Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial

"I didn't have to look her in the eyes"-participants' experiences of the therapeutic relationship in internet-based psychodynamic therapy for adolescent depression

Objective: To explore young people's perceptions of the relationship with the therapist in internet-based psychodynamic treatment for adolescent depression.Method: As a part of a randomized controlled trial, 18 adolescents aged 15-19 were interviewed after participating in treatment. Interviews followed a semi-structured interview schedule and were analyzed using thematic analysis.Results: The findings are reported around four main themes: "a meaningful and significant relationship with someone who cared", "a helping relationship with someone who guided and motivated me through therapy"; "a relationship made safer and more open by the fact that we didn't have to meet" and "a nonsignificant relationship with someone I didn't really know and who didn't know me".Conclusion: Even when contact is entirely text-based, it is possible to form a close and significant relationship with a therapist in internet-based psychodynamic treatment. Clinicians need to monitor the relationship and seek to repair ruptures when they emerge.Trial registration: ISRCTN.org identifier: ISRCTN16206254..

Time-lagged panel models in psychotherapy process and mechanisms of change research: Methodological challenges and advances

In recent years, there has been increasing interest in utilizing time-lagged panel models to study mechanisms of change in psychotherapy. These models offer valuable insights into the dynamic relationships between variables over time and offer stronger causal inference capabilities than cross-sectional analyses. Therefore, they are well-suited for modeling the intricate relationships between mechanisms of change and outcomes in psychotherapy studies, which are typically beyond experimental control. However, their complexity, coupled with the fact that detailed explanations are often embedded in dense statistical or econometric texts, poses challenges. This paper provides a background on cross-lagged panel models and delves deeper into explaining the issues of 1) dynamic panel bias, 2) long-run effects, and 3) testing whether different treatments work by different mechanisms. Using data from a psychotherapy study on treatment of adolescent depression, I demonstrate how these issues manifest in real data. In conclusion, I recommend using structural equation modeling to circumvent dynamic panel bias, reporting long-run effects to reveal the long-term impact of sustained therapeutic work on mechanisms of change, and carefully considering whether mediation, moderation, or a combination of both, best describes differential effects of mechanisms between treatments.

Guided and unguided internet-delivered psychodynamic therapy for social anxiety disorder: A randomized controlled trial

Social Anxiety Disorder (SAD) is highly prevalent and debilitating disorder. Treatments exist but are not accessible and/or helpful for all patients, indicating a need for accessible treatment alternatives. The aim of the present trial was to evaluate internet-delivered psychodynamic therapy (IPDT) with and without therapist guidance, compared to a waitlist control condition, in the treatment of adults with SAD. In this randomized, clinical trial, we tested whether IPDT was superior to a waitlist control, and whether IPDT with therapeutic guidance was superior to unguided IPDT. Participants were recruited nationwide in Sweden. Eligible participants were ≥ 18 years old and scoring ≥ 60 on the Liebowitz Social Anxiety Scale self-report (LSAS-SR) whilst not fulfilling any of the exclusion criteria. Included participants were randomly assigned to IPDT with guidance (n = 60), IPDT without guidance (n = 61), or waitlist (n = 60). The IPDT intervention comprised eight self-help modules based on affect-focused dynamic therapy, delivered over 8 weeks on a secure online platform. The primary outcome was SAD symptoms severity measured weekly by the LSAS-SR. Primary analyses were calculated on an intention-to-treat sample including all participants randomly assigned. Secondary outcomes were depressive symptoms, generalized anxiety, quality of life, emotion regulation and defensive functioning. At post-treatment, both active treatments were superior to the waitlist condition with guided treatment exhibiting larger between group effects than unguided treatment (d = 1.07 95% CI [0.72, 1.43], p < .001 and d = 0.61, 95% CI [0.25, 0.98], p = .0018) on the LSAS-SR respectively. Guided IPDT lead to larger improvements than unguided IPDT (d = 0.46, 95% CI [0.11, 0.80], p < .01). At post-treatment, guided IPDT was superior to waitlist on all secondary outcome measures. Unguided IPDT was superior to waitlist on depressive symptoms and general anxiety, but not on emotion regulation, self-compassion or quality of life. Guided IPDT was superior to unguided PDT on depressive symptoms, with a trend towards superiority on a measure of generalized anxiety. At six and twelve month follow-up there were no significant differences between guided and unguided IPDT. In conclusion, IPDT shows promising effects in the treatment of SAD, with larger benefits from guided IPDT compared to non-guided, at least at post-treatment. This finding increases the range of accessible and effective treatment alternatives for adults suffering from SAD. The study was prospectively registered at ClinicalTrials (NCT05015166).

Internet- and mobile-based anxiety and depression interventions for children and adolescents: efficacy and negative effects - a systematic review and meta-analysis

Mental disorders, most commonly anxiety disorders and fourth most common depression, are prevalent in children and adolescents. Internet- and mobile-based interventions might represent a scalable approach to improve mental health care, however, evidence so far is inconclusive and systematic reports on negative effects are missing. Four data-bases were searched for randomized controlled trials evaluating internet- and mobile-based interventions (IMIs) targeting anxiety disorders or depression in children and adolescents up to 18 years exhibiting clinically relevant symptoms. Meta-analytic evaluations were conducted in comparison to active and passive control groups, furthermore, pre-defined sub-groups were explored and reported negative effects examined. Pooled estimates showed a moderate positive effect for IMIs targeting anxiety disorders compared to passive control groups (g = -0.69; CI -0.94 to -0.45; k = 8; n = 559; p ≤ 0,001), but not for depression. Pooled estimates compared to active control groups remained non-significant. Subgroup analyses were largely omitted due to an insufficient number of trials or were non-significant. Negative effects were mainly reported as drop-out rates and (non)-response rates, while additional negative effects, such as deterioration rates or the development of additional symptoms, were reported by only one third of included studies. The focus on children and adolescents with clinically relevant symptoms allowed the present findings to complement previous work, however, the limited amount of trials hindered many planned comparisons. The overview of reported negative effects highlighted that negative effects are being neglected in the majority of RCTs. Hence, in the future RCTs should include more information about potential negative effects, at best a combination of quantitative and qualitative information. Open Science Framework (osf.io/ch5nj).

Phone-Based Text Therapy for Youth Mental Health: Rapid Review

BACKGROUND

Mental illness has become a prevalent issue impacting adolescents worldwide. Many barriers, including stigma and poor health literacy, prevent this population group from accessing reliable mental health care services. Synchronous text-therapy counseling is an underused therapeutic approach in combating adolescent mental illness. Phone-based text therapy is uniquely placed to offer personalized counseling to adolescents through a familiar and engaging treatment modality.

OBJECTIVE

This rapid review aims to understand the clinical effectiveness, usability, and accessibility of phone-based text therapy for youth mental health.

METHODS

Cochrane CENTRAL, Embase, PubMed, and PsycINFO were used to search for suitable literature. Five groups of keywords were used: those related to (1) "therapy," (2) "text," (3) "phone," (4) "youth," and (5) "mental health." Eligibility criteria were formed through the PICO (Population, Intervention, Control, and Outcome) framework. Studies were included if a synchronous phone-based text therapy intervention was used in an adolescent population, with an age range of 12-24 years. Only literature available in full-text, English, and a peer-reviewed journal was considered. Furthermore, a date limit of 5 years was set to reflect the recent development of digital interventions for mental health. Pertinent information from each study was tabulated, and a narrative synthesis was used to assess, describe, and organize the included studies comprehensively and concisely.

RESULTS

Of the 771 studies dual screened, 7 studies were included in this rapid review. Most of the exclusions occurred due to the use of the wrong intervention, such as asynchronous messaging. The selected studies had a low risk of bias and were suitable for the review. All interventional trials demonstrated reductions in mental health symptoms, primarily depression and anxiety. Most studies displayed high usability among participants, while data were unclear regarding accessibility.

CONCLUSIONS

This review reveals the high potential of phone-based text therapy as an intervention for adolescents experiencing mental illness. We hope that this review promotes further refinement of text-based phone therapies and encourages future research on this subject matter.

Psychodynamic Formulation and Psychodynamic Psychotherapy for Pediatric Anxiety Disorders

Psychodynamic psychotherapy can be an effective treatment of pediatric anxiety disorders. Psychodynamic formulation can be easily integrated with other conceptualizations of anxiety (eg, biological/genetic, developmental, and social learning theory). Psychodynamic formulation helps determine whether anxiety symptoms represent innate biological responses, learned responses from early experiences, or defensive reactions to intrapsychic conflict. Child and Adolescent Anxiety Psychodynamic Psychotherapy and Psychoanalytic Child Therapy are two evidence-based manualized psychodynamic approaches to treating pediatric anxiety disorders.

Digital technologies to support adolescents with depression and anxiety: review

Depression and anxiety are common in adolescents, but most affected will not get any formal help. Digital mental health technologies (i.e. resources and interventions to support and improve mental health) are a potential way to extend the reach and increase adolescents' access to therapies, at a relatively low cost. Many young people can access the internet and mobile technologies, including in low- and middle-income countries. There has been increased interest in integrating technologies in a range of settings, especially because of the effect of the COVID-19 pandemic on adolescent mental health, at a time when services are under pressure. This clinical review gives an overview of digital technologies to support the prevention and management of depression and anxiety in adolescence. The technologies are presented in relation to their technological approaches, underlying psychological or other theories, setting, development, evaluations to date and how they might be accessed. There is also a discussion of the potential benefits, challenges and future developments in this field.

[The German S3 guideline for depressive disorders in childhood and adolescence: new developments]

The German guideline for the treatment of depressive disorders in children and adolescents was first published in July 2013. Currently, this guideline is undergoing revision, in which the recommendations of the original version of the guideline are revisited and updated. This report aims to give an overview of the current status and the next steps for this revision.As part of the revision process, the key questions posited in the original version were expanded upon. In this, new questions were added regarding complementary therapies, that is, therapies meant to be administered in addition to the usual treatment, as well as regarding the transitionary period from adolescence into adulthood. For all key questions, new systematic literature searches were conducted in order to update the relevant evidence. For this, randomized controlled studies, systematic reviews, and non-controlled intervention studies were included and rated according to their relevance as well as possible risks of bias. Thus, all studies could be assigned a level of evidence that takes into account both the quality and the importance of the study to the guideline.This report will give a brief overview of the most important insights resulting from the new evidence base identified for the revision. While insights regarding psychotherapy are largely unchanged, there are changes in the evidence for certain antidepressants. In the field of complementary therapies, new evidence has been found for physical activity. In general, it is likely that most recommendations of the original guideline regarding first- and second-line treatments will be updated. The completion of the revision and the publishing of the revised guideline are expected to take until the end of 2023.

Internet-delivered psychological treatment as an add-on to treatment as usual for common mental disorders: A systematic review with meta-analysis of randomized trials

BACKGROUND

Psychological treatments for common mental disorders are increasingly being delivered remotely via the internet. Evidence suggests that internet-delivered cognitive behavioural therapy (iCBT) is superior to waitlist. However, the benefits are unclear of using this treatment modality as an add-on to treatment as usual (TAU) in regular healthcare.

METHODS

The literature was systematically searched up to August 2021 for randomized trials of internet-delivered psychological treatments using TAU as the comparator. Eligible participants were diagnosed with depressive, anxiety, obsessive-compulsive, or trauma- and stress-related disorders. Outcomes of interest were symptoms, functioning, quality of life, healthcare utilization, and negative effects. Results were synthesized using random-effects meta-analyses. Quality of evidence was assessed using GRADE.

RESULTS

The included studies evaluated iCBT for adults with depression (k = 9), depressive or anxiety disorders (k = 4), and post-traumatic stress disorder (k = 2) and were conducted in primary care or similar settings. For depression, low-certainty evidence suggested beneficial short-term effects on symptoms (g = -0.23; 95 % CI: = -0.37, -0.09), response rate (OR = 2.46; 1.31, 4.64), and remission (OR = 1.70; 1.19, 2.42;). The certainty of evidence was very low for long-term effects, other outcomes, and other disorders.

LIMITATIONS

TAU varied across studies and was often insufficiently described.

CONCLUSIONS

iCBT as a complement to usual care for adult with depression may result in a small incremental effect, which potentially could be clinically important. Studies are lacking for several common disorders and for children, adolescents, and the elderly. More robust studies of long-term effects are also needed, to better inform clinical decision-making.

Characteristics and Potential Challenges of Digital-Based Interventions for Children and Young People: Scoping Review (Preprint)

BACKGROUND

Digital health technologies are becoming increasingly available to children and young people and their families. However, there are no scoping reviews that provide both an overview of the characteristics of digital interventions for children and young people and potential challenges to be considered when developing and implementing them.

OBJECTIVE

This study aimed to systematically review scientific publications to identify the current characteristics and potential complications of digital interventions for children and young people.

METHODS

This scoping review was conducted using the framework of Arksey and O'Malley and adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews. A search of 5 databases (PubMed, Scopus, Embase, MEDLINE, and CINAHL) and Google Scholar was performed for eligible clinical trials published between January 1, 2018, and August 19, 2022.

RESULTS

The initial search of the 5 databases yielded 3775 citations; duplicates and those not meeting the inclusion criteria were eliminated. In total, 34 articles were included in the final review and relevant information, such as the descriptive characteristics and potential challenges, were classified. Mental health (26/34, 76%) was the most common target for the digital intervention for children and young people, exceeding physical health (8/34, 24%) by more than 3 times. In addition, a substantial number of digital interventions were dedicated solely to children and young people. Digital interventions for children and young people were more likely to be delivered via computers (17/34, 50%) rather than smartphones (13/34, 38%). More than one-third of the studies (13/34, 38%) applied cognitive behavioral theory as the theory of digital interventions. The duration of the digital intervention for children and young people was more likely to vary depending on the target user rather than the target disease. Intervention components were classified into 5 categories: guidance, task and activity, reminder and monitoring, supportive feedback, and reward system. Potential challenges were subcategorized into ethical, interpersonal, and societal challenges. For ethical challenges, the consent of children and young people or caregivers, potential risk of adverse events, and data privacy issues were considered. For interpersonal challenges, the engagement of children and young people was affected by the preference or barrier of caregivers to participate in studies. For societal challenges, restricted ethnicity in recruitment, limited availability of digital technology, differences in internet use patterns between girls and boys, unified clinical settings, and language barriers were described.

CONCLUSIONS

We identified potential challenges and provided suggestions about ethical, interpersonal, and societal aspects to consider when developing and deploying digital-based interventions for children and young people. Our findings provide a thorough overview of the published literature and may serve as a comprehensive, informative foundation for the development and implementation of digital-based interventions for children and young people.

Unpacking the active ingredients of internet-based psychodynamic therapy for adolescents

Internet-based psychodynamic psychotherapy (iPDT) for adolescents has been found to be effective for treating depression, but not much is known about its active ingredients.

OBJECTIVE

To explore the techniques used in chat sessions in an iPDT program for depressed adolescents, and to investigate whether they predicted improvement in depression symptoms.

METHOD

The study uses data collected from a pilot study. The iPDT consisted of 8 modules delivered over 10 weeks that included text, video, exercises, and a weekly text-based chat session with a therapeutic support worker (TSW). The participants were 23 adolescents meeting criteria for depression. The TSWs were 9 psychology master's students. A depression inventory QIDS-A17-SR was filled weekly by the participants, and a self-rated techniques inventory (MULTI-30) was filled by the TSWs after each chat session.

RESULTS

Common factor techniques were the most widely used techniques in the chat sessions. Both common factors and psychodynamic techniques predicted improvement in depression, with psychodynamic techniques predicting improvement at the following week. CBT techniques were also used but did not predict improvement in depression.

CONCLUSION

iPDT seem to work in line with theory, where the mechanisms thought to be important for change in treatment were predictive of outcome.

Comparison of online and in-person cognitive behavioral therapy in individuals diagnosed with major depressive disorder: a non-randomized controlled trial

Objective

The increased prevalence of major depressive disorder (MDD) amid the COVID-19 pandemic has resulted in substantial growth in online mental health care delivery. Compared to its in-person counterpart, online cognitive behavioral therapy (e-CBT) is a time-flexible and cost-effective method of improving MDD symptoms. However, how its efficacy compares to in-person CBT is yet to be explored. Therefore, the current study compared the efficacy of a therapist-supported, electronically delivered e-CBT program to in-person therapy in individuals diagnosed with MDD.

Methods

Participants (n = 108) diagnosed with MDD selected either a 12 week in-person CBT or an asynchronous therapist-supported e-CBT program. E-CBT participants (n = 55) completed weekly interactive online modules delivered through a secure cloud-based online platform (Online Psychotherapy Tool; OPTT). These modules were followed by homework in which participants received personalized feedback from a trained therapist. Participants in the in-person CBT group (n = 53) discussed sessions and homework with their therapists during one-hour weekly meetings. Program efficacy was evaluated using clinically validated symptomatology and quality of life questionnaires.

Results

Both treatments yielded significant improvements in depressive symptoms and quality of life from baseline to post-treatment. Participants who opted for in-person therapy presented significantly higher baseline symptomatology scores than the e-CBT group. However, both treatments demonstrated comparable significant improvements in depressive symptoms and quality of life from baseline to post-treatment. e-CBT seems to afford higher participant compliance as dropouts in the e-CBT group completed more sessions on average than those in the in-person CBT group.

Conclusion

The findings support e-CBT with therapist guidance as a suitable option to treat MDD. Future studies should investigate how treatment accessibility is related to program completion rates in the e-CBT vs. in-person group.

Clinical Trial Registration

ClinicalTrials.Gov Protocol Registration and Results System (NCT04478058); clinicaltrials.gov/ct2/show/NCT04478058.

Internet-based emotion-regulation training added to CBT in adolescents with depressive and anxiety disorders: A pilot randomized controlled trial to examine feasibility, acceptability, and preliminary effectiveness

BACKGROUND

Dysfunctional emotion regulation (ER) is associated with symptoms of depression and anxiety in adolescents. This pilot study aimed to examine the acceptability and feasibility of a guided internet-based emotion regulation training (ERT) added to cognitive behavioral therapy (CBT). Furthermore, we aimed to examine the feasibility of the randomized study design and to provide a first estimate of the effectiveness of CBT + ERT compared with CBT alone in adolescents with depressive or anxiety disorders.

METHODS

In a pilot randomized controlled trial (RCT) with a parallel group design, 39 patients (13-18 years) with depressive or anxiety disorder were assigned to CBT + ERT (n = 21) or CBT (n = 18). Assessments at baseline, three-months and six-months follow-up included treatment adherence, satisfaction, depressive symptoms, anxiety symptoms, and ER strategies.

RESULTS

Adherence to ERT was 66.5 %, and treatment satisfaction was adequate. 76.5 % of eligible patients participated in the study. Linear mixed-model analyses showed significantly reduced anxiety symptoms (p = .003), depressive symptoms (p = .017), and maladaptive ER (p = .014), and enhanced adaptive ER (p = .008) at six months follow-up in the CBT + ERT group compared to controls.

LIMITATIONS

The sample size was small, and results regarding effectiveness remain preliminary. Data-collection took place during COVID-19, which may have influenced the results.

CONCLUSIONS

Both the intervention and the study design were found to be feasible. In a larger RCT, however, improvement of recruitment strategy is necessary. Preliminary results indicate potential effectiveness in decreasing anxiety, depression, and emotion dysregulation in adolescents. The next step should be the development of an improved internet-based ERT and its evaluation in a larger RCT.

TRIAL REGISTRATION

Registered on January 14th, 2020 in The Netherlands Trial Register (NL8304).

Screening for Depression and Suicide Risk in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide.

Objective

To review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF).

Data Sources

PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.

Study Selection

English-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Test accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events.

Results

Twenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, -0.58 [95% CI, -0.83 to -0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, -2.25 [95% CI, -4.09 to -0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children's Depression Rating Scale-Revised mean difference, -3.76 [95% CI, -5.95 to -1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children's Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, -2.35 [95% CI, -4.06 to -0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different.

Conclusion and Relevance

Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.

Effectiveness of an add-on guided internet-based emotion regulation training (E-TRAIN) in adolescents with depressive and/or anxiety disorders: study protocol for a multicenter randomized controlled trial

BACKGROUND

During adolescence, depressive and anxiety disorders are among the most common mental health disorders. Both disorders tend to persist, are predictive for other mental disorders, and are associated with severe impairment in diverse areas. Although Cognitive Behavioral Therapy (CBT) has proven to be an effective treatment, a considerable number of adolescents do not respond to CBT and residual symptoms often remain. Therefore, it is of great importance to improve treatment outcomes for depressed and/or anxious adolescents. Dysfunctional emotion regulation appears to be a transdiagnostic factor in the development and maintenance of aforementioned disorders. Enhancing emotion regulation skills may therefore reduce symptom severity. In light of this, we developed a guided internet-based emotion regulation training (E-TRAIN) that will be added to CBT. This study aims to evaluate the effectiveness of E-TRAIN + CBT compared to CBT alone on depressive and anxiety outcomes among adolescents with depressive and/or anxiety disorder.

METHODS

In this multicenter two-arm randomized controlled trial with parallel group design, we aim to include 138 adolescents, aged 13-19 years, referred for treatment and diagnosed with depressive and/or anxiety disorder. Participants will be allocated to either CBT or CBT + E-TRAIN. Assessments will take place at baseline, and at 3 (T1), 6 (T2) and 12 (T3) months after baseline. We will conduct multi-informant assessments: the adolescent, a parent/caregiver, and the CBT therapist will be asked to fill in questionnaires. The continuous primary outcome measure is self-reported depressive and anxiety symptoms at six months after baseline, measured with the RCADS25. Secondary outcome measures include anxiety or depression diagnosis based on a semi-structured clinical interview, emotion (dys) regulation, and parent-report measures of anxiety, depression and emotion (dys) regulation.

DISCUSSION

This study is the first randomized controlled trial to examine the additional value of a guided internet-based emotion regulation training to regular CBT in adolescents with depressive and/or anxiety disorders. If this intervention is effective, it can be implemented in mental health care and improve treatment for these young people.

TRIAL REGISTRATION

Registered on June 23, 2021 in The Netherlands Trial Register (NL9564). Retrospectively registered. Recruitment started in May 2021 and is ongoing.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Self-compassion and related factors in severe mental illness: A scoping review

PURPOSE

To clarify what is known and identify research gaps on the role of self-compassion (SC) and potential interventions for individuals with severe mental illness (SMI).

DESIGN AND METHODS

We analyzed 24 studies of SC in schizophrenia spectrum disorder, bipolar disorder (BD), and major depressive disorder (MDD).

FINDINGS

Mindfulness-based cognitive therapy (MBCT) was the most common intervention. Predicting depression by SC was common in MDD and BD; however, relationships between demographics/clinical variables and SC in BD and schizophrenia spectrum disorder remain unclear.

PRACTICE IMPLICATIONS

MBCT increases SC in SMI. Data regarding predictors of SC are limited, especially in schizophrenia.

Connecting over the internet: Establishing the therapeutic alliance in an internet-based treatment for depressed adolescents

Internet-based treatments have been developed for youth mental health difficulties, with promising results. However, little is known about the features of therapeutic alliance, and how it is established and maintained, in text-based interactions between adolescents and therapists in internet-based treatments. This study uses data collected during a pilot evaluation of a psychodynamic internet-based therapy for depressed adolescents. The adolescents had instant-messaging chats with their therapists once a week, over 10 weeks. The adolescents also rated the therapeutic alliance each week, using the Session Alliance Inventory. The present study uses qualitative methods to analyse transcripts of text-based communication between the young people and their therapists. The aim is to identify and describe the key features of therapeutic alliance, and reflect upon the implications for theory and clinical practice. Analysis identified three 'values' that may underpin a strong therapeutic alliance: togetherness, agency and hope. A number of therapist techniques were also found, which seemed to create a sense of these values during text-chat sessions. These findings are discussed, alongside implications for future research.

Internet-Delivered Interventions for Depression and Anxiety Symptoms in Children and Young People: Systematic Review and Meta-analysis

BACKGROUND

Mental health difficulties in children and adolescents are highly prevalent; however, only a minority receive adequate mental health care. Internet-delivered interventions offer a promising opportunity to increase access to mental health treatment. Research has demonstrated their effectiveness as a treatment for depression and anxiety in adults. This work provides an up-to-date examination of the available intervention options and their effectiveness for children and young people (CYP).

OBJECTIVE

In this systematic review and meta-analysis, we aimed to determine the evidence available for the effectiveness of internet-delivered interventions for treating anxiety and depression in CYP.

METHODS

Systematic literature searches were conducted throughout November 2020 using PubMed, PsycINFO, and EBSCO academic search complete electronic databases to find outcome trials of internet-delivered interventions treating symptoms of anxiety and/or depression in CYP by being either directly delivered to the CYP or delivered via their parents. Studies were eligible for meta-analysis if they were randomized controlled trials. Risk of bias and publication biases were evaluated, and Hedges g between group effect sizes evaluating intervention effects after treatment were calculated. Meta-analyses used random-effects models as per protocol.

RESULTS

A total of 23 studies met the eligibility criteria for the systematic review, of which 16 were included in the meta-analyses, including 977 participants in internet-delivered treatment conditions and 1008 participants in control conditions across 21 comparisons. Random-effects models detected a significant small effect for anxiety symptoms (across 20 comparisons; Hedges g=-0.25, 95% CI -0.38 to -0.12; P<.001) and a small but not significant effect for depression (across 13 comparisons; Hedges g=-0.27, 95% CI -0.55 to 0.01; P=.06) in favor of internet-delivered interventions compared with control groups. Regarding secondary outcomes, there was a small effect of treatment across 9 comparisons for impaired functioning (Hedges g=0.52, 95% CI 0.24-0.80; P<.001), and 5 comparisons of quality of life showed no effect (Hedges g=-0.01, 95% CI -0.23 to 0.21; P=.94).

CONCLUSIONS

The results show that the potential of internet-delivered interventions for young people with symptoms of anxiety or depression has not been tapped into to date. This review highlights an opportunity for the development of population-specific interventions and their research to expand our current knowledge and build an empirical base for digital interventions for CYP.

TRIAL REGISTRATION

PROSPERO CRD42020220171; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220171.

Loss of Rituals, Boundaries, and Relationship: Patient Experiences of Transition to Telepsychotherapy Following the Onset of COVID-19 Pandemic

Telepsychotherapy is an increasingly common way of conducting psychotherapy. Previous research has shown that patients usually have positive experiences of online therapy, however, with large individual differences. The aim of this study was to explore patients’ experiences of transition from in-person psychotherapy sessions to telepsychotherapy during the COVID-19 pandemic, as well as variation in the experiences with regard to the patients’ personality orientation. Seven psychotherapy patients in Sweden were interviewed and the transcripts were analyzed using thematic analysis. Additionally, the participants were asked to rate their dissatisfaction/satisfaction with the transition, how hindering/helpful the transition was, and how unsafe/safe they felt after the transition in comparison to before. Personality orientation on relatedness or self-definition was assessed applying a self-assessment instrument (Prototype Matching of Anaclitic-Introjective Personality Configuration; PMAI). The participants experienced telepsychotherapy as qualitatively different from in-person psychotherapy. They reported several essential losses: the rituals surrounding therapy sessions were lost, including the transitional time and space between their every-day life and the therapy sessions, less therapeutic work was done, the therapists could lose their therapeutic stance, the sense of rapport was impaired, and the patients felt less open and emotionally available. On the other hand, some patients could feel freer online. As six of the participants had an anaclitic personality orientation, the present study could especially contribute to the understanding of how patients with strong affiliative needs and fear of abandonment experience the transition to meeting their therapists via communication technology. The participants’ self-ratings showed that they were only marginally dissatisfied with the transition and experienced the transition as slightly hindering, whereas they felt rather safe after the transition, indicating low concordance between qualitative and quantitative evaluations. New studies are needed to explore the introjective patients’ experiences of the transition. An essential topic is also to collect evidence and to test how the impaired sense of rapport when using communication technology can be remedied by adequate, patient-tailored interventions, a topic that has to be included in psychotherapy education and training.

The Depression: Online Therapy Study (D:OTS)-A Pilot Study of an Internet-Based Psychodynamic Treatment for Adolescents with Low Mood in the UK, in the Context of the COVID-19 Pandemic

Introduction: Face-to-face therapy is unavailable to many young people with mental health difficulties in the UK. Internet-based treatments are a low-cost, flexible, and accessible option that may be acceptable to young people. This pilot study examined the feasibility, acceptability and effectiveness of an English-language adaptation of internet-based psychodynamic treatment (iPDT) for depressed adolescents, undertaken during the COVID-19 pandemic in the UK. Methods: A single-group, uncontrolled design was used. A total of 23 adolescents, 16-18 years old and experiencing depression, were recruited to this study. Assessments were made at baseline and end of treatment, with additional weekly assessments of depression and anxiety symptoms. Results: Findings showed that it was feasible to recruit to this study during the pandemic, and to deliver the iPDT model with a good level of treatment acceptability. A statistically significant reduction in depressive symptoms and emotion dysregulation was found, with large effect size, by the end of treatment. Whilst anxiety symptoms decreased, this did not reach statistical significance. Conclusions: The findings suggest that this English-language adaptation of iPDT, with some further revisions, is feasible to deliver and acceptable for adolescents with depression. Preliminary data indicate that iPDT appears to be effective in reducing depressive symptoms in adolescents.

A Meta-Analytic Review of Emotion Regulation Focused Psychosocial Interventions for Adolescents

Emotion regulation (ER) is the ability to monitor, evaluate, and modify one's emotional responses to be appropriate for environmental demands. Poor ER has been considered a transdiagnostic risk factor for a range of internalizing and externalizing disorders and overall decreased well-being in adolescents. A range of evidence-based interventions exist which may improve ER. However, much of the intervention research to date does not include a measure of ER to assess change pre and post treatment, with limited information about the efficacy of these interventions in youth across a range of sample types. There is a clear need for a comprehensive review of the literature examining ER-focused interventions in adolescents with a wide range of presenting disorders. A literature search was originally conducted in January 2020 and an updated search was conducted in February 2021 which elicited 1245 articles, of which 605 were duplicates and were removed. Abstracts of the remaining 640 articles were screened with 121 articles being reviewed in full. Of note, 16 additional articles were identified through references and other sources during this process and were also included in the full review. Of the 137 articles reviewed in full, 41 studies were ultimately included in the present review. The present paper provides a descriptive review of intervention approaches and findings from community prevention programs, programs for war-affected youth, programs for clinical populations, and programs for incarcerated and delinquent adolescents. The overall pooled effect was significantly different from zero based on the pre/post effects [Hedge's g = 0.29, 95% CI (0.22, 0.36)] and the intervention/control effects [Hedge's g = 0.19, 95% CI (0.06-0.32)]. Although neither sex nor age significantly accounted for heterogeneity in effect sizes, there were significant findings for population type (clinical vs. community), with community samples having significantly lower effect sizes on average. Impacts of the different ER measures used and significant methodological variability (e.g., use of control groups, length of intervention) across included studies are discussed. Implications and suggestions for future research are reviewed, specifically, that additional understanding of moderators of effects are needed and that measures used to assess change in ER, both dysregulation and adaptive skill use, may need to more directly align with the intervention's focus and the strategies taught as part of the intervention.

Are online mental health interventions for youth effective? A systematic review

OBJECTIVES

This systematic review aims to examine the effectiveness of online mental health interventions for youth.

METHODS

We searched seven electronic databases (PubMed, PsycINFO, Medline, Embase, CINAHL, Web of Science and SCOPUS) for the past 10 years to identify randomized controlled trials which have evaluated the use of telehealth interventions for young people with mental health problems. The included studies were assessed for quality and risk of bias.

RESULTS

Forty-five randomized controlled trials (n = 13,291 participants) were eligible for this review. Most studies (35 trials) evaluated the use of web-based self-help platforms to deliver cognitive behavioural therapy (14 trials), mindfulness (four trials), acceptance commitment therapy (five trials) and positive psychology (two trials). Mobile/computer applications were used to deliver cognitive behavioural therapy (four trials) and coping strategies training (two trials). Web-based synchronous chat (one trial) was used to assist communication between counsellors and participants. Three studies used artificial intelligence-based conversational agents to deliver cognitive behavioural therapy (two trials) and problem-solving-strategy training (one trial). Eighty-two percent (n = 37) identified the participants as student population (i.e. university students, high school students). Sixty-four percent (n = 29) of the telehealth interventions were found to be effective in managing depression, anxiety, stress, insomnia and improving quality of life when compared with control conditions.

CONCLUSIONS

Online mental health interventions were found to be effective in managing diverse mental health conditions among youth. Online self-help platforms were the most frequently used modality and artificial intelligence-based chatbots are merging as potential solutions. Future research is warranted to investigate the solutions to improve the retention rate and satisfaction of telehealth interventions among this population.

Updates in treatment of depression in children and adolescents

PURPOSE OF REVIEW

To examine recent evidence that informs the treatment of depression in children and adolescents.

RECENT FINDINGS

There are no new leads in the prevention and early intervention of depression in children and adolescents. For acute treatment of major depressive disorder, talking therapies are moving increasingly to internet-based platforms. Family therapy may have a slight edge over individual psychotherapy in the short-term. Patients with severe depression with endogenous features have a more robust response to pharmacotherapy than do patients with mild-to-moderate depression. Findings in relation to reward sensitivity and changes in brain-derived neurotrophic factor levels contradict research conducted in adults, suggesting developmental differences in the mechanisms underlying depression. Ketamine infusion could have a role for adolescents with treatment refractory depression. There was no new evidence concerning relapse prevention.

SUMMARY

Most new findings have been concerned with moderators and mediators of treatment.

An emotion-based online intervention for reducing anxiety and depression in cancer patients: Study protocol for a randomized controlled trial

BACKGROUND

A cancer diagnosis can cause severe emotional distress and affect quality of life as well as social relationships. The transition from inpatient to outpatient treatment is burdened by stressful uncertainties and a gap of psycho-oncological care. In addition, further barriers, such as information deficits or fear of stigmatization, might hinder cancer patients to use psycho-oncological face-to-face interventions. Online interventions can be a low-threshold adjunct to existing face-to-face services. This study aims to evaluate the effect of the online self-help program epos (emotion-based psycho-oncological online self-help) on improving symptoms of anxiety and depression in German-speaking cancer patients.

METHODS

A randomized controlled trial (RCT) is carried out in a parallel group design. N = 325 patients will be enrolled in the trial, randomly assigned to an intervention and a control group. While the intervention group has access to nine modules of epos, the control group gets access to an informational website. Participants will complete online questionnaires at baseline (T0), after the intervention (T1) and three-month follow-up (T2). Primary outcome is a combined measure of depression and anxiety. Secondary outcomes include psychological distress, anxiety, depression, quality of life, emotional control, posttraumatic growth, and satisfaction with epos. Participants are at least 18 years old, have a cancer diagnosis, currently receive cancer treatment or aftercare, have sufficient German language competence, and have access to the Internet. Exclusion criteria are severe mental comorbidities (i.e. severe depression, suicidality) or somatic comorbidities (i.e. visual disabilities).

DISCUSSION

The results of this study will provide information about acceptability, feasibility, and efficacy of epos in improving symptoms of depression and anxiety in cancer patients and thus contribute to the research on web-based interventions. If found efficacious, epos will improve psycho-oncological care in cancer patients in transition from inpatient to outpatient care and in those who struggle to find adequate psycho-oncological support due to other (perceived) barriers.

Working online due to the COVID-19 pandemic: a research and literature review

Given the contemporary situation of many analysts in the world now being forced to work online due to the effects of the COVID‐19 pandemic, it is important to review the working online issue. Substantial debate over previous years has questioned whether a genuine analytic process can unfold through online work. This debate is reviewed with the conclusion that such a process is not necessarily precluded. Research outcomes are then reviewed to highlight those things that can facilitate positive outcomes when working online. These cover the ‘online disinhibition effect’, the therapeutic alliance, particular ways of using the screen, focussing on trauma, the importance of self‐awareness, knowing the predictors of mental health, certain potential positives of isolation/quarantine and psychotherapy interventions that may be currently needed. Final recommendations and suggestions are then presented as in the diagnosis issue, professional development and guidelines to do with practical and ethical considerations.

Feasibility and Efficacy of Delivering Cognitive Behavioral Therapy Through an Online Psychotherapy Tool for Depression: Protocol for a Randomized Controlled Trial

BACKGROUND

Major depressive disorder (MDD) is a prevalent and debilitating mental health disorder. Among different therapeutic approaches (eg, medication and psychotherapy), psychotherapy in the form of cognitive behavioral therapy (CBT) is considered the gold standard treatment for MDD. However, although efficacious, CBT is not readily accessible to many patients in need because of hurdles such as stigma, long wait times, high cost, the large time commitment for health care providers, and cultural or geographic barriers. Electronically delivered cognitive behavioral therapy (e-CBT) can effectively address many of these accessibility barriers.

OBJECTIVE

This study aims to investigate the efficacy and feasibility of implementing an e-CBT program compared with in-person treatment for MDD. It is hypothesized that the e-CBT program will offer results comparable with those of the in-person treatment program, regarding symptom reduction and quality of life improvement.

METHODS

This nonrandomized controlled trial intervention will provide e-CBT for MDD through the Online Psychotherapy Tool, a secure, cloud-based, digital mental health platform. Participants (aged 18-65 years) will be offered 12 weekly sessions of an e-CBT program tailored to MDD to address their depressive symptoms. Participants (n=55) will complete predesigned modules and homework assignments while receiving personalized feedback and interacting with a therapist through the platform. Using clinically validated symptomology questionnaires, the efficacy of the e-CBT program will be compared with that of a group (n=55) receiving in-person CBT. Questionnaires will be completed at baseline, at week 6 and week 12, and at a 6-month follow-up. Focus groups will be conducted to investigate personal, cultural, and social factors impacting the accessibility and feasibility of implementing a web-based psychotherapy tool from a patient and care provider perspective. Inclusion criteria include diagnosis of MDD, competence to consent to participate, ability to speak and read English, and consistent and reliable access to the internet. Exclusion criteria include active psychosis, acute mania, severe alcohol or substance use disorder, and active suicidal or homicidal ideation.

RESULTS

Ethics approval was obtained in January 2019, and recruitment of participants began in June 2019. Recruitment has been conducted via social media, web-based communities, and physician referrals. To date, 52 participants have been recruited to the e-CBT group, and 48 patients have been recruited to the in-person CBT group. Data collection is expected to be completed by March 2021, and analyses are expected to be completed by June 2021, as linear regression (for continuous outcomes) and binomial regression analysis (for categorical outcomes) are still being conducted.

CONCLUSIONS

The results of this study can provide valuable information for the development of more accessible and scalable mental health interventions with increased care capacity for MDD, without sacrificing the quality of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04478058; http://clinicaltrials.gov/ct2/show/NCT04478058.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27489.

The Evidence-Base for Psychodynamic Psychotherapy With Children and Adolescents: A Narrative Synthesis

Despite a rich theoretical and clinical history, psychodynamic child and adolescent psychotherapy has been slow to engage in the empirical assessment of its effectiveness. This systematic review aims to provide a narrative synthesis of the evidence base for psychodynamic therapy with children and adolescents. Building on two earlier systematic reviews, which covered the period up to 2017, the current study involved two stages: an updated literature search, covering the period between January 2017 and May 2020, and a narrative synthesis of these new studies with those identified in the earlier reviews. The updated search identified 37 papers (28 distinct studies). When combined with papers identified in the earlier systematic reviews, this resulted in a combined total of 123 papers (82 distinct studies). The narrative synthesis of findings indicates that there is evidence of effectiveness for psychodynamic therapy in treating a wide range of mental health difficulties in children and adolescents. The evidence suggests this approach may be especially effective for internalizing disorders such as depression and anxiety, as well as in the treatment of emerging personality disorders and in the treatment of children who have experience of adversity. Both the quality and quantity of empirical papers in this field has increased over time. However, much of the research demonstrates a range of methodological limitations (small sample sizes, lack of control groups etc.), and only 22 studies were Randomized Controlled Trials. Further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy for children and young people.

Die Affektphobietherapie

Hintergrund

Ein zentraler Faktor psychischer Gesundheit ist die Fähigkeit, Affekte wahrnehmen und adaptiv regulieren zu können. Die Verbesserung dieser Fähigkeit ist ein Ziel der psychodynamischen Psychotherapie. Psychodynamische Behandlungsmodelle, die sich aus der gut validierten Tradition der „short-term dynamic psychotherapy“ (STDP) ableiten und die heute unter dem Dach der International Experiential Dynamic Therapy Association (https://iedta.net/) versammelt sind, legen auf besondere Weise den Behandlungsfokus auf das emotionale Erleben. Ein derartiges psychodynamisches transdiagnostisches Behandlungsmodell ist die Affektphobietherapie (APT).

Ziel der Arbeit (Fragestellung)

Ziel der Übersicht ist es, den Leser mit dem Behandlungsrational und der Evidenz der APT vertraut zu machen.

Material und Methoden

Es werden die theoretischen Grundlagen der APT, typische Interventionen und Prozessinstrumente beschrieben. Die Evidenz des APT-Modells wird als narrative Übersicht der Studienlage dargestellt.

Ergebnisse und Schlussfolgerung

Die APT ist ein evidenzbasiertes psychodynamisches Behandlungsmodell. Das Rational ist schulenübergreifend. Ein Selbsthilfeprogramm auf der Basis der APT wird von Patienten gut aufgenommen. Manualisierung, Fertigkeitenorientierung und Prozessinstrumente machen es zu einem vielversprechenden Modell für die Aus- und Fortbildung.

Characteristics of effective online interventions: implications for adolescents with personality disorder during a global pandemic

In recent years, the necessity of providing online interventions for adolescents, as an alternative to face-to-face interventions, has become apparent due to several barriers some adolescents face in accessing treatment. This need has become more critical with the coronavirus disease 2019 (COVID-19) global pandemic impacting the delivery of psychotherapy and limiting accessibility of face-to-face therapy. Whilst it has been established that face-to-face psychotherapy for adolescents with personality disorder can be effective in reducing the impact these complex mental illnesses have on functioning, online interventions for adolescents are rare, and to our knowledge there are no empirically validated online interventions for personality disorder. The development of novel online interventions are therefore necessary. To inform the development of online interventions for adolescents with personality disorder or symptoms of emerging personality disorder, a two-phase rapid review was conducted. Phase one consisted of a search and examination of existing online mental health programs for adolescents with symptoms of personality disorder, to understand how to best use online platforms. Phase two consisted of a rapid review of empirical literature examining online interventions for adolescents experiencing symptoms of personality disorder to identify characteristics that promote efficacy. There were no online programs specific to personality disorder in adolescence. However, 32 online mental health programs and 41 published empirical studies were included for analysis. Common intervention characteristics included timeframes of one to two months, regular confidential therapist contact, simple interactive online components and modules, and the inclusion of homework or workbook activities to practice new skills. There is an urgent need for online interventions targeting personality dysfunction in adolescence. Several characteristics of effective online interventions for adolescents were identified. These characteristics can help inform the development and implementation of novel online treatments to prevent and reduce the burden and impact of personality disorder, or symptoms of emerging personality disorder, in adolescents. This has implications for the COVID-19 pandemic when access to effective online interventions has become more urgent.

Transitioning from face-to-face treatment to iCBT for youths in primary care - therapists' attitudes and experiences

BACKGROUND

To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care.

METHODS

Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories.

RESULTS

The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist.

CONCLUSION

The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists' positive experiences support the introduction of iCBT for youths in routine primary care.

Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents

Objective: Sudden gains (SGs) have often been found associated with better treatment outcome across different psychiatric disorders. However, no studies have evaluated SGs in internet-based treatment targeting adolescent depression. Method: The sample consisted of 66 adolescents diagnosed with major depressive disorder, attending psychodynamic internet-based treatment. Effects of SGs were evaluated at posttreatment and 6-month follow-up. We also evaluated effects of large intersession improvements (LIIs; sudden and relatively large gains, between sessions, without the stability criterion). Effects of SGs and LIIs early in treatment were also investigated. Results: A total of 17 patients (25.75%) experienced an SG. The effect of having an SG or early SG was non-significant after treatment (d = 0.48) and at follow-up (d = 0.66). However, having an LII was related to better outcome after treatment (d = 0.97) and at follow-up (d = 0.76). Early LIIs were associated with significantly better results at end of treatment (d = 0.72). Conclusions: The original criteria of SGs might be overly conservative and thus miss important improvements in depression. Relatively large intersession gains, regardless of stability, seem to be predictive of outcome.

Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression: study protocol for a non-inferiority randomized controlled trial (the ERiCA study)

Background

Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

Methods

The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15–19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

Discussion

This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about “what works for whom” and the pathways of change for two distinct types of interventions.

Trial registration

ISRCTN12552584, Registered on 13 August 2019.

Emotion Regulation as a Time-Invariant and Time-Varying Covariate Predicts Outcome in an Internet-Based Psychodynamic Treatment Targeting Adolescent Depression

OBJECTIVE

Although psychodynamic psychotherapy is efficacious in the treatment of depression, research on mechanisms of change is still scarce. The aim of this study was to investigate if and how emotion regulation affects outcome both as a time-invariant and a lagged time-varying predictor.

METHOD

The sample consisted of 67 adolescents diagnosed with major depressive disorder, attending affect-focused psychodynamic internet-based treatment (IPDT). Linear mixed models were used to analyze emotion regulation as a baseline predictor and to assess the effect of within-person changes in emotion regulation on depression.

RESULTS

Analyses suggested that emotion regulation at baseline was a significant predictor of outcome, where participants with relatively larger emotion regulation deficits gained more from IPDT. Further, the results showed a significant effect of improved emotion regulation on subsequent depressive symptomatology. When not controlling for time, increased emotion regulation explained 41.23% of the variance in subsequent symptoms of depression. When detrending the results were still significant, but the amount of explained variance was reduced to 8.7%.

CONCLUSION

The findings suggest that patients with relatively larger deficits in emotion regulation gain more from IPDT. Decreased emotion regulation deficits seem to act as a mechanism of change in IPDT as it drives subsequent changes in depression.Clinical Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 16206254, https://doi.org/10.1186/ISRCTN16206254.