Review Reports

Round 1

Reviewer 1 Report

I would like to thank you for the honor of me reviewing the article titled “Evaluating a smartphone app for university students who self-harm”. I'm of the opinion that it's helpful. and of great academic value. In coming up with an application to help students with mental health, however, I have a few questions to clarify the author's response:

- use of applications mental health help Developed to save university students from being harassed or have a single approach. Or should the expert personnel be found as well or not, together with it, it is appropriate

- University student self-harm It's a high risk. Should the application have an additional warning system linked to help?

- Flowchart shown lacks standardization in design writing appropriately could be improved If it can be improved

- Preliminary results are satisfactory. However, it is expected that this study will be conducted in the next phase. The use of RCTs will be a good confirmation of the validity of the research.

- Any further suggestions from this report?

Thank you very much,

I hope this event will be of great help to university students.

Author Response

I would like to thank you for the honor of me reviewing the article titled “Evaluating a smartphone app for university students who self-harm”. I'm of the opinion that it's helpful. and of great academic value. In coming up with an application to help students with mental health, however, I have a few questions to clarify the author's response:

Thank you for your kind feedback and helpful suggestions.

- use of applications mental health help Developed to save university students from being harassed or have a single approach. Or should the expert personnel be found as well or not, together with it, it is appropriate

There is evidence from students that they believe the app can be used as a standalone intervention or alongside counselling, which has now been discussed in lines 63-65.

- University student self-harm It's a high risk. Should the application have an additional warning system linked to help?

Students who self-harm are a high risk population, and within the app there are links to helplines if the user indicates they are at risk of self-harming. This has now been discussed in lines 68-69.

- Flowchart shown lacks standardization in design writing appropriately could be improved If it can be improved

Thank you for pointing this out, we have now standardised the style in accordance with Cochrane guidelines.

- Preliminary results are satisfactory. However, it is expected that this study will be conducted in the next phase. The use of RCTs will be a good confirmation of the validity of the research.

The authors agree, thank you.

- Any further suggestions from this report?

In accordance with yours and the other reviewers feedback, some extra comments have been included in the manuscript.

Thank you very much,

I hope this event will be of great help to university students.

Reviewer 2 Report

Dear Editor,

Thank you for the opportunity to review this manuscript - digital health interventions are a promising solution to the increasingly growing concerns around mental health among young people. The paper is very well written, cites recent literature, clearly describes the methodology and the results of the trial. There are few areas of improvement as described below that the authors may like to incorporate:

a. In the background section, it would useful to include some more perspective on importance and prevalence of self-harm than just mental health in general. For example, definition of SH that has been used in context of this project will be helpful to clearly interpret the study findings

b. The authors have noted a surge in digital health interventions to address various barriers in accessing traditional treatment pathways. In this context, it would be useful to understand what features of BlueIce distinguish it from other digital apps 

c. Were there any conflicts of interest if the recruited students were from the same university/department as the researchers? How was it managed?

d. References 20 and 21 highlight that BlueIce can be a promising intervention for this group, however, this study noted a huge drop-out rate and no significant change in SH acts. It would be interesting to note if authors were expecting these findings. If not, what were the possible reasons specific to the app which could have attributed to these findings?

e. Results: Did the authors explore an association between change in coping strategy to reduction in self-harm urges/actions? 

f. Can the authors please describe their future plans with this app especially in terms of content and intervention plan?

Author Response

Thank you for the opportunity to review this manuscript - digital health interventions are a promising solution to the increasingly growing concerns around mental health among young people. The paper is very well written, cites recent literature, clearly describes the methodology and the results of the trial. There are few areas of improvement as described below that the authors may like to incorporate:

Thank you for your kind feedback and helpful suggestions.

1. In the background section, it would useful to include some more perspective on importance and prevalence of self-harm than just mental health in general. For example, definition of SH that has been used in context of this project will be helpful to clearly interpret the study findings

Thank you for this helpful suggestion, the definition of self-harm has now been included in line 30 and more information regarding the prevalence of self-harm has been added to lines 31-33.

1. The authors have noted a surge in digital health interventions to address various barriers in accessing traditional treatment pathways. In this context, it would be useful to understand what features of BlueIce distinguish it from other digital apps 

Some of the unique features of BlueIce have now been discussed in lines 63-68, including the personalisation capabilities, anonymity, and the comprehensive toolbox.

1. Were there any conflicts of interest if the recruited students were from the same university/department as the researchers? How was it managed?

This was managed as the study was anonymous, so no participant was known to the researchers despite being from the same university. As the aim of this research was to offer a source of support to students specifically at this university, this was unavoidable.

1. References 20 and 21 highlight that BlueIce can be a promising intervention for this group, however, this study noted a huge drop-out rate and no significant change in SH acts. It would be interesting to note if authors were expecting these findings. If not, what were the possible reasons specific to the app which could have attributed to these findings?

This is now discussed in more detail in lines 261-265 and 344 – 349. In brief, these findings were somewhat expected due to high rates of attrition generally in digital intervention and self-harm research – arguably resulting from the heterogeneity of self-harm and preferences for interventions. Also, we know that changes in self-harm behaviours are not a priority for students, instead they prioritise feeling able to cope and developing skills.

1. Results: Did the authors explore an association between change in coping strategy to reduction in self-harm urges/actions? 

Thank you for this suggestion, we have explored but there was no association. It may be that the sample size was not sufficient for these analyses to be powered.

1. Can the authors please describe their future plans with this app especially in terms of content and intervention plan?

The app will soon be made widely available, which has now been mentioned in lines 366-367. There are no plans or opportunities to change the content.

Round 2

Reviewer 2 Report

The revised version is fine now.