An online, stepped care mental health service for secondary school students
Mental health concerns are prevalent among school-aged youth, and help-seeking is low. Alternative service models are needed to improve rates of help-seeking and prevent the escalation of mental illness within this population.
Online stepped-care presents a viable alternative. It is based on the premise that simple, cost-effective internet interventions are offered to youth with mild-moderate symptoms, while more costly, intensive face-to-face interventions are reserved for those with more severe and persistent symptoms (van Straten, et al. 2015).
School is an ideal setting for the implementation of online stepped-care as young people spend much of their daily lives in school. However, schools currently have a fragmented approach to mental health, with some offering a school counsellor, some offering psycho-education programs, and some not having anything at all.
To improve this situation, the Black Dog Institute has designed and built an online mental health clinic, named “Smooth Sailing,” that targets help-seeking for depression and anxiety symptoms in high-school students. Co-designed with students, school staff and parents, Smooth Sailing delivers mental healthcare using an internet program that triages students’ mental health, delivers treatment, monitors progress and links in with the school counsellor and wellbeing team.
History of the project
Up to 50% of all mental disorders emerge before the age of 18 years (Kessler et al., 2005), demonstrating the need for prevention and intervention efforts to be targeted at school-aged youth.
Stepped care models have been proposed as an innovative means of providing mental healthcare (van Straten, et al. 2015), that may be effective and scalable to address the mental health of students within the school setting. However, this type of model is yet to be trialled in an Australian context.
Over a three year period, the project will develop, evaluate and implement an online, school-based mental health service. This project has three key phases. The first phase involved stakeholder engagement (via focus groups, interviews, and surveys) to assist in the design of the online service model, which was modified accordingly. The second phase consisted of a 6-week pilot trial of the Smooth Sailing service, which aimed to evaluate the feasibility and acceptability of the service. Phase 3 (2017-2018) involved a 12-week cluster-randomised controlled trial with 22 secondary schools in NSW, Australia. Student mental health symptoms were measured as well as their help-seeking behaviours and attitudes. The effects of the service on school counsellor efficiency were also assessed.
It is expected that the results of these studies will soon be published in academic journals.
HSBC, Graf Foundation
Overall, approximately 119 end-users were consulted during this phase. Students (n=61) described the service as being helpful, with the majority reporting they liked the information (92%; n=56) and look and style (89%; n=54) of Smooth Sailing.
A total of 29 school counsellors were consulted, with 76% (n=22) reporting they liked the service, while 35% (n=10) were “entirely” comfortable about using it. Teachers (n=18) broadly supported the service (78%; n=14), while 76% (n=14) felt entirely comfortable with the idea of using it.
Interviews with parents (n=14) of high-school students indicated that overall, they were positive about the proposed service model, although were concerned about potential security and confidentiality risks that might arise.
Eleven GPs were consulted, with approximately 82% (n=9) reporting the service to be acceptable, and 55% (n=6) reporting they would be willing to integrate it into their service.
Additionally, a total of 145 school counsellors within NSW completed a cross-sectional online survey, which evaluated the acceptability of using a web-based service, like Smooth Sailing, within the school context.
The results of this study have been published:
- O’Dea, B., Leach, C., Achilles, M., King, C., Subotic-Kerry, M., & O’Moore, K. (2018). Parental attitudes towards an online, schools based, mental health service: Implications for service design and delivery. Advances in Mental health, https://www.tandfonline.com/doi/full/10.1080/18387357.2018.1514269
- Subotic-Kerry, M., King. C., O’Moore, K., Achilles, M., & O’Dea, B. (2018). General Practitioners attitudes towards an online school-based mental health service: Implications for the design and delivery of youth e-mental health. JMIR Human Factors;5(1):e12). https://humanfactors.jmir.org/2018/1/e12/
- O’Dea, B., King, C., Subotic-Kerry, M., O’Moore, K., & Christensen, H. (2017). School Counsellor perspectives on the factors influencing uptake of an online stepped care mental health service for schools: A cross-sectional online survey. JMIR Mental Health;4(4):e55. https://mental.jmir.org/2017/4/e55/
A total of 55 high-school students from four NSW secondary schools participated in a pilot study. Results indicated that almost one-third of students had concerning levels of mental health symptoms, and that nearly one in five needed to be followed-up by the school counsellor for severe symptoms or suicidality.
Further, students reported an overall increased likelihood of, and actual help-seeking from professional sources and adults. Reductions in depression and anxiety symptoms were found among students who were unwell at baseline.
A total of 1802 high school students from 22 NSW secondary schools participated in a 12-week Randomised Controlled Trial (RCT) of the Smooth Sailing service. Ten schools consisting of 704 students were allocated to use the Smooth Sailing service. The remaining schools and students were allocated to the control group, which was school as usual. Students who received the Smooth Sailing service had significant improvements in help-seeking intentions and anxiety at the completion of the 12 weeks. Importantly, the service did not increase stigma or distress.
Across the 10 intervention schools, 18.5% students were detected as having mental health problems at baseline. This indicated that on average, nearly one in five students required help for their mental health. Notably, nearly half of these were new cases for the school counsellors.
Overall, the results indicated that one third of high school students experienced psychological distress, one quarter had anxiety or depressive symptoms and one in twenty had thoughts of self-harm or death. One in five students reported needing help for their mental health but didn’t seek it. A total of 25% thought that an online program could help with their mental health.
Next steps for the project include:
- Improvements to the school counsellors’ online portal
- Increased training for school counsellors in responding to students in need
- Improvements to the students’ screening questionnaires and reducing time taken to complete
- Increasing the engagement and interactivity for students to increase interest and uptake
The team will make these changes throughout 2019-2020, with generous funding and support from The Prevention Hub. The service will also be offered to new schools during this time. If you are interested in having Smooth Sailing at your school, please contact the Smooth Sailing Team via email.
Download a summary of the Smooth Sailing Flyer [PDF, 277KB].