Effect of Internet-Delivered Emotion Regulation Individual Therapy for Adolescents With Nonsuicidal Self-Injury Disorder

Abstract

ImportanceNonsuicidal self-injury is prevalent in adolescence and associated with adverse clinical outcomes. Effective interventions that are brief, transportable, and scalable are lacking.ObjectiveTo test the hypotheses that an internet-delivered emotion regulation individual therapy for adolescents delivered adjunctive to treatment as usual is superior to treatment as usual only in reducing nonsuicidal self-injury and that improvements in emotion regulation mediate these treatment effects.Design, Setting, and ParticipantsThis 3-site, single-masked, randomized superiority trial enrolled participants from November 20, 2017, to April 9, 2020. Eligible participants were aged between 13 and 17 years and met diagnostic criteria for nonsuicidal self-injury disorder; they were enrolled as a mixed cohort of consecutive patients and volunteers. Parents participated in parallel to their children. The primary end point was at 1 month after treatment. Participants were followed up at 3 months posttreatment. Data collection ended in January 2021.InterventionsTwelve weeks of therapist-guided, internet-delivered emotion regulation individual therapy delivered adjunctive to treatment as usual vs treatment as usual only.Main Outcomes and MeasuresPrimary outcome was the youth version of the Deliberate Self-harm Inventory, both self-reported by participants prior to treatment, once every week during treatment, and for 4 weeks posttreatment, and clinician-rated by masked assessors prior to treatment and at 1 and 3 months posttreatment.ResultsA total of 166 adolescents (mean [SD] age, 15.0 [1.2] years; 154 [92.8%] female) were randomized to internet-delivered emotion regulation therapy plus treatment as usual (84 participants) or treatment as usual only (82 participants). The experimental intervention was superior to the control condition in reducing clinician-rated nonsuicidal self-injury (82% vs 47% reduction; incidence rate ratio, 0.34; 95% CI, 0.20-0.57) from pretreatment to 1-month posttreatment. These results were maintained at 3-month posttreatment. Improvements in emotion dysregulation mediated improvements in self-injury during treatment.Conclusions and RelevanceIn this randomized clinical trial, a 12-week, therapist-guided, internet-delivered emotion regulation therapy delivered adjunctive to treatment as usual was efficacious in reducing self-injury, and mediation analysis supported the theorized role of emotion regulation as the mechanism of change in this treatment. This treatment may increase availability of evidence-based psychological treatments for adolescents with nonsuicidal self-injury.Trial RegistrationClinicalTrials.gov Identifier: NCT03353961

Internet based intervention (Emotion Regulation Individual Therapy for Adolescents) as add‐on to treatment as usual versus treatment as usual for non‐suicidal self‐injury in adolescent outpatients: The TEENS randomised feasibility trial

“…However, to overcome potential bias we performed blinded outcome assessment as well as blinded statistical analyses by two independent statisticians including a consensus report and two abstracts for the steering committee to agree upon before performing the unblinding; all intentions in preparation for a large‐scale trial potentially at several sites with additional teams providing the ERITA intervention in other Danish regions to further improve the external validity. The findings of a full‐scale Swedish trial are currently under review (Bjureberg, J. et al., in review 2022 ). If evidence is provided for more benefits than harms of the ERITA therapy based on future large‐scale trials, this intervention could be considered in primary sectors and social services as up‐stream prevention in the early stages of NSSI.…”

“…The Swedish and Danish feasibility studies of the internet‐based intervention ERITA (J Bjureberg et al., 2018 ; Morthorst et al., 2021 ; Simonsson et al., 2021 ) plus the completed Swedish randomised, controlled trial (Bjureberg, J. 2022 in review) suggest that ERITA is worthy of further studies.…”

Should psychotherapists conduct visual assessments of nonsuicidal self-injury wounds?

“…Evidence-based treatments developed specifically for NSSI generally include those that target emotion regulation or differential reinforcement of alternative behaviors as mechanisms of change. Examples include Emotion Regulation Group Therapy (Gratz & Gunderson, 2006), Emotion Regulation Individual Therapy for Adolescents (Bjureberg et al, 2023), the Cutting Down Program (Kaess et al, 2020), the Treatment for Self-Injurious Behaviors (Andover et al, 2015), and a variety of digital interventions (Kruzan & Whitlock, 2023). Importantly, no treatments for NSSI include the visual examination of wounds.…”

The Global Prevalence of Nonsuicidal Self-Injury Among Adolescents

“…Third, implement evidence-based interventions using internet and media outlets for treatment of adolescents with NSSI. For example, researchers designed an internet-delivered emotion regulation individual therapy (IERITA) that treats NSSI by directly teaching and reinforcing adaptive ways to respond to emotions. Adolescents were given an online and asynchronous therapist to answer questions, engage with, and assist with problem solving (including homework assignments), supplemented by a mobile app.…”

“…Adolescents were given an online and asynchronous therapist to answer questions, engage with, and assist with problem solving (including homework assignments), supplemented by a mobile app. Compared to adolescents who had face-to-face contact with a community clinician (treatment as usual), adolescents with IERITA intervention experienced an 82% reduction in NSSI frequency (vs a 47% reduction in treatment as usual only) after 12 weeks of media-based treatment . Accessible media offers the potential to deliver evidence-based psychological treatments at low cost to adolescents with NSSI globally.…”