Adolescent depression is common and is associated with social and educational impairments, deliberate self-harm, and suicide. It can also mark the beginning of long-term mental health difficulties [1]. Early treatment and prevention of adolescent depression is therefore a major public health concern [2]. However, many adolescents with depression do not access interventions, and engaging young people in prevention and early intervention programs is challenging [1,3,4].

Guidelines for the prevention and management of depression in young people [5,6] stress the need for good information and evidence-based psychosocial interventions for the young person, family, and carer. There has been growing interest in psychoeducational interventions, which deliver accurate information to individuals, families, and carers about mental health or a specific diagnosis, management and prognosis, and relapse prevention strategies [6-8]. The American Academy of Child and Adolescent Psychiatry (2007) “Practice parameter for the assessment and treatment of children and adolescents with depressive disorders” describes psychoeducation as the “education of family members and the patient about the causes, symptoms, course, and different treatments of depression and the risks associated with these treatments as well as no treatment at all. Education should make the treatment and decision-making process transparent and should enlist parent and patient as collaborators in their own care.” [6] Although the risk factors and possible causes of adolescent depression are complex, a family history of depression, psychosocial stress, and a previous history of depression increase individual risk, and these groups could be targeted for such strategies [9].

Findings from a systematic review concluded that psychoeducational interventions were effective in improving the clinical course, treatment adherence, and psychosocial functioning of adults with depression [10]. However, a systematic review of such interventions for adolescent depression [11] showed that there were few existing programs. This is an important gap in the literature because depression is common in young people, and its presentation and management are different from those of adults [1].

Digital health or electronic health (eHealth) has been identified as a key area of future clinical practice and research in adolescent depression, especially to improve reach and access to therapies at relatively low cost [8,12]. There is evidence to support the use of some digital interventions for adolescent depression, and they have been recommended in treatment and prevention guidelines [5,13-16]. However, to our knowledge, there is no digital psychoeducational intervention that has been co-designed and specifically developed for adolescents with depression, or those at elevated risk, or developed and evaluated in line with key guidance of digital and complex interventions [17-20].

Here, we describe an early stage evaluation of MoodHwb, a digital psychosocial intervention co-designed with, and for young people with, or at elevated risk of depression, and their families and carers [21,22]. The main aim of this analysis was to examine whether the program and assessments were feasible and acceptable. This is a crucial step to support the refinement of the prototype and design of a randomized controlled trial [20]. This work could also help to inform the development and evaluation of other digital technologies in this field.

MoodHwb was designed to engage young people (and families and carers) by using developmentally appropriate language, illustrations, animations, and interactive components. It also aims to promote self help, help-seeking where appropriate, and social support. Although it was founded primarily on psychoeducation, it also includes elements of cognitive behavioral therapy, positive psychology, and interpersonal, family systems and behavioral change theories. It is multi-platform and is available as an app, which includes the interactive components and a mobile-friendly version of the main site.

The program was co-designed using a series of interviews and focus groups with potential users: young people (with depressive symptoms or at high risk), parents, carers, and professionals from health, education, social, and youth services and charities. It was also informed by the systematic review noted earlier [11]; person-centered guidelines for developing digital interventions [17-19]; design, educational, and psychological theory; a logic model; and consultations with a digital media company and clinical/research experts.

The program includes sections on mood and depression, possible reasons for low mood and depression, self-management (including planning, problem solving, and lifestyle approaches), finding help, and other issues commonly experienced alongside depression (eg, anxiety; Figures 1 and 2). There is also a section for families, carers, friends, and professionals, in part to promote social support.

On the welcome screen, there are separate user pathways for the young person (“I’m here for myself”) and for the parent, carer or another person concerned about a young person (“I’m here for someone else;” Figure 1). The user is then asked questions (eg, regarding their mood and anxiety), and the answers (1) are stored in the “My profile” section, and (2) help to signpost the relevant subsections on the subsequent dashboard screen. Along with this “Mood monitor,” there are other interactive elements: a goal setting element (“My goals”) and a section to save links to helpful resources (“Stuff I like;” Figure 3).

MoodHwb is available in English and Welsh (hwb is the Welsh translation for hub, and can also mean a lift or boost—HwbHwyliau is the Welsh name for the program). The program and the design and development process are described further by Bevan Jones et al [21,22].

A mixed methods (quantitative and qualitative) approach was taken to assess the feasibility, acceptability, and potential effectiveness of the program. Data were collected from the following: (1) semistructured interviews with young people, parents and carers who used the intervention, (2) a focus group with professionals, (3) Web usage data, and (4) pre intervention and post intervention questionnaires.

The Dyfed-Powys (Wales, the United Kingdom) and Cardiff University School of Medicine Research Ethics Committees gave a favorable opinion for the research project. Research and development approval was granted by Cwm Taf, Cardiff and Vale, Abertawe Bro Morgannwg, Aneurin Bevan, Hywel Dda, and Powys University Health Boards (UHBs), 6 of the 7 UHBs in Wales. The authors of the questionnaires were contacted where approval was required.

We planned to approach around 40 young people, as this sample size was considered sufficient to allow assessment of acceptability and feasibility in a relatively broad sample of the target group. Young people were recruited from specialist Child and Adolescent Mental Health Services (CAMHS), primary mental health teams, school counselors and nurses, and from the Cardiff Early Prediction of Adolescent Depression (EPAD) study [23]. Individuals (recruited from CAMHS and EPAD) who participated in the design and development phase of MoodHwb were also invited to participate.

Consenting participants were provided a link to the program via email, and they created their own passwords. Parents and carers could create separate accounts to their children. Participants were informed that they could use the program as they wished (MoodHwb includes a section and animation to introduce the program to the user). Young people continued to attend sessions with their practitioner or counselor, if they were seeing someone. They were given access for a minimum of 2 months to allow them sufficient time to work through the program. Professionals were provided with a link to the program 2 weeks before their focus group.

The main outcomes of the evaluation related to the feasibility and acceptability of the digital program and of the evaluation process. Secondary outcomes included the potential effect on mood, knowledge, attitudes, and behavior after using the program.

Figure 4 shows the flow of participants in the quantitative evaluation phase. In total, 59 young people expressed an interest in participating in the evaluation phase, and 44 consented to participate (75%). Of those who consented to participate, 36 young people (82%) completed either the post intervention or feedback questionnaire (ie, 2 of the young people completed only one questionnaire). In all, 31 parents or carers provided consent to participate, of whom 21 (68%) completed either the post intervention or feedback questionnaire (ie, all but one of the parents or carers completed both questionnaires).

The characteristics of participating young people are presented in Table 2. The ratio of females to males was approximately 4:1. The majority (29/31, 94%) of the parents and carers who participated were mothers. In all, 45% (14/31) of the parents and carers were receiving treatment for depression, and 72% (21/29) had been treated for depression during their lifetime. Of those who participated in the previous development phase, 17 young people and 6 parents or carers consented to participate in the evaluation (ie, 39% of young people and 19% of parents and carers who consented to participate). The levels of missing data are shown in the footnotes of the tables below, where relevant.

Descriptive information about interview and focus group participants is provided in Table 3. A total of 19 young people were interviewed; the ratio of females to males was approximately 3:1. Approximately two-thirds of the young people were interviewed along with their parents or carers (11 mothers, 1 father). In all, 9 of those interviewed spoke Welsh fluently. A total of 13 professionals from a range of disciplines participated in the focus group.

The overarching themes in the interviews and later in the focus group were as follows: (1) design features, (2) sections and content, and (3) integration and context. These themes were influenced by the primary issues the research team wished to explore, to help refine the content and design of MoodHwb. The overall feedback from participants is presented later, with verbatim examples listed in Table 5. Specific suggestions on changes to the program are described in Multimedia Appendix 1. Many of those who had participated in the development phase commented that they were pleased to see that suggestions made in the codevelopment group sessions had been adopted in the prototype.

During the interviews, young people stated they were able to discuss the program openly and appreciated that they could choose the location, and whether they were seen with their parents or carers. They found it helpful to be able to navigate through the program as it was discussed.

Data on acceptability of questionnaires were available for 43 young people and 30 parents or carers at baseline, and 34 young people and 19 parents or carers at follow-up. Most felt the number of questions was “about right.” Young people at follow-up were more likely to rate the questionnaires as having a “few too many questions” than at baseline, possibly due to the additional burden of the feedback questions.

Table 6 summarizes the results from the pre intervention and post intervention standardized questionnaires. It is important to note that these findings are considered exploratory given the small sample size and lack of power.

Most participants noted that the program was engaging, clear, easy to navigate, and well structured, and praised the graphic and animated approach. The content was described as comprehensive, motivational, holistic, and accessible to young people—and also relevant to families, carers and professionals in a range of services. Young people found it easier to use overall and were better able to understand the design elements, although parents, carers and professionals found it acceptable.

Nearly all who completed the follow-up used the program, with most young people using it alone and for at least half an hour at a time over the course of the study (minimum of 2 months), which is favorable in terms of adherence in eHealth [12]. Participants did not use it frequently; however, they found it helpful overall, and its use might vary according to the context and needs of the user (eg, the stage and severity of their difficulties) [37].

There were reports of improved depression literacy, self-efficacy (especially regarding self help strategies and knowing where to get help), and depressive symptoms—giving preliminary support for the intervention program theory [22]. There was no clear evidence of potential negative effects from using the program.

These results were consistent with a recent systematic review of psychoeducational interventions in adolescent depression [11], which found that these programs can be acceptable and feasible and can influence a range of outcomes. Overall, the development and initial evaluation of MoodHwb fills a knowledge gap identified in the review (particularly of digital programs) and meets the need for good health information and evidence-based psychosocial interventions [5].

MoodHwb might be particularly helpful when a young person starts to experience difficulties and first presents to services—for example to school counseling or nursing, primary care/mental health, youth, or social services. However, given that the majority of young people with depression do not access services [38], digital health interventions such as this could help improve reach and access to therapies. The program could also complement other approaches, for example, in the management of severe or chronic difficulties. It fits with the guided self help approach (as it can be used either independently or with another person) and the increasing interest in personalized medicine [39]. 

This evaluation will be used to inform the refinement of MoodHwb, with the aim of improving the user engagement with it. The suggestions for improvement made by participants were discussed with the digital media company and research team. The issues were prioritized according to the level of importance given to them by the participants, and whether they would improve the acceptability, feasibility, and ease of use of the program. Other considerations were the program aims, underlying theory and evidence, technical difficulty, and time, resources, and funds required to make the changes.

The main revisions considered included improving the navigation and audiovisual/interactive elements, making it more personalized, developing the app version of the program, and expanding the self help and anxiety sections (Multimedia Appendix 1). Ahead of a large trial, we would also need to ensure the program has the required technical specifications (eg, compatibility with devices and operating systems, adequate database capacity, and easy access to the app).

This early mixed methods evaluation found that the co-designed prototype of MoodHwb and assessment process were feasible and acceptable. The findings will be used to refine the intervention and inform the design of a randomized controlled trial [20]. If proven to be effective, MoodHwb could ultimately be rolled out as an early intervention program in health, education, social, and youth services and charities to help young people, families, carers, friends, and professionals.