List of questions asked.

<p>^a The original source of most of the questions used was the 9-item patient health questionnaire (PHQ-9) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref062" target="_blank">62</a>].</p><p>^b While we asked these two questions separately, they are a single question in the original PHQ-9.</p><p>^c These three questions were used to determine suicide risk.</p><p>^d The original source of the questions used was the 7-items regarding anxiety contained within the Hospital Anxiety and Depression Scale [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref066" target="_blank">66</a>].</p><p>^e The original source of the questions was the CRAAFT questionnaire which is well validated for use in youth [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref076" target="_blank">77</a>], [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref078" target="_blank">78</a>]. It is named the CRAFFT scale because of the 6 questions relating to specific risks involved with drug and alcohol abuse (in our study they were questions 4–9, with the key words involved in the acronym shown in capital letters).</p><p>^f For these scales a higher score is better (for both self-esteem and quality-of-life) in contrast to the other scales.</p><p>List of questions asked.</p

Initial Findings from a Novel School-Based Program, EMPATHY, Which May Help Reduce Depression and Suicidality in Youth

<div><p>We describe initial pilot findings from a novel school-based approach to reduce youth depression and suicidality, the Empowering a Multimodal Pathway Towards Healthy Youth (EMPATHY) program. Here we present the findings from the pilot cohort of 3,244 youth aged 11–18 (Grades 6-12). They were screened for depression, suicidality, anxiety, use of drugs, alcohol, or tobacco (DAT), quality-of-life, and self-esteem. Additionally, all students in Grades 7 and 8 (mean ages 12.3 and 13.3 respectively) also received an 8-session cognitive-behavioural therapy (CBT) based program designed to increase resiliency to depression. Following screening there were rapid interventions for the 125 students (3.9%) who were identified as being actively suicidal, as well as for another 378 students (11.7%) who were felt to be at higher-risk of self-harm based on a combination of scores from all the scales. The intervention consisted of an interview with the student and their family followed by offering a guided internet-based CBT program. Results from the 2,790 students who completed scales at both baseline and 12-week follow-up showed significant decreases in depression and suicidality. Importantly, there was a marked decrease in the number of students who were actively suicidal (from n=125 at baseline to n=30 at 12-weeks). Of the 503 students offered the CBT program 163 (32%) took part, and this group had significantly lower depression scores compared to those who didn’t take part. There were no improvements in self-esteem, quality-of-life, or the number of students using DAT. Only 60 students (2% of total screened) required external referral during the 24-weeks following study initiation. These results suggest that a multimodal school-based program may provide an effective and pragmatic approach to help reduce youth depression and suicidality. Further research is required to determine longer-term efficacy, reproducibility, and key program elements.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT02169960" target="_blank">NCT02169960</a></p></div

Distribution of drugs, alcohol, and tobacco scores at baseline.

<p>The distribution of scores for the use of drugs, alcohol, and tobacco is shown for all 7 Grades (average ages at start of study are 11.3 for Grade 6, 12.3 for Grade 7, 13.3 for Grade 8, 14.3 for Grade 9, 15.3 for Grade 10, 16.4 for Grade 11, and 17.4 for Grade 12). While these scores do not have diagnostic validity, we indicate the distribution of these scores. It can be seen that at all scores the distribution is that the oldest youth have more use of drugs, alcohol, and tobacco, and have been involved in more significant activities that may put them at risk. It is consistent with previous studies that less than 30% of youth in Grade 12 have not used drugs, alcohol, or tobacco in the previous 12-months, compared to more than 95% of those in Grade 6.</p

List of questions asked.

<p>^a The original source of most of the questions used was the 9-item patient health questionnaire (PHQ-9) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref062" target="_blank">62</a>].</p><p>^b While we asked these two questions separately, they are a single question in the original PHQ-9.</p><p>^c These three questions were used to determine suicide risk.</p><p>^d The original source of the questions used was the 7-items regarding anxiety contained within the Hospital Anxiety and Depression Scale [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref066" target="_blank">66</a>].</p><p>^e The original source of the questions was the CRAAFT questionnaire which is well validated for use in youth [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref076" target="_blank">77</a>], [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0125527#pone.0125527.ref078" target="_blank">78</a>]. It is named the CRAFFT scale because of the 6 questions relating to specific risks involved with drug and alcohol abuse (in our study they were questions 4–9, with the key words involved in the acronym shown in capital letters).</p><p>^f For these scales a higher score is better (for both self-esteem and quality-of-life) in contrast to the other scales.</p><p>List of questions asked.</p

Some of the novel multimodal approaches utilized in EMPATHY program.

<p>Some of the novel multimodal approaches utilized in EMPATHY program.</p

Correlations between the scores on the 5 subscales in the combined EMPATHY scale score, using Spearman’s rank correlation coefficient.

<p>Correlations between the scores on the 5 subscales in the combined EMPATHY scale score, using Spearman’s rank correlation coefficient.</p

Algorithm for determining which students were in the “actively suicidal” group.

<p>The figure shows how scores on the three questions regarding suicide risk determined if the student was in the high suicide risk group or the medium suicide risk group. Together, these students were considered the “actively suicidal" group, and were interviewed individually within 2 days for the high suicide risk group or within 5 days for the medium suicide risk group.</p

Some of the novel multimodal approaches utilized in EMPATHY program.

<p>Some of the novel multimodal approaches utilized in EMPATHY program.</p

Consort flow chart demonstrating allocation of students.

<p>The figure shows how many students entered the study and (on the left-hand side) how many were allocated to the CBT treatment as well as (on the right-hand side) how many completed both baseline and 12-week follow-up ratings and formed the study population.</p

Number of students in different risk levels for suicide at baseline and at 12-week follow-up for total population.

<p>Number of students in different risk levels for suicide at baseline and at 12-week follow-up for total population.</p