Effects of a Mobile and Web App (Thought Spot) on Mental Health Help-Seeking Among College and University Students: Randomized Controlled Trial

Background Mental health disorders are the most prevalent health issues among postsecondary students, yet few solutions to this emerging crisis exist. While mobile health technologies are touted as promising solutions for the unmet mental health needs of these students, the efficacy of these tools remains unclear. In response to these gaps, this study evaluates Thought Spot, a mobile and web app created through participatory design research. Objective The goal of the research is to examine the impact of Thought Spot on mental health and wellness help-seeking intentions, behaviors, attitudes, self-stigma, and self-efficacy among postsecondary students in Canada. Methods A 2-armed randomized controlled trial involving students from three postsecondary institutions was conducted. Students were eligible if they were aged 17 to 29 years, enrolled in full-time or part-time studies, functionally competent in English, and had access to a compatible digital device. The usual care group received a mental health services information pamphlet. The intervention group received the Thought Spot app on their digital device. Thought Spot is a standalone app that allows users to add, review, and search crowdsourced information about nearby mental health and wellness services. Users can also track their mood on the app. Outcomes were self-assessed through questionnaires collected at baseline and 3 and 6 months. The primary outcome was change in formal help-seeking intentions from baseline to 6 months, measured by the General Help-Seeking Questionnaire. A mixed-effects model was used to compare the impact of usual care and intervention on the primary outcome (formal help-seeking intentions). Secondary outcomes included changes in informal help-seeking intentions and help-seeking behaviors, help-seeking attitudes, self-stigma, and self-efficacy. Results A total of 481 students were randomized into two groups: 240 to usual care, and 241 to the intervention group. There were no significant differences in help-seeking intentions between the usual care and intervention groups over 6 months (F2,877=0.85; P=.43, f=0.04). Both groups demonstrated similar increases in formal help-seeking intentions at 3 and 6 months (F2,877=23.52; P<.001, f=0.21). Compared with males, females sought more help from formal resources (OR 1.86; 95% CI 1.22 to 2.83, P=.001). Females were less likely to seek help from informal sources than males (OR 0.80; 95% CI 0.22 to 0.73, P<.001). Conclusions Prompting postsecondary students about mental health and help-seeking appears to increase help-seeking intentions. mHealth interventions may be as effective as information pamphlets in increasing formal help-seeking but may confer a small advantage in driving help-seeking from informal sources. Although there is enthusiasm, developers and health policy experts should exercise caution and thoroughly evaluate these types of digital tools. Future studies should explore the cost-effectiveness of digital interventions and develop strategies for improving their efficacy. Trial Registration ClinicalTrials.gov NCT03412461; https://clinicaltrials.gov/ct2/show/NCT03412461 International Registered Report Identifier (IRRID) RR2-10.2196/resprot.6446


1a-i) Identify the mode of delivery in the title
Identify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if offline products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms.
Does your paper address subitem 1a-i? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the title is "Effects of a 1a-ii) Non-web-based components or important co-interventions in title Mention non-web-based components or important co-interventions in title, if any (e.g., "with telephone support").
Does your paper address subitem 1a-ii?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This item is not applicable in this study. The app is a standalone intervention.

1a-iii) Primary condition or target group in the title
Mention primary condition or target group in the title, if any (e.g., "for children with Type I Diabetes") Example: A Web-based and Mobile Intervention with Telephone Support for Children with Type I Diabetes: Randomized Controlled Trial Does your paper address subitem 1a-iii? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Mental health help-seeking is the primary condition. College and university students is the target population. These are both stated in our manuscript title. Does your paper address subitem 1b-i? * Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Key features of the intervention and comparator are explained in the following way: "The usual care group received a mental health services information pamphlet. The intervention group received the Thought Spot application on their digital device. Thought Spot is a standalone application that allows users to add, review, and search crowd-sourced information about nearby mental health and wellness services. Users can also track their mood on the app." https://docs.google.com/forms/d/e/1FAIpQLSfZBSUp1bwOc_OimqcS64RdfIAFvmrTSkZQL2-3O8O9hrL5Sw/viewform?hl=en_US&formkey=dGlKd2Z2Q1lNS… 11/59 subitem not at all important 1 2 3 4 5 essential subitem not at all important 1 2 3 4 5 essential 1b-ii) Level of human involvement in the METHODS section of the ABSTRACT Clarify the level of human involvement in the abstract, e.g., use phrases like "fully automated" vs. "therapist/nurse/care provider/physician-assisted" (mention number and expertise of providers involved, if any). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-ii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Level of human involvement is described like this "Thought Spot is a standalone application that allows users to add, review, and search crowd-sourced information about nearby mental health and wellness services." 1b-iii) Open vs. closed, web-based (self-assessment) vs. face-to-face assessments in the METHODS section of the ABSTRACT Mention how participants were recruited (online vs. offline), e.g., from an open access website or from a clinic or a closed online user group (closed usergroup trial), and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment). Clearly say if outcomes were self-assessed through questionnaires (as common in web-based trials). Note: In traditional offline trials, an open trial (open-label trial) is a type of clinical trial in which both the researchers and participants know which treatment is being administered. To avoid confusion, use "blinded" or "unblinded" to indicated the level of blinding instead of "open", as "open" in web-based trials usually refers to "open access" (i.e. participants can self-enrol). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) https://docs.google.com/forms/d/e/1FAIpQLSfZBSUp1bwOc_OimqcS64RdfIAFvmrTSkZQL2-3O8O9hrL5Sw/viewform?hl=en_US&formkey=dGlKd2Z2Q1lNS… 12/59 subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 1b-iii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Outcomes were self-assessed through questionnaires. It is stated in the the abstract like this: "Outcomes were self-assessed through questionnaires collected at baseline, 3 and 6 months. " 1b-iv) RESULTS section in abstract must contain use data Report number of participants enrolled/assessed in each group, the use/uptake of the intervention (e.g., attrition/adherence metrics, use over time, number of logins etc.), in addition to primary/secondary outcomes. (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-iv?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Use data is mentioned in the results section of the manuscript but not in the abstract like this: "Of the 241 people randomized to the intervention group, 168 visited Thought Spot, resulting in 3,697 clicks recorded between March 2018 and June 2019. Overall, users viewed 190 "Spots," conducted 293 searches and created 74 "Thoughts." "Spots" are locations of mental health and wellness resources. "Thoughts" are users' personal journal entries on the app. Details of the user data will be published independently of these findings." Conclusions/Discussions in abstract for negative trials: Discuss the primary outcome -if the trial is negative (primary outcome not changed), and the intervention was not used, discuss whether negative results are attributable to lack of uptake and discuss reasons. (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-v?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Negative trial is explicitly stated: "Prompting postsecondary students about mental health and help-seeking appears to increase help-seeking intentions. mHealth interventions may be as effective as information pamphlets in increasing formal help-seeking but may confer a small advantage in driving help-seeking from informal sources. " Does your paper address subitem 2a-ii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Scientific background and rationale is explained like this: "Applying principles from participatory action and participatory design research, [25,26] the research team produced Thought Spot, a mHealth intervention co-created with transition-aged youth that aims to improve help-seeking behaviour related to mental health services for postsecondary settings. [27,28] Thought Spot serves as a map-based database (via a mobile app and website) that allows users to search and geo-locate health, mental health and wellness resources ( Figure 1). Additional features of the application include mood and thought tracking, bookmarking searched information, and reading reviews about nearby resources and services. Thought Spot users can also participate in crowdsourcing by adding new resources and writing reviews." Mental health information pamphlets were chosen as the comparator because they are the standard source of information about mental health information for students at colleges and universities. Does your paper address CONSORT subitem 2b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The objectives and hypotheses are described like this "Accordingly, the main objective of this RCT was to assess the impact of Thought Spot on intentions to seek formal help. The secondary objective was to examine the impact on intentions to seek help from informal sources, and on help-seeking behaviours, help-seeking attitudes, self-stigma and selfefficacy.
[17] The research team hypothesized that Thought Spot would be superior to school-specific mental health services information pamphlets in increasing formal helpseeking intentions." Does your paper address CONSORT subitem 3a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Trial Design is described like this: "The team conducted a two-armed, double-blinded RCT" Allocation Ratio is described like this: "Participants were randomly assigned, using a 1:1 allocation ratio, to either receive access to Thought Spot or to receive a school-specific mental health services information pamphlet. Randomization and allocation was performed using REDCap, a secure, browser-based, electronic data capture system.

4a) Eligibility criteria for participants
Does your paper address CONSORT subitem 3b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study There were no important changes to methods after trial commencements to report 3b-i) Bug fixes, Downtimes, Content Changes Bug fixes, Downtimes, Content Changes: ehealth systems are often dynamic systems. A description of changes to methods therefore also includes important changes made on the intervention or comparator during the trial (e.g., major bug fixes or changes in the functionality or content) (5-iii) and other "unexpected events" that may have influenced study design such as staff changes, system failures/downtimes, etc. [2].
Does your paper address subitem 3b-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Bug fixes, Downtimes, and Content Changes were explained like this "There were no changes to methods or major changes to the features and functionalities of the app. The app content on the app changed by design because participants could add their own crowdsourced information about mental health resources and services during the trial. There were multiple bug fixes to address usability issues related to the malfunctioning buttons, slowness of search features and login credentials not saving. There were no major downtimes during the study period." Does your paper address CONSORT subitem 4a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Eligibility Criteria is described like this: "Full-time and part-time students aged 17-29 years who were enrolled at any of the three postsecondary institutions, who were functionally competent in English and who had access to a digital device compatible with the intervention were eligible to participate in the study. Active suicidality was the sole exclusion criterion, but no participants met this criterion during the screening process"

4a-i) Computer / Internet literacy
Computer / Internet literacy is often an implicit "de facto" eligibility criterion -this should be explicitly clarified.
Does your paper address subitem 4a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Computer literacy was implied if they had access to a device that was compatible with Thought Spot. This is explained in the manuscript like this "Full-time and part-time students aged 17-29 years who were enrolled at any of the three postsecondary institutions, who were functionally competent in English and who had access to a digital device compatible with the intervention were eligible to participate in the study. " Open vs. closed, web-based vs. face-to-face assessments: Mention how participants were recruited (online vs. offline), e.g., from an open access website or from a clinic, and clarify if this was a purely webbased trial, or there were face-to-face components (as part of the intervention or for assessment), i.e., to what degree got the study team to know the participant. In online-only trials, clarify if participants were quasi-anonymous and whether having multiple identities was possible or whether technical or logistical measures (e.g., cookies, email confirmation, phone calls) were used to detect/prevent these.
Does your paper address subitem 4a-ii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The assessment process is explained like this "All participants were enrolled by EH. All authors were blind to the allocation except for JS, who oversaw the randomization process.
REDCap was configured to collect data through online questionnaires at baseline, 3 months and 6 months. We asked participants in both groups to use their intervention (Thought Spot or pamphlet) as needed over 6 months. Intervention group participants received detailed instructions via email on how to download and access the Thought Spot app on their personal electronic devices. Participants were also sent two study reminders, at 6 weeks and 18 weeks, in anticipation of the 3-month and 6-month questionnaires. At the end of the study, participants in the intervention group completed an adapted version of the Usefulness, Satisfaction, and Ease of Use (USE) questionnaire, [30] and were invited to participate in qualitative interviews to evaluate Thought Spot's usability and user experience."

4a-iii) Information giving during recruitment
Information given during recruitment. Specify how participants were briefed for recruitment and in the informed consent procedures (e.g., publish the informed consent documentation as appendix, see also item X26), as this information may have an effect on user self-selection, user expectation and may also bias results.

4b) Settings and locations where the data were collected
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 4a-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Recruitment procedures are described like this: "Participants were recruited through institutional and student-related listservs, bulletin boards, websites, social media and class presentations." and "Intervention group participants received detailed instructions via email on how to download and access the Thought Spot app on their personal electronic devices. Participants were also sent two study reminders, at 6 weeks and 18 weeks, in anticipation of the 3-month and 6-month questionnaires. " Does your paper address CONSORT subitem 4b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Setting and locations described like this: The team conducted a two-armed, double-blinded RCT using participants who were students at three postsecondary institutions in the Greater Toronto Area (University of Toronto, Ryerson University, George Brown College)

4b-i) Report if outcomes were (self-)assessed through online questionnaires
Clearly report if outcomes were (self-)assessed through online questionnaires (as common in web-based trials) or otherwise. subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 4b-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Outcomes were self-assessed through online questionnaires. This item is addressed like this in abstract and methods section: "Outcomes were self-assessed through questionnaires collected at baseline, 3 and 6 months." and "The primary outcome was a change in formal help-seeking intentions from baseline to 6 months, measured by the General Help Seeking Questionnaire (GHSQ Does your paper address subitem 4b-ii? Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Your answer 5) The interventions for each group with sufficient details to allow replication, including how and when they were actually administered subitem not at all important 1 2 3 4 5 essential subitem not at all important 1 2 3 4 5 essential 5-i) Mention names, credential, affiliations of the developers, sponsors, and owners Mention names, credential, affiliations of the developers, sponsors, and owners [6] (if authors/evaluators are owners or developer of the software, this needs to be declared in a "Conflict of interest" section or mentioned elsewhere in the manuscript).

Does your paper address subitem 5-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The developers are mentioned in the acknowledgments section like this: "QoC Health served as the software developers of the Thought Spot platform." and the funders of the project are mentioned in the acknowledgments section "QoC Health served as the software developers of the Thought Spot platform."

5-ii) Describe the history/development process
Describe the history/development process of the application and previous formative evaluations (e.g., focus groups, usability testing), as these will have an impact on adoption/use rates and help with interpreting results. subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 5-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study History/development process of the application is described like this in the introduction: "Applying principles from participatory action and participatory design research, [25,26] the research team produced Thought Spot, a mHealth intervention co-created with transitionaged youth that aims to improve help-seeking behaviour related to mental health services for postsecondary settings. [27,28]" Additionally, refer to other previously published manuscripts which detail the development process:

5-iii) Revisions and updating
Revisions and updating. Clearly mention the date and/or version number of the application/intervention (and comparator, if applicable) evaluated, or describe whether the intervention underwent major changes during the evaluation process, or whether the development and/or content was "frozen" during the trial.
Describe dynamic components such as news feeds or changing content which may have an impact on the replicability of the intervention (for unexpected events see item 3b). Does your paper address subitem 5-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Your answer

5-iv) Quality assurance methods
Provide information on quality assurance methods to ensure accuracy and quality of information provided [1], if applicable.
Does your paper address subitem 5-iv?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Quality assurance was conducted through three ways. The research team did our best to validate the content of the app prior to the RCT, which was performed by JS. Additionally, the research team held workshops with students to curate and validate mental health and wellness resources that were included in Thought Spot. The workshops are detailed in a previously published article: -v) Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing flowcharts of the algorithms used Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing flowcharts of the algorithms used. Replicability (i.e., other researchers should in principle be able to replicate the study) is a hallmark of scientific reporting.

Does your paper address subitem 5-v?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Your answer

5-vi) Digital preservation
Digital preservation: Provide the URL of the application, but as the intervention is likely to change or disappear over the course of the years; also make sure the intervention is archived (Internet Archive, webcitation.org, and/or publishing the source code or screenshots/videos alongside the article). As pages behind login screens cannot be archived, consider creating demo pages which are accessible without login.

Does your paper address subitem 5-vi?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Your answer

5-vii) Access
Access: Describe how participants accessed the application, in what setting/context, if they had to pay (or were paid) or not, whether they had to be a member of specific group. If known, describe how participants obtained "access to the platform and Internet" [1]. To ensure access for editors/reviewers/readers, consider to provide a "backdoor" login account or demo mode for reviewers/readers to explore the application (also important for archiving purposes, see vi).
Does your paper address subitem 5-vii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Participants were only given access to the application if they were assigned to the intervention group. Each participant in the intervention group was given unique login information and instructions on how to download and use the application. Does your paper address subitem 5-viii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The mode of delivery/features/functionalities/components of the intervention are described in the following way: "Applying principles from participatory action and participatory design research, [25,26] the research team produced Thought Spot, a mHealth intervention co-created with transitionaged youth that aims to improve help-seeking behaviour related to mental health services for postsecondary settings. [27,28] Thought Spot serves as a map-based database (via a mobile app and website) that allows users to search and geo-locate health, mental health and wellness resources (Figure 1). Additional features of the application include mood and thought tracking, bookmarking searched information, and reading reviews about nearby resources and services. Thought Spot users can also participate in crowdsourcing by adding new resources and writing reviews. "

5-ix) Describe use parameters
Describe use parameters (e.g., intended "doses" and optimal timing for use). Clarify what instructions or recommendations were given to the user, e.g., regarding timing, frequency, heaviness of use, if any, or was the intervention used ad libitum.

Does your paper address subitem 5-ix?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The use parameters are described like this in the manuscript "We asked participants in both groups to use their intervention (Thought Spot or pamphlet) as needed over 6 months. Intervention group participants received detailed instructions via email on how to download and access the Thought Spot app on their personal electronic devices.

5-x) Clarify the level of human involvement
Clarify the level of human involvement (care providers or health professionals, also technical assistance) in the e-intervention or as co-intervention (detail number and expertise of professionals involved, if any, as well as "type of assistance offered, the timing and frequency of the support, how it is initiated, and the medium by which the assistance is delivered". It may be necessary to distinguish between the level of human involvement required for the trial, and the level of human involvement required for a routine application outside of a RCT setting (discuss under item 21 -generalizability).

Does your paper address subitem 5-x?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The intervention was intended to be a standalone app and not a co-intervention with care providers or health professionals. Thus, the involvement of care providers and health professionals was minimal.

5-xi) Report any prompts/reminders used
Report any prompts/reminders used: Clarify if there were prompts (letters, emails, phone calls, SMS) to use the application, what triggered them, frequency etc. It may be necessary to distinguish between the level of prompts/reminders required for the trial, and the level of prompts/reminders for a routine application outside of a RCT setting (discuss under item 21 -generalizability). subitem not at all important 1 2 3 4 5 essential 6a) Completely defined pre-specified primary and secondary outcome measures, including how and when they were assessed Does your paper address subitem 5-xi? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study There were two study reminders sent to participants, which are described in the manuscript like this: "Participants were also sent two study reminders, at 6 weeks and 18 weeks, in anticipation of the 3-month and 6-month questionnaires."

5-xii) Describe any co-interventions (incl. training/support)
Describe any co-interventions (incl. training/support): Clearly state any interventions that are provided in addition to the targeted eHealth intervention, as ehealth intervention may not be designed as stand-alone intervention. This includes training sessions and support [1]. It may be necessary to distinguish between the level of training required for the trial, and the level of training for a routine application outside of a RCT setting (discuss under item 21 -generalizability. Does your paper address subitem 5-xii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study There were no co-interventions that were provided in addition to the targeted eHealth intervention. subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 6a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The primary and secondary outcomes are described in the manuscript like this: "The primary outcome was a change in formal help-seeking intentions from baseline to 6 months, measured by the General Help Seeking Questionnaire (GHSQ 6a-ii) Describe whether and how "use" (including intensity of use/dosage) was defined/measured/monitored Describe whether and how "use" (including intensity of use/dosage) was defined/measured/monitored (logins, logfile analysis, etc.). Use/adoption metrics are important process outcomes that should be reported in any ehealth trial.
Does your paper address subitem 6a-ii?

Copy and paste relevant sections from manuscript text
This item is important and usage data was monitored and analyzed. A high-level overview of usage data is stated in the manuscript like this "Of the 241 people randomized to the intervention group, 168 visited Thought Spot, resulting in 3,697 clicks recorded between March 2018 and June 2019. Overall, users viewed 190 "Spots," conducted 293 searches and created 74 "Thoughts." "Spots" are locations of mental health and wellness resources. "Thoughts" are users' personal journal entries on the app. Details of the user data will be published independently of these findings." An in-depth analysis was also performed on the usage data, but the detailed findings of this analysis will be reported in a separate manuscript.

6a-iii) Describe whether, how, and when qualitative feedback from participants was obtained
Describe whether, how, and when qualitative feedback from participants was obtained (e.g., through emails, feedback forms, interviews, focus groups).
6b) Any changes to trial outcomes after the trial commenced, with reasons 7a) How sample size was determined NPT: When applicable, details of whether and how the clustering by care provides or centers was addressed subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 6a-iii?
Copy and paste relevant sections from manuscript text Qualitative feedback was collected in the following way: "At the end of the study, participants in the intervention group completed an adapted version of the Usefulness, Satisfaction, and Ease of Use (USE) questionnaire, [30] and were invited to participate in qualitative interviews to evaluate Thought Spot's usability and user experience." Does your paper address CONSORT subitem 6b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study There were no changes to trial outcomes after the trial commenced 7a-i) Describe whether and how expected attrition was taken into account when calculating the sample size Describe whether and how expected attrition was taken into account when calculating the sample size.
7b) When applicable, explanation of any interim analyses and stopping guidelines 8a) Method used to generate the random allocation sequence NPT: When applicable, how care providers were allocated to each trial group Does your paper address subitem 7a-i?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Sample size was calculated in the following way: "To determine the required sample size, power calculations were conducted using the primary outcome -the average formal help-seeking score on the GHSQ.
[27] Monte Carlo simulations were conducted in SAS 9.4 (Windows) using the means, standard deviation and within-subject associations reported in previous research using the GHSQ.
[35, 36] The calculation accounted for a 40% dropout rate and assumed the use of a mixed-effects model to test the primary hypothesis at a significance level of 0.05 (two-tailed). A sample of 472 participants (236 per arm) was found to provide 80% power to detect a small effect size (Cohen's d=0.25), which is equivalent to a 15% difference in change in GHSQ score from baseline to 6 months." Does your paper address CONSORT subitem 7b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Not Applicable 8b) Type of randomisation; details of any restriction (such as blocking and block size) 9) Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned Does your paper address CONSORT subitem 8a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The randomization method is described in the following way: "Randomization and allocation was performed using REDCap, a secure, browser-based, electronic data capture system.
[29] A randomization module within REDCap provided computer-generated random allocation of participants in blocks of 10." Does your paper address CONSORT subitem 8b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The type of randomization and block size is described like this: "Randomization and allocation was performed using REDCap, a secure, browser-based, electronic data capture system.
[29] A randomization module within REDCap provided computer-generated random allocation of participants in blocks of 10" 10) Who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions 11a) If done, who was blinded after assignment to interventions (for example, participants, care providers, those assessing outcomes) and how NPT: Whether or not administering co-interventions were blinded to group assignment Does your paper address CONSORT subitem 9? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Mechanism used to implement random allocation sequence is described below: Randomization and allocation was performed using REDCap, a secure, browser-based, electronic data capture system.
[29] A randomization module within REDCap provided computer-generated random allocation of participants in blocks of 10. All participants were enrolled by EH. All authors were blind to the allocation except for JS, who oversaw the randomization process.
Does your paper address CONSORT subitem 10? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This CONSORT sub-item is described in the manuscript like this: "A randomization module within REDCap provided computer-generated random allocation of participants in blocks of 10. All participants were enrolled by EH. All authors were blind to the allocation except for JS, who oversaw the randomization process. " subitem not at all important 1 2 3 4 5 essential subitem not at all important 1 2 3 4 5 essential 11a-i) Specify who was blinded, and who wasn't Specify who was blinded, and who wasn't. Usually, in web-based trials it is not possible to blind the participants [1, 3] (this should be clearly acknowledged), but it may be possible to blind outcome assessors, those doing data analysis or those administering co-interventions (if any).
Does your paper address subitem 11a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Blinded individuals are described in the following ways: "All authors were blind to the allocation except for JS, who oversaw the randomization process." and "Statistical analysis was performed by a biostatistician (MS) who was blinded to randomization." 11a-ii) Discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator" Informed consent procedures (4a-ii) can create biases and certain expectations -discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator".

11b) If relevant, description of the similarity of interventions
(this item is usually not relevant for ehealth trials as it refers to similarity of a placebo or sham intervention to a active medication/intervention) 12a) Statistical methods used to compare groups for primary and secondary outcomes NPT: When applicable, details of whether and how the clustering by care providers or centers was addressed Does your paper address subitem 11a-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This item is addressed like this: ". Group assignment could not be blinded for participants." Does your paper address CONSORT subitem 11b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study N/A Does your paper address CONSORT subitem 12a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Primary and Secondary outcomes were analyzed using the following statistical methods detailed in the manuscript: "Univariate analyses were conducted to describe groups at baseline (Table 1) and to compare completers and non-completers of the questionnaires. Completers were defined as participants who finished the survey at all three points of the study.
[27] To evaluate the primary hypothesis, the research team used mixed-effects models, using the intention-totreat method, where time, group and gender were entered as fixed effects and participants were entered as random effects. A linear contrast of estimated marginal means from the fixed-effect interaction between time and group was conducted to compare changes from baseline to 6 months across groups. Missing values were handled by maximum likelihood estimation, which is able to incorporate all available information in the data, under the missing at random assumptions.
[37] The team conducted sensitivity analyses, in which we added model variables found to have significant bivariate associations with dropouts, defined as participants who were randomized but who did not complete all 3 surveys, at a significance level of α=0.20. " "Similar models were conducted to explore the secondary outcomes of this study, except for help-seeking behaviour. This outcome was measured using the binary-scaled AHSQ and was analysed using a mixed binomial logistic regression model. The p-values for the secondary analysis were not adjusted for multiple comparison. "

12a-i) Imputation techniques to deal with attrition / missing values
Imputation techniques to deal with attrition / missing values: Not all participants will use the intervention/comparator as intended and attrition is typically high in ehealth trials. Specify how participants who did not use the application or dropped out from the trial were treated in the statistical analysis (a complete case analysis is strongly discouraged, and simple imputation techniques such as LOCF may also be problematic [4]). Does your paper address subitem 12a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Missing values procedures were handled using the following method: "Missing values were handled by maximum likelihood estimation, which is able to incorporate all available information in the data, under the missing at random assumptions. [37]" Does your paper address CONSORT subitem 12b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Methods for secondary analyses and per-protocol analyses are stated like this in the manuscript: "In addition to the prespecified analysis plan, the research team conducted an exploratory per-protocol analysis of the primary and secondary outcomes. Participants who logged onto Thought Spot more than once for the duration of the study were considered compliant." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study REB Approval is described in the methods section like this: "The protocol was approved by the research ethics boards of each participating postsecondary institution and the Centre for Addiction and Mental Health and is detailed in Supplement 1. Digital informed consent was obtained from each participant through REDCap before participants could be included in the trial. [29]"

x26-ii) Outline informed consent procedures
Outline informed consent procedures e.g., if consent was obtained offline or online (how? Checkbox, etc.?), and what information was provided (see 4a-ii). See [6] for some items to be included in informed consent documents.

Does your paper address subitem X26-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Informed consent procedures are described like this: "Digital informed consent was obtained from each participant through REDCap before participants could be included in the trial. [29]"

RESULTS
13a) For each group, the numbers of participants who were randomly assigned, received intended treatment, and were analysed for the primary outcome NPT: The number of care providers or centers performing the intervention in each group and the number of patients treated by each care provider in each center

X26-iii) Safety and security procedures
Safety and security procedures, incl. privacy considerations, and any steps taken to reduce the likelihood or detection of harm (e.g., education and training, availability of a hotline) Does your paper address subitem X26-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Active suicidality was the sole exclusion criterion, and the safety and security procedures for this exclusion criteria is described in Multi-media Appendix 2 like this: "If a participant indicated active suicidality within the past month, an automated process was triggered: the next set of questions was temporarily withheld and the participant received an email that offered access to a clinical team member for support and listed crisis numbers. If the participant did not contact research staff within three days, the surveys were re-started and the participant could proceed with the next step of the study. If the participant did contact the research team for support, suspension from the study continued until the participant was assessed by a clinical research team member. " 13b) For each group, losses and exclusions after randomisation, together with reasons subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 13a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The number of participants who were randomly assigned, received intended treatment, and were analyzed for the primary outcome are listed in Table 1. Baseline Characteristics of Participants Who Underwent Randomization Does your paper address CONSORT subitem 13b? (NOTE: Preferably, this is shown in a CONSORT flow diagram) * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Figure 2 of the manuscript is the CONSORT flow diagram.

13b-i) Attrition diagram
Strongly recommended: An attrition diagram (e.g., proportion of participants still logging in or using the intervention/comparator in each group plotted over time, similar to a survival curve) or other figures or tables demonstrating usage/dose/engagement. Does your paper address subitem 13b-i?
Copy and paste relevant sections from the manuscript or cite the figure number if applicable (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The attrition information is important. However, we will be reporting this information separately. In this paper Of the 241 people randomized to the intervention group, 168 visited Thought Spot, resulting in 3,697 clicks recorded between March 2018 and June 2019. Overall, users viewed 190 "Spots," conducted 293 searches and created 74 "Thoughts." "Spots" are locations of mental health and wellness resources. "Thoughts" are users' personal journal entries on the app. Details of the user data will be published independently of these findings.
Does your paper address CONSORT subitem 14a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The recruitment process is described like this: "From March 2018 to January 2019, 481 were randomized participants from three Canadian postsecondary institutions into a 6-month trial on a rolling basis. Of these participants, 240 were assigned to the control group and 241 were assigned to the intervention group ( Figure 2). The trial ended after all participants received their 6-month follow-up on June 30, 2019. "

14a-i) Indicate if critical "secular events" fell into the study period
Indicate if critical "secular events" fell into the study period, e.g., significant changes in Internet resources available or "changes in computer hardware or Internet delivery resources" 14b) Why the trial ended or was stopped (early) 15) A table showing baseline demographic and clinical characteristics for each group NPT: When applicable, a description of care providers (case volume, qualification, expertise, etc.) and centers (volume) in each group Does your paper address subitem 14a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study

Your answer
Does your paper address CONSORT subitem 14b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This consort item is addressed like this: "). The trial ended after all participants received their 6-month follow-up on June 30, 2019. " Does your paper address CONSORT subitem 15? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Demographics are reported in Table 1 of the manuscript.

16-i) Report multiple "denominators" and provide definitions
Report multiple "denominators" and provide definitions: Report N's (and effect sizes) "across a range of study participation [and use] thresholds" [1], e.g., N exposed, N consented, N used more than x times, N used more than y weeks, N participants "used" the intervention/comparator at specific pre-defined time points of interest (in absolute and relative numbers per group). Always clearly define "use" of the intervention. Does your paper address subitem 16-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The definition of "use" is stated in the manuscript like this: "Participants who logged onto Thought Spot more than once for the duration of the study were considered compliant. " The number of participants (denominator) included in each analysis are detailed in results and in Table 2: Main Results from Mixed Models. It is described like this: "240 were assigned to the control group and 241 were assigned to the intervention group".
For the per-protocol analysis. the number of participants (denominator) included in the analysis is stated like this "Of the 241 participants in the intervention group, 169 (70.1%) met the definition of compliance."

16-ii) Primary analysis should be intent-to-treat
Primary analysis should be intent-to-treat, secondary analyses could include comparing only "users", with the appropriate caveats that this is no longer a randomized sample (see 18-i).

Does your paper address subitem 16-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Primary analysis is based on intent-to-treat, as stated in Multimedia Appendix 1, page 17 like this: "Intention-to-treat analysis will be used; all participants will be analyzed as they were originally allocated after randomization" 17a) For each primary and secondary outcome, results for each group, and the estimated effect size and its precision (such as 95% confidence interval) subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 17a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Results of each primary and secondary outcome, the estimated effect size and it's precision is included in Table 2 Main Results from Mixed Models (AHSQ)

17a-i) Presentation of process outcomes such as metrics of use and intensity of use
In addition to primary/secondary (clinical) outcomes, the presentation of process outcomes such as metrics of use and intensity of use (dose, exposure) and their operational definitions is critical. This does not only refer to metrics of attrition (13-b) (often a binary variable), but also to more continuous exposure metrics such as "average session length". These must be accompanied by a technical description how a metric like a "session" is defined (e.g., timeout after idle time) [1] (report under item 6a).
17b) For binary outcomes, presentation of both absolute and relative effect sizes is recommended 18) Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing pre-specified from exploratory Does your paper address subitem 17a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This item is important and usage data was monitored and analyzed. A high-level overview of usage data is stated in the manuscript like this "Of the 241 people randomized to the intervention group, 168 visited Thought Spot, resulting in 3,697 clicks recorded between March 2018 and June 2019. Overall, users viewed 190 "Spots," conducted 293 searches and created 74 "Thoughts." "Spots" are locations of mental health and wellness resources. "Thoughts" are users' personal journal entries on the app. Details of the user data will be published independently of these findings." An in-depth analysis was also performed on the usage data, but the detailed findings of this analysis will be reported in a separate manuscript.
Does your paper address CONSORT subitem 17b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, absolute and relative effect sizes are reported as both absolute and relative effect sizes, like in Table 2  Does your paper address CONSORT subitem 18? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Secondary Analyses and per-protocol analyses are reported. Per-protocol analyses were exploratory, as stated in the methods section "In addition to the prespecified analysis plan, the research team conducted an exploratory per-protocol analysis of the primary and secondary outcomes."

18-i) Subgroup analysis of comparing only users
A subgroup analysis of comparing only users is not uncommon in ehealth trials, but if done, it must be stressed that this is a self-selected sample and no longer an unbiased sample from a randomized trial (see 16-iii).
Does your paper address subitem 18-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We conducted a per-protocol analysis Harms and unintended effects are described like this in the manuscript: "There were no reported adverse events or harms during the trial."

19-i) Include privacy breaches, technical problems
Include privacy breaches, technical problems. This does not only include physical "harm" to participants, but also incidents such as perceived or real privacy breaches [1], technical problems, and other unexpected/unintended incidents. "Unintended effects" also includes unintended positive effects [2].

Does your paper address subitem 19-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The technical problems encountered by participants are described like this: "There were multiple bug fixes to address usability issues, such as malfunctioning buttons, slowness of search features and login credentials not saving. There were no major downtimes during the study period." There were no privacy breaches or privacy-related issues that occurred during the study subitem not at all important

Does your paper address subitem 19-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Qualitative feedback from the study participants were analyzed separately and will be reported separately.
22-i) Restate study questions and summarize the answers suggested by the data, starting with primary outcomes and process outcomes (use) Restate study questions and summarize the answers suggested by the data, starting with primary outcomes and process outcomes (use). Does your paper address subitem 22-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Study question and summary of answers suggested by the data is described like this: " In the analysis of our primary outcome, there were no significant differences in the formal help-seeking intentions of postsecondary students between control and intervention groups. However, both groups experienced a similar increase in formal help-seeking intentions during the 6-month study period, as assessed by the GHSQ. " and "Analyses of secondary outcomes revealed no significant group-by-time interactions for help-seeking intentions from informal sources, attitudes toward seeking professional help, self-efficacy, or self-stigma. However, a small increase in help-seeking behaviour related to informal sources between 3 and 6 months was observed with the intervention group, whereas a small decrease was seen in the control group.

22-ii) Highlight unanswered new questions, suggest future research
Highlight unanswered new questions, suggest future research.

Does your paper address subitem 22-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Future research is suggested in the conclusions: "It is increasingly important as a next step to compare the cost-effectiveness of Thought Spot and information pamphlets for understanding the feasibility and sustainability of mHealth tools compared with existing strategies"

20-i) Typical limitations in ehealth trials
Typical limitations in ehealth trials: Participants in ehealth trials are rarely blinded. Ehealth trials often look at a multiplicity of outcomes, increasing risk for a Type I error. Discuss biases due to non-use of the intervention/usability issues, biases through informed consent procedures, unexpected events.
Does your paper address subitem 20-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The study limitations are described like this: "The study had some limitations. Group assignment could not be blinded for participants. There were also software bugs that led to an inconsistent app environment and to usability issues during the trial. These issues could have affected the level of user engagement and compliance with the intervention, and ultimately the effectiveness of Thought Spot because some participants had difficulty accessing key functions of the app during certain points of the trial. Additionally, the effect size for the change in informal help-seeking behaviour was small and was noted only in the 3-to 6-month period. Further investigation and a longer follow-up period are required to evaluate the sustained impact of mHealth solutions on informal help-seeking. Finally, the development of Thought Spot and the findings from this trial are based on the unique experiences of transition-aged youth enrolled in Canadian postsecondary institutions and may not be generalizable to youth outside Canadian academic settings."

21-i) Generalizability to other populations
Generalizability to other populations: In particular, discuss generalizability to a general Internet population, outside of a RCT setting, and general patient population, including applicability of the study results for other organizations Does your paper address subitem 21-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Limits to the generalizability of this study is stated in the manuscript like this: "Finally, the development of Thought Spot and the findings from this trial are based on the unique experiences of transition-aged youth enrolled in Canadian postsecondary institutions and may not be generalizable to youth outside Canadian academic settings."

21-ii) Discuss if there were elements in the RCT that would be different in a routine application setting
Discuss if there were elements in the RCT that would be different in a routine application setting (e.g., prompts/reminders, more human involvement, training sessions or other co-interventions) and what impact the omission of these elements could have on use, adoption, or outcomes if the intervention is applied outside of a RCT setting.

OTHER INFORMATION
23) Registration number and name of trial registry 24) Where the full trial protocol can be accessed, if available Does your paper address subitem 21-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The key difference between the study and routine application setting would be access. During the study, the participants were given login credentials access by the research team after they consent and randomization procedures. However, in routine settings, a user will be able to freely download the application through the App Store or Google Play store without engaging our research team.
Does your paper address CONSORT subitem 23? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, Registration number and name of trial registry are listed like this in the abstract: "The trial is registered under the ClinicalTrials.gov number, NCT03412461" Does your paper address CONSORT subitem 24? * Cite a Multimedia Appendix, other reference, or copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, Full trial protocol and changes are included in Multimedia Appendix 1 25) Sources of funding and other support (such as supply of drugs), role of funders

X27) Conflicts of Interest (not a CONSORT item)
subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 25? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The sources of funding and other supports are described: "This project was supported by eHealth Innovation Partnership Program (eHIPP) grant from the Canadian Institute for Health Research (EH1-143558). The Canadian Institute for Health Research was not involved in the study design, data analysis, data interpretation, and writing of the report."

X27-i) State the relation of the study team towards the system being evaluated
In addition to the usual declaration of interests (financial or otherwise), also state the relation of the study team towards the system being evaluated, i.e., state if the authors/evaluators are distinct from or identical with the developers/sponsors of the intervention.