This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.
Effective treatment of depression in young people is critical, given its prevalence, impacts, and link to suicide. Clinical practice guidelines point to the need for regular monitoring of depression symptom severity and the emergence of suicidal ideation to track treatment progress and guide intervention delivery. Yet, this is seldom integrated in clinical practice.
The objective of this study was to address the gap between guidelines about monitoring and real-world practice by codesigning an app with young people that allows for self-monitoring of mood and communication of this monitoring with a clinician.
We engaged young people aged 18 to 25 years who had experienced depression, suicidal ideation including those who self-harm, as well as clinicians in a codesign process. We used a human-centered codesign
The app incorporated a mood monitoring feature with innovative design aspects that allowed customization, and was named a “well-being tracker” in response to the need for a positive approach to this function. Brief personalized interventions designed to support young people in the intervals between face-to-face appointments were embedded in the app and were immediately available via pop-ups generated by a back-end algorithm within the well-being tracker. Issues regarding the safe incorporation of alerts generated by the app into face-to-face clinical services were raised by clinicians (ie, responding in a timely manner) and will need to be addressed during the full implementation of the app into clinical services.
The potential to improve outcomes for young people via technology-based enhancement to interventions is enormous. Enhancing communication between young people and their clinicians about symptoms and treatment progress and increasing access to timely and evidence-based interventions are desirable outcomes. To achieve positive outcomes for young people using technology- (app) based interventions, it is critical to understand and incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians.
Depressive disorders affect up to 25% of young people by the age of 18 years and account for the greatest global burden of disease in young people [
Treatment recommendations within clinical practice guidelines are predicated on establishing the severity of depression symptoms and highlight the importance of monitoring depression symptom severity as a way to monitor treatment progress and inform ongoing treatment decision making. Specific depression symptom measurement tools have been suggested [
However, there are significant challenges to implementing routine and meaningful monitoring [
Self-monitoring offers a potential solution; this involves a young person regularly completing a symptom measurement tool in between their face-to-face appointments. This allows the capture of information about current depression and suicidal ideation symptoms. Self-monitoring is increasingly becoming part of self-management programs in general health areas [
Web-based technology accessible via handheld devices offers the opportunity to implement real-time symptom self-monitoring. Such interventions have the potential to be more flexible, nonstigmatizing, accessible, and cost-effective [
There are a large number of existing apps that monitor mood, although with a few notable exceptions [
However, few apps to date have integrated self-monitoring of mood and suicidal ideation with brief interventions, including those recommended for suicide prevention apps, and apps that are designed to be integrated within clinical services have not been tested. Furthermore, few, if any, apps of this kind have been designed specifically with, and for, young people. We are aware of a very small body of research that has investigated the features young people would like to have incorporated in such an app [
Consumer involvement in the concept development and design of apps for young people has been cited as crucial to ensure that app design better matches the needs and preferences of stakeholders [
We used an overarching participatory design framework [
The study was undertaken in the Youth Mood Clinic (YMC) [
Design for mental health technology must consider both young people and their clinicians [
Young people were informed of the study by their clinicians or by the coordinator of their youth advisory group. We also recruited via a chain-referral sampling method whereby participants informed young people they knew who might be eligible for the study. Those interested were directed to a Web page that contained information about the study and included an expression of interest form to complete. One of the investigators (SH), a clinical psychologist, then contacted those young people to further describe the study, ensure they met eligibility criteria, and provide details of the codesign workshop times and locations. Young people were able to attend as many or as few of the codesign workshops as they wanted to. All youth participants were reimbursed for their time (AU $30 per hour).
On the basis of our previous study of an online monitoring tool, which was undertaken in the same clinical settings [
Onboarding (introduces the app, familiarizes the user with the purpose and functions of the app, and allows user registration)
Monitoring of mood with feedback for young people and their clinicians
An algorithm that generates automatic alerts at prespecified mood levels to encourage users to access help
Prompts for the young person to complete a depression rating scale, the patient health questionnaire (PHQ-9) [
The principal researcher (SH) and designers (EB, RB), along with the digital design student (BM), conducted 4 codesign workshops with young people and 2 focus groups with clinicians. Codesign workshops are designed to immerse participants and build a shared understanding of an issue to allow generation of concepts based on personal experience as well as previous research [
One clinician workshop was held before the codesign workshops with young people, and one was held after the final codesign workshop. The initial clinician workshop was used to present the results of our online monitoring tool [
A general inductive approach was used for analysis, which allows findings to be derived in the context of focused objectives [
All young people were required to complete “a wellness plan” before participation, and robust procedures for ensuring the safety and well-being of participants were developed and implemented.
Ethics approval was obtained from Melbourne Health Human Research Ethics Committee (Reference: HREC/15/MH/340; 2015.207), and written informed consent was gained from each clinician and young person.
A total of 8 young people attended at least 1 of the 4 codesign workshops: 5 attended 1 codesign workshop, 2 attended 2 workshops, 3 attended 3 workshops, and 1 young person attended all 4 workshops.
Of the participants, 3 identified as male and 8 as female. The mean age of participants was 21.4 years; the age of the youngest codesigner was 18 years and that of the oldest was 25 years.
Young people quickly developed a shared vision of what the app’s purpose was and of the key features it would include. They were enthusiastic about the idea of monitoring their mood: “Need some kind of pop-up—where you can note how you feel—are you in a good or bad place”; however, their overwhelming motivation was driven by the potential to develop something that would allow young people to access support in real time, when they needed it in between their face-to-face sessions, noting the limitations of current services, including telephone and online-based crisis support services: “If feeling really like [I] want to self-harm...need something that is immediately available.”
Young people were asked about key features that should be in the app. There was strong support for 5 key features that are described in detail below.
The onboarding process is the users’ first experience of an app and has to be designed so that it is easy to understand and use. Young people in the codesign workshops identified the importance of being able to customize the app. This included having the option to use the app as a guest or as a registered user. Young people highlighted the importance of being able to choose the welcome message and the color palate that was used in the app (highlighting that some colors might trigger negative mood states: “Childish colors...don't like brown...characters too bold...need something calm”)
Young people agreed that the onboarding process should be done with their clinician (“app should be opened up and started with the clinician”) and wanted the customization to allow the young person to modify and add new distraction and brief intervention activities as they learnt them: “make it an option to add to your list of things that help.”
Young people wanted the app to include a feature to monitor their mood. They highlighted that generic descriptors of mood and generic numerical ratings of mood were not necessarily useful or relevant across the population of young people who might use the app. They were clear that the app should not over simplify mood states, instead preferring a more nuanced monitoring approach: “I don’t like sad, happy or in-between faces...there’s so much more to emotions.” Thus, a key innovation for this mood monitoring feature, and again in line with recommendations about customization [
Young people described the importance of having a feature where they could enter potential influences on their mood: “space to write comments about what happened that day...you can record your thoughts.” However, they were clear that the annotations about what had impacted their negative mood should not be automatically displayed but go in a separate section that they could open if they wanted to, stating that it might not be helpful to dwell on this if something negative had happened. This highlighted again that the app should ensure a positive approach to monitoring, allowing rating of positive mood states with a potential further innovation being to provide notifications about what appears to improve mood “I don’t want to see an unhappy face on the calendar everyday” or “don’t use the word crisis.” Thus, this feature became known as a “well-being check.” They were also clear that various approaches to displaying the mood “ratings” over time should be provided so that young people would have choice about how they saw this (eg, a graph or calendar displaying colors over time).
Customization of mood monitoring feature (well-being check) using colors.
Well-being check.
Finally, young people designed an algorithm that was built into the mood monitoring feature that linked, via a pop-up, to appropriate levels of intervention (described below) corresponding to their mood state including for “trigger points” that indicate moderate and high levels of distress, which is individualized and quantified according to the young person’s own criteria.
Young people were unanimous in wanting real-time distractions that provided an immersive experience and diversion from intense and distressing mood states, including suicidal ideation. As stated above, they highlighted the need to ensure customization of these distraction interventions to suit the varying needs of different young people. The types of distractions young people discussed as being useful included the following: meditation with simple tips given to calm the user, games, music, breathing exercises, and videos (eg, inspirational, funny, or of their support people providing support messages).
This feature represents the “internal coping strategies” element of the Stanley and Brown’s safety planning app [
These brief interventions were designed by young people to be something that could be used regularly, rather than only when they were experiencing high distress. They could include all of the distraction interventions described above and also include features such as a photo album that contained meaningful photos, or photos that induced a positive emotion, supportive messages from friends and loved ones and messages that induced positive emotions, links to music playlists (eg, Spotify), and inspirational quotes (with the option of quotes generated by the user or app generated).
This feature is consistent with the interventions designed to increase distress tolerance, such as DBT and CBT, both evidence-based interventions for young people engaging in self-harm [
Algorithm of “interventions” made available according to mood monitor ratings.
Well-being rating | Levels of intervention |
Low risk | Positive affirmation |
Low to medium risk | Positive affirmation |
Link to care package | |
Medium risk | Positive affirmation |
Link to care package | |
Medium to high risk | Link to distraction |
Prompt to ask if user wants to talk to a friend or support person | |
Prompt to ask if user wants to fix an appointment with a clinician | |
High risk | |
Prompt to ask if user wants to fix an appointment with a clinician | |
Prompt them to schedule another self-assessment | |
Link to distraction | |
Prompt to ask if user needs support line: if yes, preprogramed text message to support person and 24-hour crisis support line number selected; clinician notified that user has accessed support. If no, user prompted to fix an appointment with a clinician and schedule another self-assessment | |
Link to distraction |
In line with recommendations [
Young people showed insight into the constraints of the services in which they were engaged. They were aware of the working hours of clinicians and did not expect clinicians to respond to distress messages after their working hours. They were keenly aware that crisis services, such as telephone helplines, were not always able to provide a timely service. Young people did think it was important that their clinician had access to the information generated from their mood monitoring in their face-to-face sessions, including when they had accessed the distraction function, contacted their support person, or used emergency or crisis services:
The idea isn’t that you have access to your clinicians at all times of day...it is very clear that this is not what this is...the idea is that it is to be a log so you and your clinician can see over the past month what has been good, what has been bad, what has been happening...
In total, 16 clinicians participated in the workshops. These clinicians were from a range of professional backgrounds including clinical psychologists, psychiatrists, social workers, and occupational therapists. They all had considerable experience working with young people with severe mood disorders. Many of them worked across both the YMC and a headspace clinical service.
Clinicians at both workshops expressed concerns regarding the clinical responsibilities that would ensue after being informed by the app about high levels of distress and suicidal ideation. They articulated that once this information was known, action would need to be taken to mitigate the risk of suicide. They were uncomfortable about receiving these notifications when they were not present in their clinical roles (ie, in the evenings, on weekends, and while they were on leave). Clinicians expressed concerns that developing a mechanism for being notified of a young person’s distress and responding to this would require significant additional clinical resourcing.
Clinicians highlighted the importance of clarifying and managing the expectations of young people using the app. Unmet expectations, for example, if a young person did not receive an immediate response from a support person, has the potential to result in unintended harm. Suggestions to manage this included ensuring that clinicians had choice over which clients they would use the app with and working closely with the young people in the onboarding stage to familiarize the young person with the app. They highlighted how important it was to ensure that young people were clear about when and what sort of response they should expect from their clinician. In this regard, they highlighted that receiving emails documenting the mood monitoring results for a client would not be appropriate because it was not possible to guarantee a timely response due to workload or circumstances such as the clinician being on leave. The preference of clinicians was to view the mood monitoring information only in their face-to-face sessions with young people. They emphasized that they wanted knowledge of any suicidal crisis and related intervention via traditional means such as notification from other clinicians, as well as from the information within the app that they would view during the face-to-face session with their client. They did note that it would be clinically useful to incorporate a discussion of the mood monitoring results and the potential influences on mood states, as well as what and how young people had used the distraction and care package interventions into their face-to-face clinical sessions. They also suggested that it might be useful to ensure a printable version of the mood monitoring results, for example, a PDF document that could be used in sessions and included in the clinical record. It was the clinician’s view that, although the app allowed the young person to monitor his or her mood in real time, it would not be feasible for clinicians to have access to or respond to these data in real time. They suggested that the app should be considered as, and more appropriately named, a “digital diary” rather than “mood monitoring,” a term that gives the impression that it is a live monitoring device.
The clinician interface tool that was designed as part of the app was designed to be utilized as a separate Web app tool through which clinicians could view the young people under their care and their details. In this tool, clinicians would be able to view the young person’s mood through a calendar or chart function to visually see details of mood ratings over time. Clinicians would also be able to see if any emergency calls were made, what interventions (either from the care packages or distractions) were utilized, and their impact on mood ratings. Allowing the clinician to see this information in the clinician's own time allows them to access the information quickly and alleviates the perception that a young person could rely on the digital diary as a source of immediate or on-demand treatment.
With regard to managing the expectations of young people, they also made the point that young people also needed to be made aware that their support people may not always be available, for example, if there was a delay in the message being sent due to network problems, if their support person’s phone was not charged, if they were away from their phone, or if they were unwell. Clinicians raised some concerns at both workshops about the potential burden on the support person and how this person needed to be carefully selected and made aware that they were going to be contacted by the young person in this way.
Clinicians highlighted a potentially counterproductive effect of one feature of the app (the function allowing a preprogramed default message to be sent when a young person was distressed), in that it could create a learned helplessness with regard to help seeking. Clinicians were concerned that young people might develop an expectation that others should respond and initiate supportive contact when they were in distress, discouraging the young person to learn active help-seeking skills.
The development of this app utilized a codesign process, predominantly with young people but also involving clinicians. Young people and clinicians were enthusiastic about the app including mood monitoring as a key function. Young people wanted a positive approach to this and developed a creative and innovative approach to this function that allowed an individual to customize their well-being scale to indicate when and what type of intervention was needed [
The codesign process used in this study has been undertaken with help-seeking young people who were predominantly recruited via their clinicians or the coordinator of the youth advisory group in which they were involved. To ensure we could safely manage risk, we imposed criteria on inclusion that required that we only include older adolescents and young adults who had not experienced suicide-related behaviors within the previous 3 months. We acknowledge that some young people may have been unwilling to participate given their participation in the codesign workshops meant others would be aware of their history of depression and suicide-related behaviors. Thus, the app may not be relevant or acceptable to all young people or to those accessing different kinds of services. Young people in the codesign workshops had some awareness of this and highlighted the need for customization because “young people” are not a homogenous group, but all have different needs and preferences. Customization has been highlighted as important by adolescents in similar codesign processes [
Although our app conforms to clinical practice guideline recommendations with regard to routine monitoring of symptoms (depression) and medication side effects (suicidal ideation) and its prototype has been beta-tested [
Through the process of codesign, we have been made aware of some of the barriers to implementing this app into face-to-face clinical care. Further work will be required to tailor implementation of the app into various service settings and governance structures. This is potentially challenging, given the different processes used across various services, and highlights that health providers and young people have different expectations and preferences with regard to the use of technology in mental health care.
The functionality of the app is consistent with prototypes developed for adults experiencing depression [
The inclusion of distractions, which are essentially self-soothing interventions or “internal coping strategies” as well as one-touch access to personal support, is consistent with Stanley and Brown’s widely used safety planning intervention [
Young people clearly expressed a need to have mechanisms to overcome help-seeking barriers when they were very distressed, consistent with what is described as help-negation in the literature [
Clinicians also raised significant concerns about the implications of real-time mood monitoring with regard to ensuring the safety of their clients, consistent with concerns raised in similar studies [
A key issue is balancing the needs of young people with the potential clinical burden, and the need for moderation in a landscape where mental health services are already underfunded and overstretched. Although in Australia the integration of technology into clinical care is a national priority [
Extending and enhancing treatment services for young people with depression are important goals given the necessity to ensure that early and evidence-based interventions are delivered to this group. There is significant potential to improve the lives of young people experiencing depression via the provision of technology-based enhancement to interventions, although it may mean significant redesign of current mental health service systems. Our findings have highlighted the critical need to ensure both clinicians and young people are involved in the development of these kinds of interventions to ensure the needs of young people as well as clinicians, and the services in which they are working, are addressed in the design of the intervention.
For clinicians, the app has been designed to assist with ensuring guideline concordant care (symptom monitoring). For young people, it addresses their need for support when they experience distress and suicidal ideation in between their face-to-face appointments. Thus, the app has the potential to enhance communication between young people and their clinicians about symptoms and treatment progress and increase access to timely and evidence-based interventions. Understanding and incorporating the expectations and motivations of both young people and their clinicians are critical to ensure that this can be done.
cognitive behavioral therapy
dialectical behavioral therapy
Orygen Youth Health
patient health questionnaire
Smart, Positive, Active, Realistic, X-Factor thoughts
Youth Mood Clinic
The investigators would like to acknowledge the young people who participated in the codesign process. JR is supported by a National Health and Medical Research Council (NHMRC) Early Career Fellowship. MA was supported via a Career Development Fellowship (APP1082934) by the NHMRC. The authors would also like to thank the young people who participated in the design workshops.
None declared.