Primary Care Online Emotion-regulation Treatment (POET)

Study Overview
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Brief Summary
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Mental health problems in youth are a global problem, causing incalculable suffering in youth and families, harming long-term prospects of youths, and creating substantial economic costs to society. The overall objective of this study is to build an evidence base for a highly scalable transdiagnostic intervention called the Primary care Online Emotion-regulation Treatment (POET) for youth (12-17 years) seeking treatment for mental health problems. In a randomized controlled trial, the investigators will examine the effects of POET. The investigators will test if emotion regulation mediates reduction in mental health problems during treatment. In addition the investigators will test if POET is more effective for some individuals than others and evaluate if POET is cost-effective. The investigators will also test whether there are detectable effects of POET on distal outcomes utilizing registry data following participants up to 10 years post treatment.

Detailed Description
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Introduction: Mental health problems among young people are prevalent and many youth in need of treatment for mental health problems do not meet criteria for any mental health disorder or they meet criteria for several disorders. Most existing treatments focus on a subset of mental disorders and do not address subthreshold or multi-disorder mental health problems. In addition, available treatments do not typically target transdiagnostic disease mechanisms. Furthermore, the available treatments are limited in efficacy and most youth in need do not receive treatment due to social stigma and structural barriers such as geographical distance to treatment providers. The aim of this randomized clinical trial is to determine the clinical efficacy of a digital emotion regulation treatment in adolescents with mental health problems. Participants will be randomized to a digital emotion regulation treatment or to an active comparator. Treatments in both conditions will include therapist support, and will be delivered in a blended treatment format combining asynchronous therapist-guided online modules with one synchronous session delivered over video-link. The primary endpoint is at post- treatment. Primary objectives: To test the effects of POET on mental health problems. To test the effects of POET on emotion regulation. Secondary objectives: To test if emotion regulation mediates reductions in mental health problems during treatment. To test if POET is cost-effective. To test if POET works better for some individuals than others (i.e., moderation). To test if there are detectable differences in distal outcomes between POET and active control 12 to 60 months post treatment and if individual baseline characteristics moderates these effects. Research questions: What are the effects of POET on mental health problems? What are the effects of POET on emotion regulation? Are reductions in mental health problems during the POET treatment mediated through emotion regulation? Is POET feeling cost-effective? Does POET work better for some individuals than others? Are there detectable differences in distal outcomes between POET and active control 12 to 60 months post treatment and if individual baseline characteristics moderates these effects

Official Title
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Primary Care Online Emotion-regulation Treatment (POET)

Conditions
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Mental Health Issue

Intervention / Treatment
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* Behavioral: POET feeling
* Behavioral: Supportive treatment


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age between 12 - 17 years Seeking care for mental health problems At least one guardian interested in participating in the parent program Deemed capable of making decisions Exclusion Criteria: Psychiatric problems that require more extensive treatment. Low global functioning (under 41 points on clinician rated C-GAS or functioning that requires more extensive treatment). Elevated suicide risk Insufficient Swedish comprehension. Life circumstances that complicate or make treatment impossible (eg severe deficits in parental care, domestic violence).

Ages Eligible for Study
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Minimum Age: 12 Years
Maximum Age: 17 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: POET feeling<br>POET will include six guided digital treatment modules for the youth, and six modules for the parents administered over the course of six weeks. | Behavioral: POET feeling<br>* POET is adapted from online Emotion Regulation Individual Therapy for Adolescents developed by the research group (ClinicalTrials.gov Identifier: NCT03353961). POET is also based on the Modal model of emotion and Process model of emotion regulation that provides a framework for understanding how emotions are generated, experienced and how they can be regulated. The youth component of POET will include psychoeducation, addressing maladaptive beliefs about emotions and emotion regulation, and teaching adaptive emotion regulation strategies, such as acceptance of emotions and flexible cognitive reappraisal. The parent component will include psychoeducation and teaching effective support and responding to their adolescent's and their own emotions.<br>|
| Active Comparator: Supportive treatment<br>The active control will be supportive treatment. It includes six guided digital treatment modules for the youth, and six modules for the parents administered over the course of six weeks. | Behavioral: Supportive treatment<br>* The treatment will include educative material on mental health and self-reflection on themes such as school, family and friends. The parent component will include educative material and self reflection in how to support their adolescent.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The Clinical Global Impressions -Severity scale (CGI-S) | Used to assess symptom severity rated on a single item ranging from 1-7, with higher scores indicating more severe symptoms. Clinician-rated. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The Clinical Global Impressions - Improvement scales (CGI-I) | Used to assess symptom improvement rated on a single item ranging from 1-7, with lower scores indicating more improvement. Clinician-rated. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| The Revised Child Anxiety and Depression Scale-C (RCADS-C) | Used to assess symptoms of depression and anxiety. This scale has 47 items, total score ranging from 0 to 141, with higher scores indicating more severe symptoms. Clinician-rated. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| The Revised Child Anxiety and Depression Scale-P (RCADS-P) | Used to assess symptoms of depression and anxiety in their offspring. This scale has 47 items, total score ranges from 0 to 141 points, with higher scores indicating more severe symptoms. Caregiver-reported. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| Brief 11-item version of the Revised Child Anxiety and Depression Scale for Adolescents (RCADS-11) | Used to assess symptoms of depression and anxiety in children and adolescents. This scale has 11 items, total score ranges from 0-33 points, with higher scores indicating more severe symptoms. Self-rated by adolescents. | Week 0 and Week 1, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7 after treatment start and 3,12 and 60 months after treatment has ended | 
| Children's global assessment scale (CGAS) | Used to assess global impairment on a single item ranging from 1 to 100, with a higher value indicating better functioning. Clinician-rated. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| The Work and Social Adjustment Scale (WSAS) | Used to assess impaired functioning in school, everyday life, friends and social life, recreation and hobbies and family and close relationships. This scale has 5 items, total score ranges from 0 to 40, with higher scores indicating greater impairment. Clinician-rated. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| The Positive and Negative Affect Schedule for Children (PANAS-C) | Used to assess positive and negative feelings. This scale has 2 subscales. Each total subscale score range from 5-25, with higher scores indicating more negative or positive feelings. Self-rated by adolescents. | Week 0 and Week 1, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7 after treatment start and 3,12 and 60 months after treatment has ended | 
| The Emotion Regulation Questionnaire for Children and Adolescents (ERQ-CA) | Used to assess cognitive reappraisal. The subscale has 6 items, total subscale score ranges from 6-30, with higher scores indicating greater usage of cognitive reappraisal. Self-rated by adolescents. | Week 0 and Week 1, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7 after treatment start and 3,12 and 60 months after treatment has ended | 
| Difficulties in Emotion Regulation Scale - 16 item version (DERS-16) | Used to assess difficulties in emotion regulation. The scale has 16 items, total score ranges from 16-80, with higher scores indicating more difficulties. Self-rated by adolescents. One subscale named impulse (3 items ranging from 3-15) will be administered once every week during treatment. | Week 0 and Week 1, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7 after treatment start and 3,12 and 60 months after treatment has ended | 
| The Process Model of Emotion Regulation Questionnaire -short (PMERQ-S) | Used to assesses individual differences in emotion regulation. This scale has 30 items, total score ranges from 30-180, with higher scores indicate a greater usage of emotion regulation. Self-rated by adolescents. The three subscales named Confront unpleasant situations (3 items, totalt subscale score ranges from 6-18), Avoid unpleasant situations (3 items, totalt subscale score ranges from 6-18) and Cognitively distract (3 items, totalt subscale score ranges 6-18) will administered to adolescents weekly. | Week 0 and Week 1, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7 after treatment start and 3,12 and 60 months after treatment has ended | 
| The Perth Alexithymia Questionnaire-Short Form (PAQ-S) | Used to assess alexithymia. This scale has 6 items, totalt score ranges from 6 to 42, with higher scores indicate higher levels of alexithymia. Self-rated by adolescents. | Week 0 and Week 1, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7 after treatment start and 3,12 and 60 months after treatment has ended | 
| Self-Efficacy Questionnaire for Children (SEQ-C) | Used to assess social self-efficacy. The subscale named social self-efficacy has 8 items, total subscale score ranges from 8-40, with higher scores indicating greater social self-efficacy. Self-rated by adolescents. | Week 0 and Week 1, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7 after treatment start and 3,12 and 60 months after treatment has ended | 
| Child Health Utility 9D (CHU-9D) | Used to assess health-related quality of life. This scale has 9 items, total score ranges from 9 to 45, with higher scores indicating worse quality of life. Self-rated by adolescents. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| Borderline symptoms checklist supplement (BSL-23) | Used to assess high-risk and problematic behaviors. This scale has 10 items, total score ranges from 0 to 40, with higher scores indicating greater usage of high-risk and problematic behaviors. Self-rated by adolescents. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| The Emotion Beliefs Questionnaire (EBQ) | Used to assess beliefs about emotions. This scale 16 items, total score ranges from 16 to 112, with higher scores indicating more maladaptive beliefs about emotions. Self-rated by adolescents. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| Coping with Children's Negative Emotions Scale Adolescent Version (CCNES-A) | Used to assess parents' perceived ability to cope with children's negative emotions. This scale has six subscales which include emotion focused, problem-focused, minimization, punitive, expressive encouragement, and distress responses. Each subscale has 9 items, total subscale score ranges from 1-7, with higher scores indicating greater usage of a certain parental coping style. Care-giver reported. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| Difficulties in Emotion Regulation Scale - 16 item version (DERS-16) | Used to assess difficulties in emotion regulation. The scale has 16 items, total score ranges from 16-80, with higher scores indicating more difficulties. Self-rated by parents. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| Behavioral emotion regulation questionnaire (BERQ) | Used to assess parents' perception of the adolescent's behavioral emotion regulation. This scale has 5 subscales. Each total subscale score ranges from 4-20, with higher scores indicating greater usage of a certain strategy. Care-giver reported. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended | 
| Trimbos Questionnaire for Costs associated with Psychiatric Illness (TiC-P) | Used to assess healthcare and other societal resource use for both children and caregivers. Caregiver-reported. | Week 0, 7 weeks after treatment start and 3,12 and 60 months after treatment has ended |