Hollis, Falconer and Martin2017; Grist Reference Grist, Croker and Denne2019). There is a need for more technologies that have been co-developed and evaluated rigorously according to research frameworks (e.g. Craig Reference Craig, Dieppe and Macintyre2008). Many of the studies available are small and primarily undertaken by the programme developers. Follow-ups are lacking and therefore little is known about the longer-term benefits of digital interventions. Even technologies recommended by NICE have limited evidence, for example the most recent evaluation of Stressbusters did not find a positive effect at 12 months (Wright Reference Wright, Tindall and Hargate2020).

Other challenges include low user engagement, uptake and adherence to these programmes. Uptake and adherence might be improved by providing support by practitioners, which might require further time, resources and training. However, a systematic review found that support can be provided by practitioners with various levels of clinical training (Baumeister Reference Baumeister, Reichler and Munzinger2014).

There are concerns related to data protection, security, and privacy or confidentiality – which can affect the user's engagement and trust in the technology (Hollis Reference Hollis, Falconer and Martin2017; Fleming Reference Fleming, Bavin and Lucassen2018). This is especially relevant if a technology enables communication between users, such as with social media or forums, and moderation is important in this context. Other elements to ensure compliance with data protection regulations include the use of usernames and passwords to log in, locks, data encryption and secure servers. There is a risk that the use of technologies might cause harm, especially where there is an absence of rigorous evaluation and data on effectiveness or safety by independent research groups.

Most of the studies and technologies identified in this review were delivered only in English and were created in high-income countries. However, there is an increasing interest in the use of digital technologies in LMICs, where many have access to the internet and mobile devices, but lack formal face-to-face approaches to mental healthcare (Naslund Reference Naslund, Aschbrenner and Araya2017). There is also a lack of studies involving those with neurodevelopmental difficulties, intellectual disabilities and other specific difficulties.

Another significant challenge is that many of the interventions for young people cited in Table 1 are not yet widely available or have not been evaluated outside of a specific country and setting – as interventions developed in one setting might not be transferrable to another. There might also be different legal requirements regarding government approvals and data storage requirements across international boundaries. There is a divide between programmes that are evaluated but not available and those that are readily available but not evaluated independently (Wasil Reference Wasil, Venturo-Conerly and Shingleton2019). This may be partly because of the resources required to complete studies and the long time frames associated with research cycles, for instance from securing funding for the initial research to intervention development and evaluation, then to the implementation of the technology, if this occurs (Craig Reference Craig, Dieppe and Macintyre2008). This contrasts with the fast pace of progress in technology generally.

Therefore, in practice, young people and families/carers seeking online support for depression or anxiety might access general mental health websites that provide written information (e.g. on NHS webpages) or programmes developed primarily for adults (e.g. Headspace, Calm), and some of these involve subscription costs.

Addressing user needs and preferences

There are several other factors to consider when choosing the most appropriate digital programme for depression or anxiety, as noted earlier. Young people and families/carers need to consider whether the technology is appropriate given the user's characteristics, such as their age, development, gender identity, and the nature and severity of their difficulties. In a scoping study, Fleming et al (Reference Fleming, Merry and Stasiak2019) concluded that younger adolescents who experienced stress or low mood were more likely to be interested in interactive and gamified digital interventions that were specifically targeted to support them, whereas older adolescents who experienced these difficulties were more interested in ‘direct-to-the-point’, serious approaches with a clean and clear design.

Technologies have also been developed or adapted to engage with specific cultures and subgroups (e.g. Ip Reference Ip, Chim and Chan2016; Bansa Reference Bansa, Brown and DeFrino2018). Considerations in this context include language, text, iconography, symbols, metaphors, colours, characters and, in some cases, the general principles or philosophy of the technology. For example, SPARX was created by a game company led by a Māori director and included co-design work facilitated by a Māori clinician among rangatahi (adolescents). This work was overseen by a Kaumātua (respected Māori elder) as well as a cultural advisory group. These efforts were employed to create a programme that would be maximally appealing and relevant to Māori (as well as non-Māori) adolescents (Shepherd Reference Shepherd, Fleming and Lucassen2015). SPARX has also been translated into several languages, including Dutch, French, Japanese and Inuktitut (Nunavut, Canada), and adapted for sexual minority youth, as noted earlier (Lucassen Reference Lucassen, Merry and Hatcher2015).

Another consideration is whether the technology might be more relevant for specific settings, such as clinics, communities and schools. In addition, young people will have their individual preferences regarding the content and design of technologies and their overall approach (e.g. social media, chatbot). Some might prefer to engage only with face-to-face therapy or self-help in printed literature format. Therefore, it is important that young people have a choice, where possible, regarding how they access support.

Future developments

Given the fast pace of digital technology and culture, there are a number of possible future developments in digital mental health practice and research. Technologies are likely to become more complex, flexible and personalised, including the use of avatar-based virtual therapy. For instance, a study is underway that explores whether a virtual reality intervention provides a more engaging user-directed experience than a comparable purely web-based intervention (Schleider Reference Schleider, Mullarkey and Weisz2019). Although avatars might facilitate communication with verbally uncommunicative adolescents, professional attitudes and concerns about a lack of information technology (IT) expertise, time or effectiveness need to be addressed if these are to be widely used (Falconer Reference Falconer, Davies and Grist2019).

Collaboration and co-design with young people and other stakeholders are recommended throughout the research cycle of technologies, including the development, evaluation and implementation stages (see stakeholder involvement in Table 1). This is to ensure that technologies meet the users’ needs and preferences, and that they are potentially more engaging, feasible and effective. This might also lead to increased uptake and adherence. There are additional challenges here, and further guidance and research is required in this field (Bevan Jones Reference Bevan Jones, Stallard and Agha2020a).

To help with the faster translation of findings into the community, more flexible and rapid models of development and evaluation in the ‘real world’ will be needed, for example using digital ecosystems that support rapid retesting as the technologies evolve (Rice Reference Rice, Gleeson and Davey2018; Merry Reference Merry, Cargo and Christie2020). However, there should still be a rigorous approach to development and evaluation, with no harm to participants and users and an assessment of cost-effectiveness where possible. More research is required, in particular into the implementation phase of technologies (Craig Reference Craig, Dieppe and Macintyre2008), specifically how to get programmes from the ‘lab’ into different settings. To help to achieve these aims, there could also be greater collaboration and sharing of knowledge between those developing and evaluating technologies (including research and commercial groups) across the world.

Although there are studies involving certain subgroups, young people with intellectual disabilities and specific difficulties will have particular needs and preferences, and should be involved further in research. Digital technologies might be particularly helpful for those who have difficulties with verbal communication. More technologies could be developed for children and younger adolescents, and those who might provide support, such as peers, families, carers and practitioners. Further attention is also required on developing or adapting technologies to tackle the mental health difficulties arising from the COVID-19 pandemic/crisis across the world, including in LMICs (Ford Reference Ford, John and Gunnell2021; Newlove-Delgado Reference Newlove-Delgado, McManus and Sadler2021).