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Psychological treatments targeting emotion dysregulation in adolescents reduce nonsuicidal self-injury (NSSI) but predicting treatment outcome remains difficult. Identifying sub-groups based on repeated measurements of emotion dysregulation pre-treatment may guide personalized treatment recommendations. We used data from a recent trial evaluating internet-delivered emotion regulation therapy for adolescents with NSSI ( n  = 138). Latent profile analysis was used to identify sub-groups based on pre-treatment responses on the 16-item version of the Difficulties in Emotion Regulation Scale. The primary outcome was self-rated NSSI frequency during treatment, and secondary outcome was the proportion of participants with no NSSI 1-month post-treatment. Three sub-groups of emotion dysregulation were identified: low variability and low mean (Group 1), low variability and high mean (Group 2), and high variability and low mean (Group 3). Sub-groups did not differ in NSSI frequency during treatment (Group 2 IRR = 1.06 [95% CI 0.49-2.29], p  = .88; Group 3 IRR = 1.22 [95% CI 0.31-4.76], p  = .77). However, more participants in Group 1 compared to Group 2 abstained from NSSI at 1-month post-treatment (OR = 3.63 [95% CI 1.16-11.33], p  = 0.01). Latent profile analysis identified sub-groups predictive of NSSI absence post-treatment, demonstrating clinical utility. more...

Depression is one of the most common psychiatric conditions. Given its high prevalence and disease burden, accurate diagnostic procedures and valid instruments are warranted to identify those in need of treatment. The Patient Health Questionnaire-9 (PHQ-9) is one of the most widely used self-report measures of depression, and its validity and reliability has been evaluated in several languages. However, the Swedish translation has yet not been subject to psychometric evaluation, and no previous psychometric evaluation of the instrument have used both Rasch analysis and classic test theory. The aim of this study was to investigate validity and reliability of the PHQ-9 in a Swedish sample of individuals with self-reported current or past mental health problems using Rasch analysis and confirmatory factor analysis. A sample of 4958 participants was recruited from an online survey covering different aspects of covid-19 and mental health targeted towards individuals with mental health problems. Results showed that a one-factor solution fit the data after removing one item and that some items had a different response pattern for older respondents. Furthermore, after removing item 2 and merging the two middle response categories for item 9, the Swedish translation of PHQ-9 showed adequate psychometric properties. The findings suggests that the Swedish translation of PHQ-9 may need to be adapted in order to make adequate interpretations of an individual score and to differentiate between populations. Further tests of its validity and reliability in other Swedish samples are needed to fully understand the properties of the Swedish version of PHQ-9., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Swedish Ethical Review Authority (Dnr 2020–02798 and 2021 − 00521) and all participants provided informed consent. Consent for publication: All of the authors have provided consent to submit manuscript. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).) more...

Background: Nonsuicidal self-injury is a common health problem in adolescents and associated with future suicidal behavior. Predicting who will benefit from treatment is an urgent and a critical first step towards personalized treatment approaches. Machine-learning algorithms have been proposed as techniques that might outperform clinicians' judgment. The aim of this study was to explore clinician predictions of which adolescents would abstain from nonsuicidal self-injury after treatment as well as how these predictions match machine-learning algorithm predictions., Methods: Data from a recent trial evaluating an internet-delivered emotion regulation therapy for adolescents with nonsuicidal self-injury was used. Clinician predictions of which patients would abstain from nonsuicidal self-injury (measured using the youth version of Deliberate Self-harm Inventory) were compared to a random forest model trained on the same available data from baseline assessments., Results: Both clinician (accuracy = 0.63) and model-based (accuracy = 0.67) predictions achieved significantly better accuracy than a model that classified all patients as reaching NSSI remission (accuracy = 0.49 [95% CI 0.41 to 0.58]), however there was no statistically significant difference between them. Adding clinician predictions to the random forest model did not improve accuracy. Emotion dysregulation was identified as the most important predictor of nonsuicidal self-injury absence., Conclusions: Preliminary findings indicate comparable prediction accuracy between clinicians and a machine-learning algorithm in the psychological treatment of nonsuicidal self-injury in youth. As both prediction approaches achieved modest accuracy, the current results indicate the need for further research to enhance the predictive power of machine-learning algorithms. Machine learning model indicated that emotion dysregulation may be of importance in treatment planning, information that was not available from clinician predictions., Trial Registration: NCT03353961|| https://www., Clinicaltrials: gov/ , registered 2017-11-21. Preregistration at Open Science Framework: https://osf.io/vym96/ ., Competing Interests: Declarations. Ethics approval and consent to participate: The trial was approved by the Stockholm Regional Ethical Review Board (no. 2017/1807–31). All participants provided informed consent, with older participants providing written consent and younger participants verbal consent with parental written consent. Consent for publication: Not applicable. Competing interests: Dr Flygare has received speaking fees from the Swedish OCD Association, Insight Events AB, WeMind AB, and Kry International AB, as well as reimbursement for writing articles for Inside Practice Psychiatry, all outside the submitted work. Dr Bjureberg receives royalties from Natur & Kultur, outside the submitted work. The other authors declare no potential conflicts of interest., (© 2024. The Author(s).) more...

Background: Individuals reporting self-injury are at greater risk of several adverse outcomes, including suicide. There is reason to be concerned how these individuals cope when stressful life events increase. This study aimed to investigate the trajectories of anxiety and depressive symptoms and the predictive value of self-injury history in individuals with psychiatric symptoms during the unique and stressful conditions of the COVID-19 pandemic., Methods: In a longitudinal population cohort study (N = 1810) ranging from 2020 to 2022, anxiety (measured by Generalized Anxiety Disorder, GAD-7) and depressive symptoms (measured by Patient Health Questionnaire, PHQ-9) were self-reported monthly during 12 months. Latent growth curve models with and without self-reported self-injury history as predictors were conducted., Results: Overall, anxiety and depressive symptoms decreased from baseline, but remained at moderate severity at follow-up. Individuals reporting suicidal or nonsuicidal self-injury reported significantly higher symptom severity at baseline. In addition, individuals reporting suicidal self-injury demonstrated a slower rate of decline in the symptom load over the course of 12 months., Conclusions: Over the course of 12 months, anxiety and depressive symptoms decreased in individuals with psychiatric symptoms, but still indicate a psychiatric burden. Individuals with a history of self-injury could be more vulnerable in face of stressful conditions such as those experienced during the COVID-19 pandemic., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ojala et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.) more...

Objectives: We explore adolescents' and their parents' experiences of internet-based emotion regulation therapy for non-suicidal self-injury (NSSI)., Design: A qualitative study nested within a controlled feasibility trial., Methods: Online, semi-structured focus group interviews were conducted with outpatient adolescents with NSSI aged 13-17 years (n = 9) and their parents (n = 8) who had received therapist-guided Internet-delivered Emotion Regulation Individual Therapy for Adolescents (IERITA). Transcripts were analysed using reflexive thematic analysis., Results: Three main themes were generated: (1) Fatigue - barriers to and during treatment, comprised of two sub-themes 'Arriving to services exhausted, needing motivation, and leaving feeling abandoned' and 'the burden of IERITA and the consequences of fatigue', (2) inter- and intrapersonal insights as facilitators of change and (3) Online, written contact with the therapist is beneficial and contributes with less pressure, comprised of three sub-themes 'the therapist behind the screen is essential', 'less pressure sitting alone: the physical absence of a therapist' and 'engaging on your own terms, in your own tempo'. Themes were consistent among adolescents and parents., Conclusion: Fatigue due to therapeutic engagement and previous help-seeking processes created barriers for engagement. Emotion regulation therapy was experienced as beneficial leading to inter- and intra-personal insights, facilitating change of maladaptive patterns. Therapists were regarded as indispensable, and the internet-based format did not hinder therapeutic alliance. The written format allowed for reflection and alleviated the pressure of relating to the therapist. Further research should explore experiences of other online treatment formats (e.g. synchronous or video-based) with regard to benefits, fatigue and therapist interaction., (© 2024 The Author(s). Psychology and Psychotherapy: Theory, Research and Practice published by John Wiley & Sons Ltd on behalf of The British Psychological Society.) more...

Background: Despite the wide-ranging negative consequences of nonsuicidal self-injury (NSSI), there are few evidence-based treatments for NSSI among adolescents and little is known about what treatments that work best for whom. The objective of this study was to investigate moderators (i.e., for whom a specific treatment works) and predictors (i.e., factors associated with treatment outcome independent of treatment type) of treatment outcome in a randomized clinical trial comparing internet-delivered emotion regulation individual therapy for adolescents (IERITA) plus treatment as usual (TAU) to TAU alone., Methods: Adolescents ( N  = 166; mean [SD] age = 15.0 [1.2] years) with NSSI disorder were randomized to IERITA plus TAU ( n  = 84) or TAU-only ( n  = 82). Adolescent emotion regulation difficulties, suicidality, NSSI frequency, depressive symptoms, sleep difficulties, global functioning, and age, and parental invalidation, were measured pre-treatment and investigated as moderators and predictors of treatment outcome (i.e., NSSI frequency during treatment and for 4 weeks post-treatment). A zero-inflated negative binomial generalized linear mixed effects regression model was used to estimate the rate of NSSI change as a function of both treatment condition and moderator/predictor., Results: No significant moderators of treatment outcome were found. Parental invalidation was a significant predictor of treatment outcome regardless of treatment condition, such that high levels of parental invalidation pre-treatment were associated with a less favorable NSSI frequency., Conclusions: We did not find evidence of a differential treatment effect as a function of any of the examined client factors. Future research should investigate moderation in larger samples and with sufficient statistical power to detect moderation effects of smaller magnitude. Results suggest that parental invalidation may have a negative impact on treatment response and highlight the importance of further investigating parental invalidation in the context of NSSI treatments., Competing Interests: Ojala, Hesser, Hedman‐Lagerlöf, Ljótsson, and Hellner declare no competing interests. Sahlin and Bjureberg receive royalties from Natur & Kultur. Gratz receives royalties from New Harbinger Publications and Cambridge University Press. Tull receives royalties from Academic Press and New Harbinger Publications., (© 2024 The Authors. JCPP Advances published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.) more...

Importance: Nonsuicidal self-injury is prevalent in adolescence and associated with adverse clinical outcomes. Effective interventions that are brief, transportable, and scalable are lacking., Objective: To 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 Participants: This 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., Interventions: Twelve weeks of therapist-guided, internet-delivered emotion regulation individual therapy delivered adjunctive to treatment as usual vs treatment as usual only., Main Outcomes and Measures: Primary 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., Results: A 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 Relevance: In 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 Registration: ClinicalTrials.gov Identifier: NCT03353961. more...

Objectives: To explore how former patients in dialectical behaviour therapy for adolescents (DBT-A) experience their treatment, and specifically if there were aspects of the treatment that they retrospectively identify as particularly meaningful, helpful or unhelpful., Design: From a larger sample of 75 former DBT-A patients 19 were selected for a qualitative semi-structured interview study., Methods: Young adults (N = 19; 18 females, one male), who as adolescents had been enrolled in DBT-A due to self-harming behaviours and features of borderline personality disorder, were interviewed up to 8 years (median 6.0; min 1.3; max 8.2) after end of treatment, at mean age 23 years (SD 2.5). Reflexive thematic analysis was implemented., Results: Six key themes were revealed; (1) The need to be seen, listened to and believed in, (2) the importance of teamwork between patient and therapist, (3) the value of group and structure, (4) therapy as lifesaving and life-changing, (5) the risks of feeling misplaced and (6) the risks of abrupt endings., Conclusion: A trusting relationship with the therapist promoted commitment and motivation for treatment. This relationship was facilitated by the therapist showing explicit care and belief in the patient's own competence in changing their destructive behaviours. Meeting peers in group skill training offered a salient form of validation and was reported to be of particular value. The format of meeting peers and the importance of the dialectical therapeutic stance need to be studied further. Not all youth experienced DBT-A as suitable and the need for sufficient treatment dose was emphasized., (© 2023 The Authors. Psychology and Psychotherapy: Theory, Research and Practice published by John Wiley & Sons Ltd on behalf of The British Psychological Society.) more...

Objective: To evaluate the relative impact of three brief therapist-supported internet-delivered emotion regulation treatments for maladaptive anger (mindful emotion awareness [MEA], cognitive reappraisal [CR], and mindful emotion awareness + cognitive reappraisal [MEA + CR]) and to test whether baseline levels of anger pathology moderate treatment outcome., Method: Treatments were evaluated in a randomized controlled trial. In total, 234 participants (59% female; mean age = 41.1, SD = 11.6) with maladaptive anger were randomized to MEA (n = 78), CR (n = 77), or MEA + CR (n = 79). Self-reported primary and secondary outcomes were followed up at primary endpoint, 3 months after treatment termination (88% retention). Primary outcomes were also assessed weekly during a prolonged baseline phase (4 weeks) and an active treatment phase (4 weeks)., Results: At the primary endpoint, the MEA + CR was superior in terms of anger expression (d = 0.27 95% confidence interval, CI [0.03, 0.51]), aggression (d = 0.43 [0.18, 0.68]), and anger rumination (d = 0.41 [0.18, 0.63]). MEA + CR was particularly effective in reducing anger expression (d = 0.66 [0.21, 1.11]), aggression (d = 0.90 [0.42, 1.39]), and anger rumination (d = 0.80 [0.40, 1.20]) for individuals who reported high values (+1SD) of the outcomes at baseline., Conclusions: Brief therapist-supported internet-delivered MEA and CR treatments are effective interventions for maladaptive anger. Combining MEA and CR is especially effective in reducing anger expression and aggression, particularly, in individuals who report higher levels of initial anger pathology. The present study highlights the importance of emotion regulation as an important treatment target for reducing maladaptive anger. (PsycInfo Database Record (c) 2023 APA, all rights reserved). more...

When the COVID-19 pandemic started spreading globally, there was a fear that addictive behaviors would increase due to changes in everyday life caused by restrictions due to COVID-19. Studies were carried out to explore if this was true for gambling, typically revealing no overall increase in gambling behavior, although individuals who had previous experience with gambling problems were more likely to increase gambling during the pandemic. However, these studies only included individuals with previous gambling problems. It remains unknown whether other vulnerable groups, such as individuals with common mental disorders increased their gambling. This study aimed to explore the level of gambling problems among individuals with a history of mental disorders, namely, (i) pre-pandemic gamblers and (ii) pandemic-onset gamblers. Furthermore, we explored if worry and isolation mediate gambling and problem gambling. The data were analyzed using descriptive statistics and a structural equation model to investigate mediation. The results showed a high prevalence of at-risk and problem gambling in both groups. The pre-pandemic gamblers had a high level of at-risk and problem gambling. Furthermore, the individuals that started to gamble during the pandemic had an even higher degree of at-risk and problem gambling. The mediation showed that the onset of gambling was linked with the worry of COVID-infection and that worry predicted the level of gambling problems. This study highlights that vulnerability factors, isolation, and worry can be triggers for individuals with common mental disorders to engage in gambling as well as the importance of screening this population for gambling problems., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Forsström, Lindner, Månsson, Ojala, Hedman-Lagerlöf, El Alaoui, Rozental, Lundin, Jangard, Shahnavaz, Sörman, Lundgren and Jayaram-Lindström.) more...

Background: Non-suicidal self-injury (NSSI) is common in adolescents receiving psychiatric treatment and is a significant risk factor for suicidal behavior. There are few randomised clinical trials assessing interventions for NSSI in youth, and knowledge about internet-delivered interventions is limited., Objective: We assessed the feasibility of Internet based Emotion Regulation Individual Therapy for Adolescents (ERITA) in psychiatric outpatients aged 13-17 years who engaged in NSSI., Method: A randomised clinical feasibility trial with a parallel group design. Non-suicidal self-injury engaging patients were recruited from Child and Adolescent Mental Health Outpatient Services in the Capital Region of Denmark from May to October 2020. ERITA was provided as add-on to treatment as usual (TAU). ERITA is a therapist-guided, internet-based program of emotion regulation and skills training involving a parent. The control intervention was TAU. Feasibility outcomes were the proportion who completed follow-up interviews at end of intervention; proportion of eligible patients who participated in the trial; proportion of participants completing ERITA. We further investigated relevant exploratory outcomes, including adverse risk-related events., Results: We included 30 adolescent participants, 15 in each group (ERITA vs. Treatment as usual). 90% (95% CI, 72%-97%) of the participants completed post-treatment interviews; 54% (95% CI, 40%-67%) of the eligible participants were included and randomised; and 87% (95% CI, 58%-98%) of the participants completed at least six out of 11 ERITA modules. We identified no difference for the primary exploratory clinical outcome of NSSI between the two groups., Conclusion: There are few randomised clinical trials assessing interventions for NSSI in youth, and knowledge about internet-delivered interventions is limited. Based on our results we conclude that a large-scale trial seems feasible and warranted., Competing Interests: The authors have declared that they have no competing or potential conflicts of interest., (© 2022 The Authors. JCPP Advances published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.) more...

Background: The knowledge of how the separate Attention-Deficit/Hyperactivity Disorder (ADHD) subdimensions (impulsivity, hyperactivity, and inattention) are associated with nonsuicidal self-injury (NSSI) and suicidal behavior (SB) is limited. The objective of this study was to investigate the associations of childhood ADHD subdimensions with NSSI and SB in children at risk of neurodevelopmental disorders (NDDs; including ADHD)., Methods: The sample (N = 391) included twin pairs where at least one twin screened positive for at least one NDD or common comorbidity at age 9 or 12. Data on ADHD subdimensions was collected through a telephone interview with a caregiver/legal guardian at age 9 or 12, and data on NSSI and SB was collected through an in-person clinical assessment at age 15. The associations between the ADHD subdimensions and NSSI or SB were tested in three different models: (1) univariable, (2) together with the other ADHD subdimensions, and (3) in a confounder-adjusted model including other NDD symptoms in addition to ADHD subdimensions, for NSSI and SB separately., Results: A total of 32 (8.2%) adolescents reported life-time engagement of NSSI, and 18 (4.6%) SB. Childhood impulsivity was associated with SB and childhood inattention with NSSI, in all models. Hyperactivity was not meaningfully associated with any of the outcomes., Conclusion: Impulsivity and inattention, but not hyperactivity, may be of particular importance in understanding SB and NSSI. Brief screening for impulsivity and inattention in childhood could facilitate detection of children vulnerable to NSSI and SB and indicate valuable information for preventive and intervention strategies., (© 2022. The Author(s).) more...

Objective: Individuals with psychiatric disorders may be both vulnerable and sensitive to rapid societal changes that have occurred during the COVID-19 pandemic. To fully understand these impacts, repeated measurements of these individuals are warranted. The current longitudinal study set out to perform monthly assessment of individuals with common psychiatric disorders using established questionnaires with a possibility for them to self- rate their symptoms, over time., Methods: Recruitment of individuals who identified themselves as struggling with mental health problems, living in Sweden between July 2020 and June 2021 using an online survey. The individuals answered questions on demographics, psychiatric history, current psychiatric symptoms (e.g., Patient Health Questionnaire, PHQ-9; General Anxiety Disorder, GAD-7), somatic health, health-care contacts and any changes therein during the pandemic. Monthly, longitudinal assessments are still ongoing (consenting participants provide data for 1 year), and here we present descriptive statistics from the baseline measurement. All measurements from baseline (>400 items), and follow-ups are presented in detail., Results: A total of 6.095 participants (average age 35 years) submitted complete baseline data. Marital status (43% single) and number of years of education (48% highest degree being high school) were evenly distributed in this population. The most common lifetime psychiatric disorder in the sample was depressive disorder (80.5%) and generalized anxiety disorder (45.9%), with a substantial proportion having severe symptoms of depression. (30.5%) and anxiety (37.1%). Lifetime suicidal ideation (75.0%) and non-suicidal self-harm (57.7%) were prevalent in the group and 14.5% reported drug use during the pandemic. Allergies (36.8%) were the most common somatic condition, followed by irritable bowel syndrome (18.7%). For those having experienced a traumatic event, 39% showed symptoms during the pandemic indicating PTSD. Regarding contact with mental health services during the pandemic, 22% had established a new contact, and 20% reported to have increased their psychiatric medication compared to before the pandemic., Conclusion: Baseline data collected during the pandemic from individuals in Sweden with pre-existing psychiatric disorders demonstrate that this sample represents a population suitable for an investigation on the long-term impact of the pandemic, as intended by the longitudinal investigation that is ongoing. Follow-up questionnaires over a 12-month period are being collected and will indicate how the health and well-being of this population was impacted during the changes and uncertainties that have been characteristic of the past 2 years., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Rozental, Sörman, Ojala, Jangard, El Alaoui, Månsson, Shahnavaz, Lundin, Forsström, Hedman-Lagerlöf, Lundgren and Jayaram-Lindström.) more...

The value of apparent diffusion coefficient (ADC) measurements in intervertebral disc has been studied because ADC provides an estimate of free diffusion of unbound water and could be used as a quantitative tool to estimate degenerative changes. However, the challenging nature of diffusion imaging of spine and limited numbers of subjects in earlier studies has produced contradictory findings. We aimed to determine the relation between ADC and visual degenerative changes in lumbar intervertebral discs in a sufficiently large homogeneous study group. Lumbar spines of 228 volunteer middle-aged men were MR imaged at 1.5 T including anatomic and diffusion-weighted imaging. ADC values, T2 signal intensity and height, and width of the three lowest lumbar intervertebral discs were measured and disc degeneration visually graded. The calculated average ADC of 530 measured discs was 2.01 x 10(-3) mm(2)/s+/-0.29 (+/-S.D.). The reduction in ADC between visually normal and moderately degenerated discs was 4%. Severely degenerated discs showed 5% larger ADC values than normal discs, presumably due to free water in cracks and fissures of those discs. T2 signal intensity of the disc was significantly correlated with the ADC values, whereas other measured parameters did not show correlation. There was no evident difference in ADC between the studied anatomic lumbar levels. Because there is considerable overlap between ADC values of normal and degenerated discs, we conclude that ADC measurements of intervertebral discs, at least with current technology, have limited clinical value. more...