COMET; Student Mental Health and Single-Session Interventions

For this podcast, we are joined by Dr. Maria Loades, clinical psychologist and senior lecturer at the Department of Psychology at the University of Bath.

The focus of this podcast is on the Common Elements Toolbox (COMET), a study testing a digital intervention to help university students improve their wellbeing.

To set the scene, Maria provides us with an insight into what the COMET programme entails and describes some of the specific interventions that are being tested.

With the programme targeted at students, Maria details why she has chosen to focus on this particular demographic and discusses student mental health as well as the impact that the pandemic has had on students entering university.

As COMET was originally developed in the US, Maria shares what is already known about the COMET intervention from the USA, plus comments on the difference between COMET GB and COMET US, including adaptations to account for cultural differences.

Furthermore, Maria talks to us about the online survey itself, who the participants are, how they are recruiting participants, how many participants are needed, plus the timescale.

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Dr. Maria Loades is a Senior Lecturer/Clinical Tutor for the Doctorate in Clinical Psychology programme at the University of Bath. She is a qualified Clinical Psychologist, working in a variety of mental health settings, including adult mental health, a children’s inpatient unit, and various community CAMHS. She has a post-graduate diploma in CBT for children, young people and families from the Anna Freud Centre/University College London, and a Postgraduate Certificate in the Supervision of Applied Psychology Practice at the University of Oxford. She secured an NIHR doctoral research fellowship in 2016 to further her research into depression in paediatric Chronic Fatigue Syndrome at the University of Bristol, and the Paediatric CFS team at the Royal United Hospital in Bath. Her research interests include: developing and delivering CBT for children and young people with depression, including those with chronic illnesses, therapist competence in delivering CBT, particularly in the field of child and adolescent mental health, and CBT supervision.

Follow on Twitter @MariaLoades

Transcript:

[00:32] Jo Carlowe: Hello. Welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I am interviewing Dr. Maria Loades, clinical psychologist and senior lecturer at the Department of Psychology at the University of Bath. In today’s podcast we’ll focus on COMET, a study testing a digital intervention to help college students improve their well-being.

If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review, and do share with friends and colleagues. Maria, welcome. Can you start by introducing yourself?

Dr. Maria Loades: Hi, Jo. Sure. And thank you so much first for having me back again. As you said, I’m a clinical psychologist by training, and I have a particular interest in young people’s mental health. So as a clinical tutor and lecturer at the University of Bath, I help to train our clinical psychologists of the future. And in my research, I’m really particularly interested in how we can develop brief, scalable interventions to help young people with their mood and any struggles they’re having with their well-being as early as possible before the problems escalate.

[01:59] Jo Carlowe: Which brings us to COMET. What does COMET stand for, and what does the program entail?

Dr. Maria Loades: Yeah, absolutely. So COMET is exactly an example of this. And COMET stands for the Common Elements Toolbox. So it’s an online, single-session intervention without any therapist contact. So it’s self-help, essentially, and takes less than an hour to complete. The real advantage of it is that it can be done anonymously from anywhere, any device with an internet connection. So it could be on a computer, on a tablet, or on a smartphone. It doesn’t require you to download anything. We all know how easy it is to download those apps and never open them again. And it also does not presume that you’ll come back again. So it’s designed to be a one-shot intervention. The key ingredients, the things that we think are going to make a difference are within that one session. And they’re based on evidence-based, non-stigmatizing concepts, like cognitive restructuring, so helping us to think differently and in more helpful ways, on behaviour activation, so doing more of what really matters to you, and on gratitude of noticing the positives and the good things in our lives, and celebrating those rather than just noticing and attending to the negatives or the struggles.

[03:41] Jo Carlowe: Can you describe some of the specific interventions that are being tested?

Dr. Maria Loades: Absolutely, of course. So we’re testing COMET as the single-session intervention, which is divided within the single sitting into three different modules, essentially. So in the flexible thinking section, people learn to identify and to reframe their negative thoughts. And we do this by first having them read about a hypothetical character, who is busy adjusting to changes in their routine, for instance. And then using that character’s story as a kind of case example, we ask them to identify the negative thoughts that the character may be having and ways that they think the character could reframe or rethink those negative thoughts. And we then invite them to apply this kind of technique to a situation that might be relevant to them in their own lives. So that’s the thinking section. Then there’s the positive activities section where we ask people to identify and reflect on activities that are personally enjoyable, meaningful, and important to them. And once they’ve reflected on why these activities are important, why they matter to them, we get them to make a plan for how they’re going to engage in these activities in the weeks ahead. And then part two is the bit about gratitude. And it really asks people to think about things that they are grateful for and enjoy, and just spend a bit of time noticing and reflecting on those. And essentially, we’re interested in whether doing that, all three of those bits as a single-session COMET toolbox is better than not doing anything specific at all. So in other words, anyone who takes part in our study will be randomly allocated either to getting COMET right away, or after they’ve waited a month and filled out some questionnaires for us. So we’re looking at after a month, if you’ve had COMET, are you doing relatively better than you were compared to people who didn’t have COMET till the end of the month?

[06:16] Jo Carlowe: As you said, the program is targeted at students. What can you tell us about student mental health and why you have chosen to focus on this particular demographic?

Dr. Maria Loades: Yeah, gosh, that’s a really interesting question. And for anyone who knows me, they know that my research normally focuses on teenagers, adolescents, who are high school age rather than university students. But during the pandemic, I was very active in looking at the mental health impacts of loneliness in children and young people, including into early adulthood. And of course, I previously talked to you about this on a podcast, Jo. And really, as a result of some of that work, I was invited by colleagues here at the University of Bath working in the student support services to talk to them about what we knew from the research evidence emerging in the pandemic about how young people’s lives and their well-being had been affected by the pandemic. And the reason why they wanted to know that was because they wanted to be best prepared for the new incoming university students who had finished school during the pandemic and really recognizing that those students may have different needs and really different experiences than those who had arrived at university pre-pandemic. So they might have missed out on those rites of passage of final exams and proms. And they might not have been interacting very much in real life with other young people, for instance. They might have not had opportunities to go on gap years in the same way, et cetera. So in really exploring the evidence with them, and discussing it, and presenting it to them, my awareness of how difficult the pandemic has been for young people at this transition age to university was really heightened.

And beyond that, I became more acutely aware of how much university student well-being was affected by the pandemic, whether they were just starting university or wherever they were at in their university studies. So we know from studies of university students across the globe that, actually, in the pandemic times, at least a third, if not more, are struggling with pretty significant symptoms of depression and/or anxiety. It makes sense, of course, given how much they’ve been impacted. They’ve been transitioned to online learning. They’ve been in cramped quarters where they’re isolated from peers, maybe sitting in their bedroom all day following along to online lectures or in a bubble where they are constrained. We’ve seen the pictures on the news about when accommodation blocks were locked down and all of these things. And then, of course, there’s isolation from peers, but also the financial consequences. And I think students have been hit particularly hard, because students often rely on those transient part-time roles to earn money to pay their way through university, like hospitality jobs. And those dried up, didn’t they? It’s been a really tough time for students. But students were also saying they just weren’t able to access support early and when they needed it. There was greater need, and capacity was the same or even less than normal. So there’s been this real gaping hole between needs and access.

And I’ve been really finding out more about single-session interventions. And again, these have previously featured in one of your podcasts from the real pioneer of these for youth mental health in the USA as Jessica Schleider. And at around the time I listened to the podcast by Jessica, I also found out about COMET, which is one of these single-session interventions and developed specifically for college students, as they call them in the States, university students here. And I thought, wow, well, this could be a solution. In addition to all the great things our student services already offer, wouldn’t it be great if we had this online, free to access, single-shot source of support that someone could access anonymously without having to go to anyone to ask for help that just might help them to boost their well-being? So essentially, that’s where I came from in why I wanted to focus on this.

[10:47] Jo Carlowe: Great. And as you’ve said, COMET was originally developed in the US. So Maria, what is already known about the COMET intervention from the USA?

Dr. Maria Loades: This was really led to by Akash Wasil from the University of Pennsylvania, who developed a COMET. And I have to give a big shout out to him, because the innovation here is really his. And he developed it along the lines of the interventions Jessica Schleider has developed. And I know he does collaborate with Jessica and her team as well. So he first developed a version of COMET for teenagers in India, and then pivoted that in the pandemic context for students at universities in the USA. And from his work, we know that these previous versions in India and in the USA have been found to be acceptable and useful. So postgraduate students in the USA reported pre to post COMET improvements in secondary control.

Now, that means they were more accepting of the circumstances they were in. So that improved as a result of taking part in COMET. There were also improvements that they reported in the perceived negative impact of the pandemic on their lives. And in undergraduate students in the USA, there is evidence that COMET resulted in improvements in their depression symptoms at both four week and 12 week follow ups. So from this single shot that takes less than an hour to do, they were seeing reductions in depressive symptoms at four weeks, or a month, and three months later. Of course, that latter work in undergraduates is yet to be published. But what was really important to me in bringing this to the UK is there really didn’t seem to be anything like this available here in the UK.

So I really wanted to think, OK, well, this is showing promise in the USA. Can we bring it here? Can it be of benefit? Can we get it out there to people in the UK, and figure out if it works, and if it does, make it available wherever possible?

[13:02] Jo Carlowe: So the project has now joined with the University of Bath as well as the University of Pennsylvania. Are COMET GB and COMET US the same, or has the program been adapted to account for cultural differences?

Dr. Maria Loades: Yes, I should say, we’ve also got a number of other UK based university collaborators on board. So I do need to give a big shout out to them too. So that includes Stella Chan, who’s recruiting at the University of Reading, and Victoria Pile at KCL, Lucy Robinson up at Newcastle, Arif Mahmud at University of Roehampton, and others. So we’re trying to get this out as widely as possible across the UK. But essentially, when we were planning the study last summer, what I did was to seek input from my young person’s advisory group members, who steer all the research that me and my group do here at Bath. And one of our advisory members in particular went through the USA version of the COMET program and gave us feedback about what adaptations they thought we needed to make it fit the UK context. So these were things like language. So in the US, we talk of college students where, in the UK, we talk of university students. In the US, we talk of soccer. In the UK, we talk of football. So those kinds of things. But what we didn’t do was make any substantial changes to the content itself, given that our aim here is to test the UK version of COMET rather than a novel intervention which is based on COMET, but different from it. So that was really what we were doing was adapting it to make it culturally fit without changing what we thought were the core elements, let’s say. And our advisory group really also helped us to spot ways in which the questions we asked for research purposes to collect our research data needed to be reworded for the UK.

So for example, in the USA version of the trials, of course, the ethnicity categories were ones that were appropriate in the UK context, including things like people from Hawaii, for instance, where the ethnic categories commonly used in England would look different to that. So the content hasn’t been substantially adapted, although we have tweaked it for the GB version.

[15:37] Jo Carlowe: Tell us more about the online survey itself. Who are the participants? How are you recruiting them? How many participants are needed? And what’s the timescale?

Dr. Maria Loades: We’ve been recruiting any UK university student. So by this, I do mean any university in the UK, any course, whether it’s undergraduate, whether it’s postgraduate, whether it’s Masters, whether it’s doctoral, whether it’s PhD, so any UK university student. We started recruiting last October, and we plan to continue recruiting until the end of September this year, so basically for the whole year, starting at the beginning of the academic year last October. And we’re aiming to recruit at least 400 students. And so far, we’ve recruited just a bit over half of that. And anyone can find out more and sign up right away. So I’m sure we can put the link to that in your show notes. But it’s bit.ly/comet-gb. And so all the information about how to sign up is there. And the students either get to access COMET straightaway, or they fill out some questionnaires for us now, and again in a month, and then get access to COMET GB. So either way, they get to use this, either now or after waiting for a month.

[17:04] Jo Carlowe: And are there any interim results that you can share with us?

Dr. Maria Loades: So it is a little too early to have anything to share at this stage, but it would be absolutely wonderful to come back and tell you about all our findings down the line. But I guess, for now, Jo, we’re keen to get the word out there so that any student who wants to sign up and try out COMET GB can. And that will help us not only to know if it works, but it could also really help them with their well-being. And we know that well-being impacts on academic achievement. So we know that students are very motivated by getting higher grades. So here’s the plug from me. Spending an hour on well-being could boost your grades. It’s not a wasted hour of revision. It’s an hour towards improving your grades.

[17:55] Jo Carlowe: It’s a really important message. I’ll pass the information onto my daughter who is exactly in the sweet spot of the age affected by the pandemic. She just started her second year at university. Maria, what else feels important to mention with regards to this study?

Dr. Maria Loades: I think there are three things additional I’d like to add in. So one, in case students need any more persuasion and motivation to sign up, we’ve got a prize draw also for a number of 50 pound Amazon vouchers. So if you take part, you can have a chance of winning one of those. As I alluded to earlier, it’s really important to acknowledge how much this is a shared endeavour. And there are many colleagues working with me on this. So there’s Akash and the team at University of Pennsylvania, but here in the UK too across several universities, including some Masters students and PhD students who are working with me on this. So like all research, I think it’s really important to acknowledge that it’s always a team effort.

And thirdly, I think it’s really important to say that I see single-session interventions like COMET as only one part of the solution. I think they’re a good addition, but not a replacement for anything else that we have. They may actually even help people to come forward for other sources of help sooner. And they may help people who would never otherwise come forward for help to get some evidence-based help. But we really do need studies like this to figure out how best to use them, for whom, and when, and to continue to explore what gets in the way of using them. For instance, we recognize that actually what we haven’t done here in COMET GB that could really do as a follow-on study is think about how we simplify things like the language and text density for people who might struggle with reading. So we know that, for particular groups, we might need adapted versions. And I think that’s a real direction for the future. So I think single-session interventions are only one part of the solution. Great as an addition, but not meant to replace anything else like traditional student services support that offer things like counselling, longer term therapy, evidence-based therapies, like cognitive behaviour therapy, et cetera.

[20:22] Jo Carlowe: Is there a danger in terms of funding or resources that, if you emphasize the success of single-session interventions, that people could pull the plug from other services?

Dr. Maria Loades: I think there’s always that danger when we are promoting brief, scalable interventions that commissioners see it as an opportunity to offer only the lowest common denominator, as it were. And I’m really passionate about ensuring that this is part of a package of care. Different people need different things at different times. And we need to have a whole host of choices in terms of what’s on offer, and for whom, and at what time. What I think COMET and other single-session approaches do really well is they provide something that’s based on evidence-based principles, right now, anonymously, in the moment when you need it. But that absolutely doesn’t do away with the place there is for longer term therapies. I’m trained as a clinical psychologist, and I train other clinical psychologists. So of course, I’m also invested in the human presence in the therapeutic encounter, the need for much more personalized and individualized approaches where there’s a listening ear and a trained expert therapist providing that space for a young person to work through, developing a shared understanding, et cetera. So Jo, I think it’s always a risk, but I’m really clear whenever I talk about these single-session interventions that they’re one part of a bigger picture.

[22:02] Jo Carlowe: I’m wondering, do the people that access these kind of single-session interventions, perhaps, they are people that you wouldn’t previously have reached?

Dr. Maria Loades: Definitely. Yeah, so what Jessica Schleider’s found in her work with teenagers in the USA is that the people who sign up for her interventions are a much more diverse group than those we traditionally see in clinic-based and community-based services. So we know, for instance, that we don’t see population representative proportions of minority ethnic groups coming forwards for traditional services. We see disproportionately white populations accessing our services. Actually, in Jessica’s trials, she’s recruited a much more population-congruent representation of different minoritized and stigmatized groups, including both ethnic groupings, but also a high proportion of LGBTQ+ young people. So we do think that these could– especially because they are provided anonymously– be better at reaching communities who are currently underserved by our mental health services. So I do think that’s a real advantage. But what we also see is that, actually, it might encourage them, when you follow them up over time, to seek further help. So it might help them to feel they can reach out to someone for further help down the line, which is a great outcome, actually. If we can get people asking for help sooner, and if we can have help available in a more timely manner, then we’ve really started to address that needs access gap.

[23:54] Jo Carlowe: Absolutely. Maria, is there anything else in the pipeline that you’d like to mention?

Dr. Maria Loades: Yeah, so going forward, I’m planning to apply for funding here in the UK to test these online single-session interventions that they’ve developed in Jessica Schneider’s lab in the USA for teenagers here in the UK to see if they work in terms of reducing adolescent depression symptoms when offered at that early stage and as an anonymous, online, free to access intervention. So I’m really excited to see how this progresses, and really thereby enable young people and students alike to get that access to evidence-based help quickly when they need it and, hopefully, get them seeking more help sooner if they do need something else as well.

[24:47] Jo Carlowe: Great. And finally, Maria, what is your take-home message for those listening to our conversation?

Dr. Maria Loades: I think my take-home message overall is, it’s never too early to look for help with your mental health. If you are struggling in any way, then reach out. Online single sessions have the advantages of being anonymous and available at any time from any place you have an internet connection. But of course, that’s not for everyone. And we need that whole menu of options with a kind of no wrong door approach. Anywhere you ask for help should be able to offer it. So there’s loads of work for us to do as researchers working together with practitioners, with service commissioners, with young people themselves to improve on what’s available and to ensure that we build better, and more responsive, and more relevant services so that when you take that step to reach out, you find what you’re looking for.

[25:44] Jo Carlowe: Wonderful. Maria, thank you so much for speaking to me today. For more details on Dr. Maria Loades, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review, and do share with friends and colleagues.