Depression is a leading cause of morbidity in adolescents, and a major risk factor for suicide, the second most common cause of death in this age group [
1]. Depression has a high rate of relapse and commonly starts in adolescence. The effect of depressive disorder is pervasive and affects not only function but overall development. Depressive disorder is associated with various adverse outcomes, including lower educational attainment, social dysfunction, substance use, attempted and completed suicide [
2,
3]. Co-morbidity is high, with nearly 60% of those with major depressive disorder having a life time occurrence of another psychiatric disorder [
3]. In New Zealand, depressive disorder is the most common mental health disorder amongst adolescents, with prevalence rates of 4–8% at the age of 15 increasing rapidly to 17–18% by 18 years of age [
4]. Recent New Zealand representative study showed that rates of depression for Māori (the indigenous people of New Zealand) high school students (at 13.9%) were comparable to New Zealand European young people (12.1%). Of concern is the high rate of reported clinical depressive symptoms (18.3% for Māori girls and 8.7% for Māori boys) measured by the Reynolds Adolescent Depression Scale – Short Form (RADS-SF) [
3,
4]. Evidence from the past two decades suggests that prevention programmes reduce the incidence of mental health problems [
5]. The importance of preventive interventions has been emphasized by numerous expert panels [
6,
7]. The serious developmental consequences of adolescent depression, the associated treatment challenges and the high costs once it has developed, underscore the need for interventions aimed at prevention [
8,
9]. Current clinical practice, generally limited to treating depression in its acute phase, fails to alleviate the disease burden in a significant way at the population level [
10].
Parents as an important target for prevention and early intervention
A critical factor in an adolescent’s outcome is the extent to which their parents are responsive and supportive to their developmental needs and skilled in managing their child’s behaviour [
11,
12]. Research from the field of developmental psychopathology links a number of family risks and protective factors (e.g. quality of parent-child relationship, parental self-efficacy, parental adjustment, and parenting practices) to adverse mental health outcomes in adolescents [
11,
13‐
15]. Stressful family environment (e.g., frequent arguments, escalating hostility, criticism, or anger) can undermine adolescents’ coping resources and increase their risk for depression [
2,
14,
15]. Parents play a significant role in mediating risk for youth exposed to high levels of adversity [
15,
16] and the protective role of positive parenting holds, irrespective of socio-economic status and levels of neighbourhood distress [
17].
Grounded in evidence-based approaches, including social learning models, self-regulation theory, and cognitive behavioural therapy, parenting programmes aimed at strengthening parenting skills and increasing knowledge on adolescent development have led to significant improvement in parent-adolescent relationships and a reduction in adolescent mental health problems [
6,
18‐
22]. Studies have reported that parent’s acknowledgement of their child’s depression is associated with adolescent’s readiness (i.e., perceptions about viewing depression as a problem, understanding the symptoms, and wanting to get help) to seek professional help [
23]. Young people themselves also see parents as one of the most important sources of support for receiving help on mental health problems [
24]. The prevention and early intervention efforts that effectively up skill parents thus have great potential in preventing depression in youths.
Barriers to accessing services
Even when promising programmes are available to support parents, engaging families can be challenging, with engagement rates as low as 10% for supplemental parenting training when added to individual treatment for depressed adolescents [
25]. Traditional face-to-face intervention is resource intensive and, depending on the setting, can be difficult to implement on a large scale with limited reach to some population groups. Primary logistic barriers for accessing services include lack of time, cost, transport, rural isolation, scheduling conflicts and competing demands. These are further compounded by other barriers including perceived stigma, shame, scepticism, distrust of the system/professionals, and low mental health literacy, including poor awareness of signs/symptoms and resources [
26‐
29]. While home visits are known to be effective for reaching parents, there are limitations to resourcing and some families are also resistant to these [
30,
31].
In short, sole reliance on traditional modes of intervention is insufficient for the level of need and demand. Interventions that make use of technology-based platforms and that reach parents, might be at least as effective and potentially more efficient and acceptable in addressing adolescent mental health problems.
Mobile health (mHealth) intervention in supporting parents of adolescents
MHealth interventions have great potential for public health impact because of their broad reach and convenience [
26]. mHealth offers a wide range of potential benefits over traditional approaches, such as (1) programmes can be delivered anywhere at any time, and for extended periods, facilitating regular communication and behavioural maintenance; (2) support via messages or notifications are sent directly to people in a time-sensitive manner, which means the program can be designed to fit in with the individual’s lifestyle and provide prompts at the most appropriate times (3) program are more proactive (initiated by the service) than traditional services, which often require action or attendance by the participant before they can impart information or provide support; (4) they are flexible, and can be personalised and tailored to specific cultural, age group, and health needs; (5) reach is increased because the barriers of face-to-face contact (such as time, cost and travel) are removed and; (6) disparities in access across the socio-economic status gradient are decreased due to the high penetration of mobile phones across all groups [
26]. Opinion surveys indicate that parents who are interested in family programmes have a stronger preference for mhealth interventions over face-to-face delivery [
32,
33].
While text messaging may not be considered a ‘novel’ mobile phone application, globally, it remains the most widely used [
26]. It is also inexpensive to develop and deliver and it requires minimal technological ‘know how’. Text messaging also requires very basic, low-cost phones (to receive and send messages), which reduces potential socioeconomic disparity of access (‘digital divide’). Text messaging programmes have successfully promoted parenting behaviour change in a number of important domains for parents of young children: decreasing the likelihood of abuse and neglect, increasing childhood vaccinations, and encouraging healthy pregnancies [
34‐
36]. Studies have reported that text messaging interventions were well received by parents of various populations including those that are socially deprived [
36]. While there is evidence to suggest the feasibility and effectiveness of SMS mobile-based interventions to address other health issues [
34,
35,
37], its application and impact among adolescent parent populations are unknown.
Rationale for research
The prevalence of mental health problems in youth is substantial; and efforts aimed at strengthening parenting skills and increasing knowledge on adolescent development hold much promise to prevent and mitigate adolescent mental health problems. To date there have been no reported investigations on the efficacy of delivering a parenting support intervention for parents of adolescents via a mobile-based intervention. We evaluate the effectiveness of a SMS-based mobile intervention for parents of adolescents on promoting parental competence and mental health literacy.
Objective
The aims of this trial is to determine whether a 4-week SMS-based mobile intervention (MyTeen) for parents of adolescents can lead to:
1.
Early improved parental sense of competence (primary outcome)
2.
Continued improvement in parental sense of competence
3.
Improved parental knowledge on depression
4.
Improved knowledge on mental health seeking
6.
Improved quality in parent-adolescent communication