Johan Bjureberg

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.

Research idea and purposeThis application pertains to a preparatory study within a larger project on jealousy. The goal of this study is to generate knowledge for advancing assessment and developing treatment for obsessional jealousy. Despite jealousy leading to significant suffering for individuals and their partners, and in its most severe form being the second most common cause of men’s lethal violence against women in intimate relationships, research on how to treat jealousy is almost nonexistent.The study consists of three parts. Part 1 investigates whether obsessional jealousy meets the criteria for being considered a psychiatric condition. Part 2 explores how we can understand obsessional jealousy from a learning-theoretical perspective and how it can be treated within the framework of cognitive-behavioral therapy (CBT). Part 3 involves workshops with psychologists and representatives from organizations and agencies working on this issue, aiming to develop a CBT-program for obsessional jealousy.Work plan, methods and project realizationTo explore the boundary between obsessional and "normal" jealousy, 60 participants with varying levels of jealousy will be recruited. Participants will undergo a telephone screening and complete an online survey. All participants will be interviewed by a psychiatrist, and those with significant suffering or impairment will also be interviewed by a psychologist. Finally, three workshops aimed at developing a treatment program will be conducted.The study is approved by the Swedish ethical review authority. The research team has extensive expertise in anxiety, obsessive-compulsive disorders and anger. The study will commence in January 2025, with recruitment and interviews until June 2025. Workshops to develop the treatment program will be held in the fall of 2025.Societal relevance and utilizationThe study is highly relevant because it (1) addresses a significant research gap, (2) has the potential to lead to the development of an effective treatment for individuals with obsessional jealousy, and (3) could, in the long term, reduce negative consequences for partners and family members and ultimately help prevent serious events such as violence.The research team’s close connection with clinical practice provides a solid foundation for developing a treatment for jealousy within this study’s framework and for implementing it in the future, which could benefit many individuals.

Suicide is the leading cause of death among 10–18-year-olds in Sweden. Suicide attempt is the most robust predictor of future attempts and suicide. Yet, no evidence-based treatment currently exists for preventing suicide reattempts. Safe Alternatives for Teens and Youths (SAFETY) is a novel scalable family-based cognitive-behavioural suicide prevention program designed to fill this critical gap. SAFETY has shown promise in reducing suicide attempts. In the present trial we aim to evaluate the effect of SAFETY on youth suicide attempts by comparing SAFETY to the active control condition “Enhanced Treatment as Usual” in a randomized clinical trial (RCT

N=282), recruiting from five sites across Sweden. The analyses will be conducted on an intention-to-treat basis. The primary outcome is the difference in the proportion of individuals with a new suicide attempt between the two groups at 3- (primary end-point) and 12-month post-treatment, analyzed using Pearson´s chi-squared test. Patients will be enrolled and treated between 2025 and 2027. Our initial findings from a feasibility RCT of SAFETY (N=30) in Stockholm indicate that our research protocol, including participant recruitment and treatment conditions, is feasible. The present study will investigate the impact of SAFETY on suicide attempts, evaluate the durability of the effects, and evaluate the cost-effectiveness of the intervention. The pilot and planning for the RCT have already been partially funded by other sources.

Suicide is the leading cause of death for ages 10-19 years in Sweden. The most reliable predictor of suicide is self-harm (including suicide attempts). Decades of research have failed to produce reliable assessments of risk factors for self-harm that could be applied with confidence in the clinic. Further, few evidence-based out-patient treatments for self-harm exist to date. Instead, involuntary care is increasingly used in this population, despite evidence indicating that it may worsen prognosis. Two studies will be conducted. Study 1 aims to identify clinically applicable risk factors of self-harm and Study 2 is a randomized clinical trial for youth who self-harm. Study 1 will for the first time assess youth at risk of self-harm prospectively (aged 12 to 14 years) at two timepoints: pre onset of self-harm and at follow-up. Participants will be assessed using a range of psychophysiological, cognitive, and psychosocial measures, with a particular focus on pain-sensitivity. Identified individuals with self-harm will be included in a parallel randomized controlled trial (total N=200) of a cognitive behavioral family treatment targeting risk factors for self-harm and suicide, compared to an active control group. By identifying clinically applicable risk factors and evaluating a potentially effective out-patient intervention, this project aims to reduce the need for involuntary care and prevent suicide in youth.

Mental health problems in youth is causing incalculable suffering in youth and families. Existing treatments in Primary Care are not fully addressing these problems because they focus on a subset of mental health problems

are limited in efficacy, and are not provided to most youth in need. Transdiagnostic online treatments addressing mechanisms underlying mental health problems, such as emotion regulation, have been called for. We will include 388 participants aged 12-17 years and their parents in a RCT comparing a 6-week Primary care Online Emotion-regulation Treatment (POET) to a 6-week active Supportive Treatment (ST) during 2023-2025, at several Primary Care clinics across Sweden. Both interventions will be delivered in blended format combining online therapist-supported treatment modules with a video-link session. Findings from our pilot RCT (N=30) demonstrated that the study procedures and treatment protocols are feasible and that POET is promising. The primary study aims are to examine the effects of POET vs ST at post-treatment, 3-, and 12-month follow-up on mental health problems, emotion regulation, and to test whether changes in emotion regulation mediates reduction in mental health problems. The broad long-term goal is to examine cost-effectiveness, for whom the treatment is efficacious, and to show how a brief treatment provided in youth in a Primary Care setting may have a positive impact on the trajectory into young adulthood.