Internet-Delivered Emotion Regulation Therapy Reduces Self-Harm Frequency in Swedish Teens

A 12-week internet-delivered emotional regulation therapy intervention successfully reduced non-suicidal self-injury (NSSI) among teens ages 13-17 years compared to usual treatment, according to findings published in JAMA Network Open.

"One way to treat NSSI more effectively is to target key mechanisms underlying NSSI," they wrote. "Emotion regulation has been identified as one of the most relevant mechanisms underlying this behavior, and a key mechanism of change in NSSI interventions. Open trial data provide support for the utility of a 12-week internet-delivered emotion regulation individual therapy for adolescents (IERITA) in the treatment of NSSI. Not only does this treatment aim to improve NSSI by directly targeting its underlying mechanism of emotion dysregulation, internet-delivered treatments with minimal clinician support have the potential to augment community therapy and increase availability of specialized psychological treatments."

Bjureberg and colleagues conducted the current study—which, to their knowledge, is the first randomized clinical trial of internet-delivered treatment for adolescents with NSSI disorder (NSSID)—to assess the efficacy of therapist-guided IERITA delivered alongside treatment as usual (TAU) versus TAU alone, as well as to examine emotion regulation as a mechanism of change in this intervention.

They found that IERITA plus TAU "resulted in greater improvements in NSSI frequency (both self-reported and assessor-rated) and emotion dysregulation from pretreatment to 1-month post-treatment than TAU only. Results also revealed superior effects of IERITA plus TAU (versus TAU only) on global functioning and other self-destructive behaviors, with between-group effect sizes in the moderate range. Notably, treatment effects were maintained at 3-month post-treatment, suggesting durability of effects. Finally, week-to-week improvements in emotion dysregulation mediated week-to-week reductions in NSSI frequency in IERITA, providing further support for the theoretical framework underlying this treatment."

For this three-site, single-masked, randomized superiority trial, Bjureberg et al recruited adolescents ages 13-17 years from within the Child and Adolescent Mental Health Services (CAMHS) in Stockholm, Västra Götaland, and Skåne, Sweden, from Nov. 20, 2017, through April 9, 2020. Teens were included if they met diagnostic criteria for NSSID, experienced one or more NSSI episode in the past month, and had one guardian who could participate in the parent portion of the IERITA program. Patients were excluded if they had immediate suicide risk, a diagnosis of psychotic or bipolar I disorder or ongoing substance use disorder, other primary psychiatric disorders requiring immediate treatment, life circumstances that might prevent treatment participation, or a clinician-assessed global functioning level corresponding to a Children’s Global Assessment Scale (CGAS) score below 40.

Eligible participants were randomized to either IERITA plus TAU or TAU only.

"IERITA is a web-based, acceptance-based behavioral treatment that includes 11 modules for the adolescent participant and six modules for the parents delivered over the course of 12 weeks," the study authors explained. "The modules include text, animations, and interactive scripts. The treatment on which IERITA is based, emotion regulation group therapy, was designed to treat NSSI by directly targeting its theorized underlying mechanism of emotion dysregulation. Thus, treatment modules aim to teach participants more adaptive ways of responding to their emotions. A dedicated therapist (psychologist or psychotherapist) provided asynchronous online contact with both adolescent and parent (separately) via a message function in the platform. The therapist reinforced treatment engagement, answered questions, and assisted with homework assignments and problem solving. A mobile app was used to complement the adolescents’ internet-delivered treatment modules."

TAU consisted of supportive therapy sessions every 2 weeks, along with weekly self-rated assessments and as-needed follow-up from the research team.

The study’s primary outcome was self-reported and clinician-rated NSSI frequency, as measured by the youth version of the Deliberate Self Harm Inventory (DSHI-Y). The self-reported version was administered pre-treatment, once per week during the treatment period, and for 1 month post-treatment, while the clinician-rated version was administered at pre-treatment, 1-month post-treatment, and 3-months post-treatment.

Secondary outcomes included clinician-rated assessment of global functioning (CGAS) and adolescent-reported emotion dysregulation (Difficulties in Emotion Regulation Scale [DERS]), self-destructive behaviors (Borderline Symptom List [BSL]), and psychiatric symptoms (Depression, Anxiety, and Stress Scales [DASS-21]).

A total of 166 participants (mean age, 15 years; 92.8% girls) were randomized to IERTA plus TAU (n=84) or TAU only (n=82). Of these, 12 patients—five in IERITA plus TAU, seven in TAU alone—dropped out of treatment, with the majority dropping out between the first and sixth week.

Among the findings:

• Ratings of treatment credibility, expectancy, and satisfaction with IERITA were moderate to high; adolescents completed a mean of 9.6 modules out of 11, and parents completed a mean of 5.5 out of 6. Mean therapist time for IERITA intervention was 378.8 minutes per family.
• Reductions in self-reported NSSI frequency were larger for the IERITA plus TAU group versus TAU only from pre-treatment to 1-month post-treatment (β [SE], −0.08 [0.02]; P<0.001; IRR, 0.29; 95% CI, 0.14-0.58); participants who received IERITA reported a 68% reduction in NSSI frequency (IRR, 0.32; 95% CI, 0.17-0.6) from pre-ttreatment to 1-month post-treatment, while patients in the TAU only group did not see any improvement (IRR, 1.11; 95% CI, 0.62-1.99).
• "IERITA plus TAU led to greater reductions than TAU only in assessor-rated NSSI (DSHI-Y) (β [SE], −1.09 [0.27]; P<0.001; IRR, 0.34; 95% CI, 0.20-0.57). At 1-month posttreatment, participants in IERITA evidenced an 82% reduction in NSSI frequency (IRR, 0.18; 95% CI, 0.09-0.36), whereas those in TAU only evidenced a 47% reduction (IRR, 0.53; 95% CI, 0.26-1.07). At 3-month posttreatment, IERITA plus TAU still showed a superior reduction in NSSI frequency than TAU only (β [SE], −0.62 [0.29]; P=0.04; IRR, 0.54; 95% CI, 0.30-0.96)."
• Patients receiving INERITA plus TAU also had larger improvements in self-reported emotion dysregulation (DERS: d=0.52; 95% CI, 0.14-0.89), self-reported self-destructive behaviors (BSL-Supplement: IRR, 0.46; 95% CI, 0.28-0.77), and assessor-rated global functioning (CGAS: d=0.43; 95% CI, 0.10-0.79) at 1-month post-treatment, as well as 3-month post-treatment (DERS: d=0.41, 95% CI, 0.09-0.73; BSL-Supplement: IRR, 0.54; 95% CI, 0.33-0.87; CGAS: d=0.48; 95% CI, 0.13-0.87); there were "no statistically significant differences between the conditions in psychiatric symptoms (DASS-21) at 1-month or 3-month post-treatment."

That psychiatric symptoms did not differ significantly, Bjureberg and colleagues argued, suggests "that IERITA results in improvements in emotion dysregulation and global functioning despite comparable levels of depression and anxiety (relative to TAU). These findings are consistent with the emphasis in IERITA on the acceptance of internal experiences and control of behaviors in the context of emotional distress (vs the control or downregulation of emotions themselves), and suggest that targeting emotion regulation may not be sufficient for the treatment of anxiety and depression among adolescents."

Limitations of the study cited by researchers included that "the lack of equipoise between conditions precludes any conclusions regarding the specific effects of IERITA or mechanistic claims of the intervention," that not receiving IERITA may be equivalent to a nocebo condition, that potential posttreatments were not assessed, that most patients were clinician-referred, the inclusion of mostly girls, missing data, and the failure to include a threshold for clinical significance.

This study was supported by the Swedish Research Council, Markus and Amelia Wallenberg Foundation, Fredrik and Ingrid Thuring’s Foundation, Clas Groschinsky’s Foundation, Sven Jerring Foundation, Kempe-Carlgrenska Foundation, and Bror Gadelius Foundation, as well as the National Self Injury Project in Sweden.

Bjureberg reported receiving book royalties from Natur & Kultur.

Bjureberg J, et al "Effect of internet-delivered emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: A randomized clinical trial" JAMA Netw Open 2023; 6(7): e2322069. DOI: 10.1001/jamanetworkopen.2023.22069.