This exploratory study is the first to evaluate the acceptability and safety of a smartphone app (BlueIce) for university students who self-harm. Overall, the app was found to be acceptable and safe, as well as helpful for participants to manage their self-harm and promote behaviour beneficial to well-being. Safety was determined quantitatively, with no scores on well-being measures deteriorating over the period, and qualitatively, with participants reporting that BlueIce was safe to use and presented no risks to students. Similarly, no adverse events were reported by participants or well-being staff. However, some limitations of the app were also noted, such as the motivation required to engage with it.

Levels of anxiety and depression symptomatology within the sample were higher than have been found in clinical samples with similar age groups. For example, Bentley et al 40 found mean GAD-7 and PHQ-9 scores of 8.5 and 10.6, respectively, compared with 12.5 and 16.5 in the current sample. Interestingly, surveys of university students have found scores that are comparable to those found in non-student clinical populations; Akram et al 41 reported a mean GAD-7 score of 9.3 and a PHQ-9 score of 10.1 based on a sample of 1273 students. This endorses findings that university students are at a significantly heightened risk of struggling with mental health difficulties.2 42 In the baseline measures, all participants classed themselves as either having self-harmed within the past 2 months or as currently having thoughts of self-harm. Despite this, in the 2 weeks prior, very few had self-harmed or had thoughts of self-harming. This raises interesting questions regarding how individuals who self-harm perceive their self-harm status. Claréus et al 43 investigated this and identified that individuals typically perceive themselves as having stopped self-harming if they had done so few times within the past month or year. However, some participants still did identify as someone who self-harms despite not having self-harmed within the past year. Importantly, it was found that how individuals perceive their recovery is more important than the time that has elapsed since the last act of self-harm. This corroborates the importance of asking participants to self-identify their self-harm status, rather than presuming they no longer self-harm in accordance with a certain time frame.

The current sample scored lower on measures of coping self-efficacy at baseline than in other studies of university students who self-harm.35 It is important to acknowledge the context in which this research occurred, as the trial period was within a national lockdown due to the COVID-19 pandemic, in which everyone was encouraged to stay at home to stop the spread of the virus. Contact with anyone outside of the household was restricted. Consequently, many institutions closed, including universities, and most interaction had to occur in online spaces instead. This meant that university students were no longer attending in-person lectures, and the participants in this study were no longer attending in-person counselling sessions. This context may explain participants’ lower coping self-efficacy, as students may have had less access to resources that positively impacted their abilities to cope, such as social networks.44 A survey of 576 students did indeed find that the pandemic negatively impacted students’ mood and wellness,45 suggesting they may have been particularly vulnerable during this time.

Despite this sample comprising students who had all disclosed self-harm to a mental health professional, a quarter of participants in this study indicated that they usually do not tell anybody when they self-harm. This suggests that, even for this group who have disclosed self-harm to a mental health professional and volunteered for a research study regarding a self-harm intervention, discussing self-harm can still be challenging. Importantly, this sample seemed to struggle more with self-harm urges than self-harm behaviours, with 12 participants indicating that they had self-harmed either rarely or never within the past 2 weeks, but with two-thirds indicating that their urges to self-harm were strong. This reinforces the importance of measuring self-harm urges as well as behaviours, as they can be predictive of future self-harm and can still be very distressing for the individual.46 47 Moreover, a questionnaire completed by 1296 students found that self-harm thoughts alone are still able to allow the individual relief from difficult emotions.48

Generally, there was a high level of engagement with the app with several participants using it frequently, adding personalised content to the app, tracking their mood and using BlueIce in moments of distress. High levels of engagement with BlueIce have also been found in previous studies with adolescents.49 Despite the app originally being designed with and for adolescents, this did not seem to deter university students from engaging with it and finding it beneficial. Participants in this study typically praised the simplicity of the app and enjoyed the design, although some found the mood diary too simple to capture their experiences; this split in opinion replicates findings from the previous evaluation of the acceptability of BlueIce with university students.21 Nonetheless, those who did benefit from the mood diary discussed how it helped them to manage their emotions by providing an outlet for them through which they could get some relief from their difficult feelings, as well as being able to identify triggers for different moods. This mirrors findings from another study with young adults who self-harm, who found mood tracking via a smartphone app beneficial in managing emotions and identifying triggers.50 Participants in the current study also found it helpful being able to reflect on their mood in difficult moments, as well as more broadly in order to gain perspective and feel more optimistic by realising that they do have good days as well as bad. These qualitative findings resonate with the quantitative findings showing an increase in participants perceived self-efficacy in being able to stop unpleasant thoughts or emotions following the trial period, rated using the Coping Self-efficacy Scale.34 It may be that the techniques participants learnt to manage their emotions, promote positive well-being and to cope in alternative ways as opposed to self-harm, as discussed above, may have contributed to their heightened beliefs in their abilities to stop difficult thoughts and emotions.

Around half of the participants indicated that BlueIce had stopped them from harming themselves at certain points. While this is important, previous research with university students with lived experience of self-harm highlighted that relying on a reduction in self-harm behaviours is not necessarily the best way to measure the success of an intervention,51 preferring a more holistic and wider perspective that also considers their general well-being.52 In particular, university students who self-harm have emphasised wanting self-harm interventions to help them to learn more adaptive coping strategies and to address their broader mental health difficulties that are ‘triggers’ for their self-harm.13 80% of participants in the interviews discussed some positive impact of the app, including helping them to develop long-term, alternative coping strategies, and encouraging action that was beneficial for their well-being. As mentioned, participants’ perceived abilities to stop unpleasant thoughts and emotions also improved. Furthermore, participants in this study believed that BlueIce could help students struggling with a range of mental health difficulties, as well as typical university stressors such as exams. Overall, this would suggest that BlueIce typically aligned with university students’ favoured outcomes of interventions. However, one participant did specify that professional support is necessary for getting to the root of the issue behind their self-harm. This reinforces the heterogeneity surrounding preferences for support that has been found previously,13 53 54 emphasising the need to ensure university students are able to access a variety of resources and sources of support.

The function that BlueIce could provide was explored, with participants suggesting it could be a helpful adjunct to counselling that allowed users to log how they had been feeling inbetween sessions to relay back to their counsellor. Participants also discussed finding it helpful in moments of distress by reminding them of techniques to manage their emotions or distract themselves, without the user having to search for techniques themselves. The long-term impact was also discussed, with participants commenting on having a better understanding of their triggers and how to manage their emotions, without even having the app in front of them. This confirms the perception identified in a previous study investigating the acceptability of BlueIce with university students, where it was identified as a useful reminder of adaptive coping strategies in difficult moments, as well as a means of learning ways of processing emotions.21 This also reflects findings with adolescents who reported that BlueIce helped them to reframe difficult thoughts and provided a helpful distraction.20 This suggests that BlueIce could be a useful tool that is scalable, able to offer ‘out of hours’ support, can help students cope in difficult moments and reach more students who may be struggling with self-harm and feel unable to directly ask for help. Research into self-harm interventions in university settings is very limited, for example, Nawaz et al 55 found only two studies meeting this criteria, neither of which were found to be effective in reducing self-harm. More research is needed to establish the effectiveness of BlueIce, nevertheless, the current study identifies it as a valuable and acceptable tool for students.

First, participants in this study all used the app alongside counselling provided by the university well-being services. As such, it is not possible to directly attribute the improvements in participants’ well-being to either the counselling or the app. Similarly, participants were recruited from one university well-being service who had already sought help for their self-harm. These findings may not be representative of students attending other universities or those who self-harm but have not sought help. Similarly, the sample were demographically homogenous so these results may not generalise to students from other genders or ethnicities, for example. As BlueIce was found to be safe to use, future research should seek to assess the impact of implementing BlueIce more widely with students in the general university population.

Second, this was an exploratory open study with a small number of participants and as such data are limited and must be interpreted with caution. Challenges to recruitment were experienced including problems accessing students during the university summer break and the COVID-19 pandemic when students were not physically present on campus. In addition, to maximise student safety, we recruited participants through the university well-being services but this meant that we had no direct access to possible participants. Steps were taken to try and mitigate these challenges, such as drafting email templates and eligibility checklists to reduce staff burden, but recruitment remained limited. Consequently, future research would benefit from a large-scale study to determine the effectiveness of BlueIce in this population.

Finally, this research occurred during a period of national lockdown due to the COVID-19 pandemic. This could have affected our results which may be lacking temporal validity.