Evaluation of a computerised cognitive behavioural therapy (cCBT) program for depressive symptoms in sexual minority youth.

Lucassen, Mathijs (2012). Evaluation of a computerised cognitive behavioural therapy (cCBT) program for depressive symptoms in sexual minority youth. PhD thesis The University of Auckland.


In this thesis I have described a body of work designed to address the problem of depression in sexual minority youth. I started by determining whether sexual minority youth have unique mental health and help-seeking needs. Subsequently the primary aim of my doctoral project was to design and evaluate the acceptability of a self-help program, specifically a computerised cognitive behavioural therapy (CCBT) program specially adapted for sexual minority youth with mild to moderate depressive symptoms. This thesis comprises four studies.

In Study One I used multiple logistic regression to examine the associations between sexual attraction and depressive symptoms, suicidality, self-harming and help-seeking behaviours, in data collected from a nationally representative secondary school health and well-being survey (Youth’07). Sexual minority students consistently had higher prevalence estimates of depressive symptoms (p=<0.0001), suicide attempts (p=<0.0001) and self-harming (p=<0.0001) than students attracted to the opposite sex. Students who reported they were attracted to both sexes had the highest odds ratios for depressive symptoms (OR 3.7, 95% CI 2.8–4.7), suicide attempts (OR 7.0, 95% CI 5.2–9.4) and self-harm (OR 5.8, 95% CI 4.4–7.6). Non-heterosexual students were more likely to report having seen a health professional for an emotional worry and having difficulty accessing help for emotional concerns.

For Study Two, I used thematic analysis based on the general inductive approach to analyse the results of three focus groups. In these groups nine sexual minority participants discussed the unique challenges they face and whether these challenges could usefully be addressed in a CCBT program. Participants also provided feedback on prototypes of a 3D fantasy-based role-play CCBT program (SPARX), designed for a general youth population, and made suggestions about how SPARX could be adapted for sexual minority youth. Participants reported experiencing a number of challenges in their day-to-day life including living within a homophobic and gender-stereotyped world. They highlighted issues unlikely to be experienced by their heterosexual or opposite-sex attracted peers related to discrimination and mistreatment due to their sexuality. As a result of participants’ feedback a specially modified version of SPARX, called SPARX: The Rainbow Version, was developed for sexual minority youth.

In Study Three I conducted an open trial to assess the acceptability and feasibility of SPARX: The Rainbow Version (or Rainbow SPARX) amongst 21 sexual minority youth with depressive symptoms. I also collected preliminary data on the efficacy of Rainbow SPARX. The depressive symptoms of sexual minority youth (assessed using the Child Depression Rating Scale – Revised) decreased significantly post intervention (p<0.0001), with a large pre- to post-effect size (d=1.01) and this positive change was maintained at three-month follow-up. There were also significant improvements on secondary outcomes including self-rated symptoms of depression and anxiety, and a reduction in hopelessness. Over 80% of the sexual minority youth completing SPARX: The Rainbow Version thought CCBT would appeal to other young people. The results from the open trial were compared with those of a randomised controlled trial, where 154 exclusively opposite-sex attracted youth were equally randomised to SPARX and treatment as usual (TAU). With the exception of mean age of participants, open trial and RCT participants did not differ significantly in terms of baseline demographic data, baseline clinical characteristics and changes in assessment scores over time. However, open trial participants were more likely to complete treatment when compared with RCT participants (p=0.007).

Study Four was a qualitative study which involved analysing the results of semi-structured interviews using the general inductive approach. Interviews were conducted with 25 youth immediately after they completed SPARX: The Rainbow Version. Twenty of these interviews were with open trial participants from Study Three. Of the remaining five interviews, four interviewees did not have depressive symptoms at baseline and one interviewee identified as being “straight”. Seventeen participants reported that SPARX: The Rainbow Version helped them feel better or less depressed and most of the participants reported that the program included useful messages or content. The majority liked the look and feel of the program. Eighteen participants highlighted minor technical issues that they thought needed to be addressed. Participants in Study Four also identified suggestions or tips that would help encourage sexual minority youth to participate in future research.

I have shown that, relative to their peers, sexual minority youth are more likely to have depressive symptoms and to experience difficulty accessing appropriate healthcare. To address these issues I sought the views of sexual minority individuals and then incorporated their views into an adapted form of CCBT for sexual minority youth. Taken together the results of my open trial (Study Three) and the qualitative study (Study Four) indicate that SPARX: The Rainbow Version shows promise as an intervention for mild to moderate depressive symptoms in sexual minority youth and that this intervention was acceptable to participants and that delivery was feasible.

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