Promoting mental health among at-risk adolescents in Malaysia (MyHeRo): study protocol for a cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of a school-based intervention compared with study skills condition for adolescents identified as at risk for anxiety and depression.

Adolescent anxiety and depression are increasing in Malaysia, with rising suicidal behaviour rates particularly among those in deprived communities.

• The paper states that 'adolescent anxiety and depression are increasing faster than ever' in Malaysia.
• Rates of suicidal behaviour are described as rising especially among those living in deprived communities.
• Malaysia's mental health system is 'constrained by limited workforce capacity, affecting the delivery of effective interventions.'

The trial uses a two-arm cluster randomised controlled trial design comparing Super Skills for Life (SSL) to a Study Skills Programme (SSP) control condition.

• The design is a two-arm cluster RCT with a 1:1 allocation ratio.
• Classrooms will be the cluster unit for randomisation.
• Three stratification factors will be used: school size, classes/forms, and school location (urban vs rural).
• The study will recruit from at least 20 secondary schools in economically deprived, rural and urban regions in Malaysia.

Participants will be adolescents aged 12-14 years who screen positive for moderate to severe anxiety and depression on the DASS-21.

• Screening will use the Depression Anxiety and Stress Scale-21 (DASS-21).
• Based on power calculations, 428 adolescents (214 per arm) who experience moderate to severe levels of anxiety and depression will be invited to participate.
• Adolescents will be recruited from secondary schools in economically deprived rural and urban regions of Malaysia.

Assessments are planned at five time points spanning screening through 12 months post-intervention.

• Assessment will be conducted at screening, pre-intervention (baseline), post-intervention (2 months), and at two follow-ups (6 and 12 months post-intervention).
• Primary outcomes are reduction in anxiety and depressive symptoms and improvement in mental wellbeing at 12 months post-intervention.

The trial includes secondary aims to identify moderators of treatment response and contextual factors affecting implementation.

• The study aims to 'determine the characteristics of adolescents who benefit from SSL, compared to those who do not.'
• The study also aims to 'identify contextual factors related to the successful implementation of SSL in Malaysian schools.'
• The trial will generate 'new knowledge on the role of socio-cultural and other contextual factors in predicting intervention uptake and treatment outcome.'

The intervention (SSL) will be delivered by school staff rather than external mental health professionals.

• The trial is designed to determine 'if delivering a group school-based intervention by school staff for adolescents at risk of anxiety and depression is effective and cost-effective.'
• Findings will 'advance understanding of the role of school staff in the delivery of a school-based intervention.'
• This approach addresses the constraint of limited mental health workforce capacity in Malaysia.

The trial includes a cost-effectiveness evaluation alongside the clinical effectiveness assessment.

• Cost-effectiveness is listed as a co-primary aim alongside effectiveness in reducing anxiety and depression and improving mental wellbeing.
• The trial is registered on ClinicalTrials.gov (NCT07138664), registered on August 16, 2025.