Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However, existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs and feasibility of their use, for users and health care professionals. This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to moderate depression cases. The Preventing Depression and Improving Awareness through Networking in the European Union consortium undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions, with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized training program. Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool is accompanied by a 3-hour training intervention for health care professionals. It is intended that the iFightDepression tool and associated training for health care professionals will represent a valuable resource for the management of depression that will complement existing resources for health care professionals. It is also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to improving the care of depression and preventing suicidal behavior in Europe.

Objectives: Health care reform in Bulgaria has been ongoing for two decades. Since 1990, it has been transforming from a socialized system of medical care with free access, to one which is decentralized, includes private health care services, the general practitioner model and a National Health Insurance Fund. In this context, we are conducting an international EC Framework 7 project: ‘Improving quality and safety in the hospital: The link between organizational culture, burnout, and quality of care ’. We focus on health professionals’ perceptions of organizational hierarchies in Bulgarian hospitals and how doctors and nurses connect these to organizational justice. Methods: We conducted seven focus groups and four interviews, with a total of 42 participants (27 nurses, 15 physicians and medical residents) in three hospitals. Data were analysed through thematic analysis and discourse analysis with Atlas.ti. Results: From the perspective of health professionals, health reform has intensified traditional hierarchies and inequalities and has created new ones in Bulgarian hospitals. These hierarchies are continuously (re)constructed through language and practices and also destabilized through resistance. The health professionals protest fact that these hierarchies are permeated with unfairness and silence voices. All health professions (nurses, doctors, residents) in our study experience being unjustly positioned and disempowered in various hierarchies. They connect these experiences to stress and anxiety. Conclusions: Participatory action research needs to address multiple dimensions of organizational relationships in Bulgarian hospitals, including hierarchical relationships and ways of promoting organizational justice. Statement of Contribution: What is already known on this subject? Health care organizations are hierarchically organized. Organizational injustice can contribute to burnout in health professionals. There is a high level of stress and burnout for health professionals in Bulgaria. What does this study add? This study adds understanding of changing hierarchies in hospitals during health care reform in the post‐socialist period. Illuminates how health professionals' discourse sustains and resists hierarchical relationships in Bulgarian hospitals. Adds understanding of health professionals' perspectives on implications of injustice for their well‐being.

To investigate adolescents' perception of the impact of the COVID-19 pandemic on several aspects of their lives (mental health, well-being, family situation, peers, school, dieting, and physical activity) in relation to risk behaviors such as smoking, alcohol use, drunkenness, and cannabis use. Data were used from the Health Behaviour in School-aged Children (HBSC) study conducted in 2021/2022, comprising 106,221 adolescents aged 11-15 (50.9% females) from 21 European countries. The data analysis plan involved Multilevel Generalized Latent Class Analysis (GLCA) models, latent class membership, and substance use behaviors, with alcohol consumption, smoking, drunkenness, and cannabis use as distal outcomes. GLCA identified 14 % of the adolescents as negatively or very negatively impacted by the pandemic and 42 % with a positive or very positive impact. The remaining 44 % of adolescents were not attributed with either a negative or positive impact. In the first group, girls, older adolescents, and adolescents from less affluent families were overrepresented. The negatively impacted group was particularly prevalent (>25 %) in countries such as Hungary, Cyprus, Greece, and Poland. Negatively impacted adolescents exhibited a higher risk of smoking, drunkenness, and cannabis use compared to their peers in the positively impacted group after adjusting for sex, age, and family wealth. Results of the 2021/22 HBSC study highlighted an elevated level of substance use among adolescents who perceived a stronger negative impact of the COVID-19 pandemic on their lives. These findings indicate that the pandemic has put a particular strain on girls, older and less wealthy adolescents. They highlight the need for special attention and tailor-made interventions to deal with stressful future events that may impact on the life and mental health of these adolescents.