Child and Adolescent Mental Health 28, No. 4, 2023, pp. 559–561 doi:10.1111/camh.

12659

Technology Matters: Online, self-help single session

interventions could expand current provision,
improving early access to help for young people
with depression symptoms, including minority
groups
Maria E. Loades1 & Jessica L. Schleider2,3
1
Department of Psychology, University of Bath, Bath, UK
2
Department of Psychology, Stony Brook University, Stony Brook, NY, USA
3
Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

Current mental health service provision for young people was primarily designed based on an assumption of
repeat attendance to enable access to interventions. This applies to in-person therapy and, in recent years, dig-
itally provided apps and programmes. Yet, discontinuation after only one or two attendances or uses is a com-
mon problem. However, there is a different model, which is intentionally designing provision without
assuming repeat attendance, that is, single session interventions. Evidence from the United States, where a
suite of digital, self-help single session interventions, accessible anonymously, have been designed, indicates
that these are helpful to young people with reductions in depression symptoms at up to 9 months later. These
interventions also have had better reach into currently underserved populations (e.g. LGBTQ+ and ethnic
minority adolescents). Therefore, these may be a potentially helpful way to expand existing provision at scale,
enabling all young people to access evidence-based help quickly.

Key Practitioner Message

• Young people want to access help that works when they first start to struggle with their mental health
• Online, self-help single session interventions could be a way to expand on current provision, ensuring that
all young people can access evidence-based help when they want it and anonymously
• In the United States, several single session interventions have been developed and evaluated, showing bet-
ter uptake and reach into currently underserved communities, and effectiveness in reducing depression
symptoms with a very low risk of harm

Keywords: Adolescence; intervention; mental health

Background The potential of digitally provided evidence-

One in three adolescents has elevated depression symp-
toms and even subdiagnostic depression has substan-
tial consequences. Prompt treatment can reduce the
burden of depression symptoms, yet it is difficult to
access, particularly for those who are beginning to
struggle as traditional Child and Adolescent Mental
Health provision has prioritised those who are most
severely unwell or risky. This needs-access gap is dis-
proportionately large for minority adolescents (e.g. eth-
nic minorities, LGBTQ+) who are particularly vulnerable
to depression (Deighton et al., 2019) and also less likely
to access traditional mental health service provision.
Yet, adolescents want to be able to access help when
they start to experience difficulties before they become
significantly impaired. Therefore, we need timely, scal-
able, effective interventions with better reach into
underserved populations.
based treatment
Digital technology offers an effective way to deliver
evidence-based treatment at scale as on-demand self-
help and can overcome many help-seeking barriers,
including stigma. However, currently available digital
treatments like internet-based cognitive behaviour ther-
apy (iCBT) assume repeat use but suffer from significant
dropout and, frequently, are only used once or twice. The
few mental health apps that have been rigorously evalu-
ated also assume repeat use and may have a cost to the
user, as well as a requirement to have a specific compati-
ble device on which to download and use them. Indeed,
even when provision is in person, many adolescents dis-
engage before completing all the sessions available to
them and those from minority backgrounds are dispro-
portionately more likely to attend only once (Edbrooke-
Childs et al., 2021).

Ó 2023 The Authors. Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and
Adolescent Mental Health.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.

560 Maria E. Loades & Jessica L. Schleider
Why single session interventions may be a
useful way to expand on current provision
Single session interventions (SSIs) are one-off therapeu-
tic interventions by design. Thus, they do not assume
repeat use, although they do not preclude this either. A
meta-analysis of SSIs (n = 10,508 adolescents with
mental health problems) found a pooled mean pre-post
intervention effect size of g = 0.32 (Schleider &
Weisz, 2017). Although this effect size is relatively small,
it is impressive given how small the treatment dose is.
And more extensive therapy does not perform that much
better; for comparison, a meta-analysis of psychological
treatments targeting subthreshold adolescent depres-
sion has an effect size g = 0.38 (Cuijpers et al., 2021).
And, even more persuasive is that the evidence showed
that self-help SSIs were as effective as therapist-
delivered SSIs (Schleider & Weisz, 2017).
Online self-help SSIs can be accessed anonymously,
which is particularly important for those who are already
stigmatised and excluded. Several brief (<30 min) online
SSIs have been developed for adolescents and trialled in
the United States by the Lab for Scalable Mental Health.
These SSIs include psychoeducational materials in writ-
ten and visual form, brief videos, vignettes and self-
reflexive exercises. There is some personalisation within
each SSI using branching logic. Content is based on four
elements, B: Brain science – to normalise concepts in the
programme, E: Empower adolescent to a ‘helper’ or
‘expert’ role, S: Saying-is-believing exercises to consoli-
date learning and T: Testimonials and evidence from val-
ued others.
The two SSIs with the best existing evidence for reduc-
ing depression symptom severity in American adoles-
cents are a cognitive and a behavioural SSI. The
cognitive SSI [OSF (https://osf.io/a9uv2) | Schleider +
Weisz 2019 – Project Personality.pdf] teaches how and
why people’s traits or habits are malleable rather than
fixed (i.e. growth mindset). The behavioural SSI [OSF
(https://osf.io/a9uv2) | The ABC Project: Action Brings
Change] teaches that engaging in valued activities can
increase positive mood (i.e. behavioural activation).
Three randomised controlled trials (RCTs) have found
that these SSIs reduce depression symptoms in Ameri-
can adolescents at up to 9-month follow-up compared
with a supportive (placebo) control SSI. In the largest of
these trials, conducted mid-pandemic, almost 2500 ado-
lescents with at least some symptoms of depression
(aged 13–16) were recruited via social media (mainly
Instagram) within just 3 weeks. Those randomly allo-
cated to one of the two active SSIs (vs. control) had
reduced depressive symptoms (Cohen’s d = 0.18)
3 months later (Schleider et al., 2021). The participants
recruited to the trial were a population-congruent repre-
sentation of ethnic minorities and an over-
representation of sexual minorities, and outcomes were
just as good for minority adolescents.
The Lab for Scalable Mental Health has also shown
that in the United States, these online SSIs could be use-
ful as openly accessible resources in practice beyond
their use in trials. Specifically, their evaluation sup-
ported the acceptability and utility of the SSIs for young
people experiencing psychological distress outside of a
trial and importantly, those accessing this platform were
Ó 2023 The Authors. Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and
14753588, 2023, 4, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12659 by CASA Institution Identity, Wiley Online Library on [24/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Child Adolesc Ment Health 2023; 28(4): 559–61
diverse on several dimensions including >50% non-
White and >40% sexual minorities (Schleider, Dobias,
Sung, Mumper, & Mullarkey, 2020). Through an
academic-community partnership in San Antonio,
Texas, they have also shown that it is possible to trans-
late, culturally adapt and disseminate these resources
specifically for low-resourced and minoritized communi-
ties with evidence of good uptake, acceptability and util-
ity (Shroff et al., 2023).
It is important to consider potential unanticipated
adverse consequences of any therapeutic provision.
Based on the existing work in the United States and
two feasibility studies in the United Kingdom, the risk
of adverse events/harms is low. However, there could
be unintended consequences of offering SSIs, including
assuming that SSIs will be accessible, appropriate and
sufficient for all young people, and the risk that they
may be used in the place of, rather than as an expan-
sion to current provision. More large-scale work is
needed to determine safety, uptake and reach, as well
as the experience of SSIs within minority adolescents
specifically.
Conclusions
Online, single session interventions could be an addition
to existing provision, which enables all adolescents to
access evidence-based help in a timely manner. Because
they are intentionally designed to be used in a single sit-
ting, from any device with an internet connection, they
overcome the persistent problem many more extensive
interventions face of drop out. And because they can be
offered anonymously, they also overcome stigma as a
potential barrier to participation, increasing their poten-
tial reach into underserved communities who may other-
wise not access help.
Acknowledgements
MEL (Development and Skills Enhancement Award, 302367;
Advanced Fellowship, 302929) is funded by the National
Institute for Health Research (NIHR) for this research project.
The views expressed in this publication are those of the
author(s) and not necessarily those of the NIHR, NHS or the
UK Department of Health and Social Care. JLS receives
funding from the National Institute of Health Office of the
Director (DP5OD028123), National Institute of Mental Health
(R43MH128075), National Science Foundation (2141710),
Health Research and Services Association (U3NHP45406-01-
00), the Society for Clinical Child and Adolescent Psychology
and the Klingenstein Third Generation Foundation. Prepara-
tion of this article was supported in part by the Implementa-
tion Research Institute (IRI), at the George Warren Brown
School of Social Work, Washington University in St. Louis;
through an award from the National Institute of Mental
Health (R25MH080916; JLS is an IRI Fellow). MEL has no
conflicts of interest to declare. JLS serves on the Scientific
Advisory Board for Walden Wise and the Clinical Advisory
Board for Koko; is co-Founder and co-Director of Single Ses-
sion Support Solutions. Inc.; and receives book royalties from
New Harbinger, Oxford University Press and Little Brown
Book Group.
Ethical information
No ethical approval was required for this article.
Adolescent Mental Health.

doi:10.1111/camh.12659
Correspondence
Maria E. Loades, Department of Psychology, University
of Bath, Bath BA2 7AY, UK; Email: m.e.loades@bath.a-
c.uk, mel26@bath.ac.uk
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Accepted for publication: 10 May 2023