Erik Forsell

Self-injury is a growing health crisis among youth, and the strongest risk factor for suicide attempts. Scalable treatments are needed but lacking. We have recently shown that a brief digital treatment, IERITA (Internet-delivered Emotion Regulation Individual Therapy for Adolescents), can be efficacious and cost-effective. However, not all patients respond sufficiently to the standard treatment procedure. Now we aim to implement and evaluate IERITA within regular health services and optimize treatment outcomes. First, we will develop and validate a classification tool to predict non-remission (continued self-injury after treatment). This tool will subsequently be used in the second step: a randomized controlled trial (N=341) between 2025 to 2028, which compares adaptable to standard IERITA. Adolescents allocated to adaptable IERITA and classified as likely non-remission in treatment week four will recieve adapted IERITA (e.g., personalized dose and treatment delivery) for the remaining eight weeks. We will (1) follow participants one- three- and twelve-month post-treatment

(2) use self-reports and blinded assessments

(3) study distal effects in national registers

(4) investigate several clinically relevant outcomes

and (5) conduct cost-effectiveness analyses. If successful, more patients could receive evidence-based treatment for self-injury, and treatment outcomes could be improved. In extension, queues to care may be reduced, and suicide attempts and suicides prevented.

Research idea and purposeSelf-injury is a growing and urgent health crisis among youth and the strongest risk factor for suicide attempts. Scalable and evidence-based treatments are needed but lacking. We have recently shown that a brief digital treatment, IERITA (Internet-delivered Emotion Regulation Individual Therapy for Adolescents), can be efficacious compared to treatment as usual only. However, not all patients respond sufficiently to the standard treatment procedure, and established efficacy does not guarantee successful uptake in regular care. This project aims to implement and evaluate IERITA in real-world settings and optimize treatment outcomes. A planning grant creates opportunities to test the project´s feasibility, an essential part of preparation for a large-scale study.Work plan, methods and project realisationFirst, a classification tool to predict continued self-injury after treatment (non-remission) will be developed and subsequently used in a randomized controlled pilot trial (N=30) comparing adaptable to standard IERITA. Adolescents allocated to adaptable IERITA and classified as likely non-remission in treatment week four will change to adapted IERITA (e.g., personalized dose and treatment delivery) for the remaining eight weeks. Feasibility will be evaluated through the number of completed treatment parts, degree of participation in data collection, satisfaction, adherence, and therapist time. Clinically relevant outcomes will also be measured, which include remission (primary clinical outcome), frequency of self-injurious behaviour, suicidality and level of functioning. Participants will be followed up one- and three months post-treatment. The project will be conducted within regular health care services in several regions which we have collaborated with previously. Patient organizations and health professionals will contribute to increasing relevance and feasibility. The budget includes salaries for the project manager and patient organization, and a smaller part for operating costs.Societal relevance and utilisationSelf-injury is rapidly increasing, posing severe risks for youths. The queue to healthcare services is long, and current treatments are costly and not widely or equally accessible. If this project is successful, more youths across the country could receive effective early intervention for self-injury, with the hope of reduced waiting times, equal care, and suicide preventive effects.

About 15% of mothers suffer from postpartum depression, which besides their suffering often affects the relation to the child and partner negatively. Depression during pregnancy constitutes a high risk for postpartum depression, and better screening and access to treatment is needed.Mom2B is a mobile application aimed towards all pregnant individuals, and includes screening for depression. If detected, general information regarding health care for depression is presented. We want to randomize half of these indicated risk users to instead receive targeted information about guided, internet-based CBT (ICBT) for depression during pregnancy.Our hypothesis is that more of these will start our evidence-based ICBT and lower their symptom levels and risk for postpartum depression 8-10 weeks after delivery, measured with structured interview and registry data. We also expect the strategy with targeted information and ICBT to be beneficial from a health economic perspective. ICBT is preceded by an assessment, and during the 12-week treatment the participant works with a self-help material while actively supported by a psychologist via text messages. We have evaluated the ICBT-program used in this study with positive results, but in line with other research on ICBT we have seen that more support and adjustments are often asked for. In line with Personalized Care, we will thus randomize some of those seeking ICBT, via Mom2B or other channels, to receive more personalized care by letting them choose type of visits (physical/video/telephone) and get extra visits with a midwife with the purpose of better adjusting the care to their needs. Others will receive no extra visits and are randomized to type of visit. For sub-analyses, some also choose type of visit but receive no extra visits, and vice versa.Our hypothesis is that personalized ICBT will lead to increased treatment engagement and patient empowerment, as well as reduced symptoms and risk for postpartum depression.