Adolescent self-harm is common with most occurring whilst the young person is on their own. However, nearly all young people have access to a mobile phone at the time of injury. Aim: We discussed this with our young people's participation group and agreed to explore whether a telephone app could help young people to manage their urges to self-harm. Team: BlueIce was developed by Paul Stallard, co-produced with the Oxford Health young people's participation group and with input from CAMHS professionals.
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
Adolescent self-harm is common with most occurring whilst the young person is on their own. However, nearly all young people have access to a mobile phone at the time of injury. Aim: We discussed this with our young people’s participation group and agreed to explore whether a telephone app could help young people to manage their urges to self-harm. Team: BlueIce was developed by Paul Stallard, co-produced with the Oxford Health young people’s participation group and with input from CAMHS professionals. BlueIce: Is a prescribed app, designed to be used alongside a face to face CAMHS intervention, to help young people manage urges to self-harm. It includes a mood diary, toolbox of evidence based techniques to reduce distress (based on cognitive behaviour therapy and dialectical behaviour therapy) and automatic routing to emergency numbers if urges to harm continue Our approach: We adopted a user-centered, agile development process to create, refine, and evaluate BlueIce. This was a tripartite process whereby the product users (young people and clinical staff), academics, and app developers worked together. This process aimed to maximize the acceptability and use of the app by our target group and ensured that the content reflected current evidence and best clinical practice.
What makes your service stand out from others? Please provide an example of this.
Novel: We undertook a literature review and were unable to find any telephone apps specifically developed for young people who self-harm. Grist, R., Porter, J. and Stallard, P., 2017. Mental health mobile apps for preadolescents and adolescents: a systematic review. Journal of medical internet research, 19(5), p.e176. Co-production: Our approach involved co-design and production with young people with mental health problems, our target group. The app was therefore designed with the intended users. Evaluated: Few apps are evaluated and we therefore do not know whether they are safe and helpful. We therefore undertook an evaluation of BlueIce to demonstrate that it was acceptable, safe and effective. Stallard, P., Porter, J. and Grist, R., 2018. A smartphone app (BlueIce) for young people who self-harm: open phase 1 pre-post trial. JMIR mHealth and uHealth, 6(1), p.e32.
How do you ensure an effective, safe, compassionate and sustainable workforce?
Our process of development involved co-design and co-production with young people, academics and CAMHS professionals. The app is now available for use 24/7 and does not require any additional input or training. The app is used alongside the face to face CAMHS intervention the young person receives and does not require any additional training. BlueIce therefore offers a low cost, sustainable way of supporting young people who self-harm.
Who is in your team?
BlueIce was developed by Paul Stallard, Consultant Clinical Psychologist, Band 8D
How do you work with the wider system?
BlueIce is used alongside a specialist face to face CAMHS intervention. It provides the young person with a way of managing their urges to self-harm. It includes a mood monitoring diary, personalised toolbox of self-help strategies and emergency routing to emergency numbers (Childline or 111) if their urges to self-harm persist.
Do you use co-production approaches?
Young people with a history of self-harm have been involved throughout the development of BlueIce. CO-DESIGN: BlueIce was developed through a series of workshops with young people with a lived experience of self-harm which discussed (i). the concept (would an app be helpful?), (ii). what should it look like (examples of apps young people liked and used) (iii) BlueIce design (font, colours, flow) and (iv). content (evidence based and ideas young people found helpful). USER FEEDBACK: Qualitative interviews from 44 BlueIce users highlighted that it was very well received and led to some subsequent changes in the final version of the app. These were the addition of different emotions on the mood wheel, development of an android version and the opportunity to provide feedback option. Our young people’s participation group are making a video for the BlueIce site summarising the comments from young people who have used BlueIce.
Do you share your work with others? If so, please tell us how.
BlueIce has met the standards required to be endorsed on the NHS app library.https://www.nhs.uk/apps-library/blueice/ The evaluation of BlueIce has been peer reviewed and published in open access publications Stallard, P., Porter, J. and Grist, R., 2016. Safety, acceptability, and use of a smartphone app, BlueIce, for young people who self-harm: protocol for an open phase I trial. JMIR research protocols, 5(4), p.e217. Grist, R., Porter, J. and Stallard, P., 2018. Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience. JMIR mental health, 5(1), p.e16. Grist, R., Porter, J. and Stallard, P., 2018. Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience. JMIR mental health, 5(1), p.e16.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
We undertook an open trial where we recruited young people aged 12 to 17 years attending specialist child and adolescent mental health services (CAMHS) who were currently self-harming or had a history of self-harm. Eligible participants were assessed at baseline and then given BlueIce. They were assessed 2 weeks later (post familiarization) and again at 12 weeks (post use). A behavior-screening questionnaire (Strengths and Difficulties Questionnaire) was completed along with standardized measures of depression (Mood and Feelings Questionnaire or MFQ) and anxiety (Revised Child Anxiety and Depression Scale or RCADS), taking into account self-reports of self-harm, app helpfulness, and safety. Results: All core CAMHS professional groups referred at least 1 young person. Out of 40 young people recruited, 37 (93%) elected to use BlueIce after familiarization, with 29 out of 33 (88%) wanting to keep it at the end of the study. No young person called the emergency numbers during the 12-week trial, and no one was withdrawn by his or her clinician due to increased risk of suicide. Almost three-quarters (73%) of those who had recently self-harmed reported reductions in self-harm after using BlueIce for 12 weeks. There was a statistically significant mean difference of 4.91 (t31=2.11; P=.04; 95% CI 0.17-9.64) on postuse symptoms of depression (MFQ) and 13.53 on symptoms of anxiety (RCADS) (t30=3.76; P=.001; 95% CI 6.17-20.90), which was evident across all anxiety subscales. Participants reported that BlueIce was accessible, easy to use, and convenient. Many highlighted the mood diary and mood lifter sections as particularly helpful in offering a way to track their moods and offering new strategies to manage their thoughts to self-harm. No adverse effects were reported. For those who did not find BlueIce helpful, issues around motivation to stop self-harming impeded their ability to use the app.
Has your service been evaluated (by peer or academic review)?
Our results have been peer reviewed and published in open access journals. We have successfully secured research funding to undertake a definitive evaluation. This involved our work being reviewed by the National Institute of Health Research (NIHR), NHS Digital and the Health Foundation.
How will you ensure that your service continues to deliver good mental health care?
BlueIce is a sustainable app. It is available under licence and is already being used by CHUMs in Bedford and the Children’s Hospital in Brisbane, Australia. Other UK CAMHS are considering the use of BlueIce.
What aspects of your service would you share with people who want to learn from you?
Co-production: The success of BlueIce is due to the process of co-design and co-production. Young people with a lived experience of self-harm were involved throughout the design, development and evaluation of BlueIce. It therefore has high acceptability with our intended user group Evaluation: We are committed to evaluating BlueIce and providing evidence that it is safe and effective. Our results show that after using BlueIce, 75% of young people reported a reduction in self-harming. Few apps have any evidence of effectiveness.
Brief description of population : Young people aged 12-17 attending child and adolescent mental health services.
Size of population and localities covered: Available to young people attending CAMHS in BaNES, Buckinghamshire, Bedfordshire, Oxfordshire, Swindon and Wiltshire,
Commissioner and providers
Commissioned by : Provided across Oxford Health NHS Foundation Trust and commissioned by CHUMS CIC, Bedford
Provided by (e.g. name of NHS trust) or your organisation: Oxford Health NHS Foundation Trust
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