The role of emotion regulation in early intervention and prevention of mental health problems in adolescents

The present thesis examined the role of emotion regulation in the early intervention and prevention of mental health problems in adolescents. The research literature identifies six principle emotion regulation strategies: cognitive reappraisal, problem-solving, interpersonal emotion regulation, response modulation, acceptance, and up-regulating positive emotions. To date, early intervention and prevention programs have primarily been based on cognitive reappraisal, with few studies that evaluated the others. However, research has indicated that all six strategies are important to manage life adversities and address symptoms of anxiety and depression and thus adolescents may be under-equipped in learning only the strategy of cognitive reappraisal.The present thesis comprises three studies: a) a feasibility quasi-randomised controlled evaluation of an acceptance-based program derived from acceptance and commitment therapy using a sample of 48 high school students; b) a combined acceptance and up-regulating positive emotions program, Strong Minds, evaluated in a sample of 267 students using a randomised controlled study design; and c) a feasibility study using a randomised controlled design of a comprehensive emotion regulation program based on dialectical behaviour therapy evaluated in a sample of 96 high school students. All three programs were delivered at the school in a large-group format by the PhD candidate. The control condition consisted of students usual classes, either Pastoral Care or career guidance classes.In all three studies, either qualitative data or effect sizes suggested that compared to the control condition, the program evaluated was beneficial for helping to reduce symptoms of anxiety and depression. Furthermore, in the Strong Minds program, the differences in anxiety and depression scores were statistically significant. Differences were observed between the outcome measures, with scales focused more on symptoms of anxiety and depression demonstrating greater improvement than those that measured presence of emotions such as anger, anxiety, and sadness.These results suggest that early intervention and prevention programs should consider the range of emotion regulation strategies. Adolescents may need training in all emotion regulation strategies, as well as how to apply them depending on the demands of the situation, to effectively manage life adversities without developing mental health symptoms

A randomized controlled trial of strong minds: A school-based mental health program combining acceptance and commitment therapy and positive psychology

To date, most early intervention programs have been based on emotion regulation strategies that address dysfunctional cognitive appraisals, problem-solving skills, and rumination. Another emotion regulation strategy, 'acceptance' training, has largely been overlooked. To examine the efficacy of this strategy, a school-based mental health program combining positive psychology with acceptance and commitment therapy (Strong Minds) was evaluated in a randomized controlled trial with a sample of 267 Year 10 and 11 high-school students in Sydney, Australia. Mixed models for repeated measures examined whether the program led to reductions in symptoms amongst students who commenced the program with high depression, anxiety, and stress scores, and increased wellbeing scores amongst all students. Results demonstrated that compared to controls, participants in the Strong Minds condition with elevated symptom scores (n=63) reported significant reductions in depression (p=.047), stress (p=.01), and composite depression/anxiety symptoms (p=.02) with medium to strong effect sizes (Cohen's d=0.53, 0.74, and 0.57, respectively). Increased wellbeing (p=.03) in the total sample and decreased anxiety scores (p=.048) for students with elevated symptoms were significant for Year 10 students with medium effect sizes (Cohen's d=0.43 and 0.54, respectively). This study tentatively suggests that including the emotion regulation strategy of acceptance in early intervention programs may be effective in reducing symptoms and improving wellbeing in high school students. Further research to investigate the generalizability of these findings is warranted

Acceptance and commitment therapy universal prevention program for adolescents: A feasibility study

Background: There is a need to prevent anxiety and depression in young people and mindfulness contains important emotion regulation strategies. Acceptance and commitment therapy (ACT), a mindfulness-based therapy, has yet to be evaluated as a prevention program, but has demonstrated an ability to reduce symptoms of anxiety and depression in adult and adolescent populations. This study examines the feasibility of using an ACT-based prevention program in a sample of year 10 (aged 14-16 years) high school students from Sydney, Australia. Methods: Participants were allocated to either their usual classes or to the ACT-based intervention. Participants were followed for a period of 5 months post-intervention and completed the Flourishing Scale, Depression Anxiety Stress Scale, and a program evaluation questionnaire. Analyses were completed using intention-to-treat mixed models for repeated measures. Results: The results indicated that the intervention was acceptable to students and feasible to administer in a school setting. There were no statistically significant differences between the conditions, likely due to the small sample size (N = 48). However, between-group effect sizes demonstrated small to large differences for baseline to post-intervention mean scores and medium to large differences for baseline to follow-up mean scores, all favouring the ACT-based condition. Conclusion: The results suggest that an ACT-based school program has potential as a universal prevention program and merits further investigation in a larger tria

Legal aspects of medical practice : the journal of legal medicine ; publ. of the American College of Legal Medicine

Background: Adolescent mental health is characterized by relatively high rates of psychiatric disorders and low levels of help-seeking behaviors. Existing mental health programs aimed at addressing these issues in adolescents have repeated inconsistent results. Such programs have generally been based on techniques derived from cognitive behavioral therapy, which may not be ideally suited to early intervention among adolescent samples. Positive psychology, which seeks to improve well-being rather than alleviate psychological symptoms, offers an alternative approach. A previous community study of adolescents found that informal engagement in an online positive psychology program for up to 6 weeks yielded significant improvements in both well-being and depression symptoms. However, this approach had not been trialed among adolescents in a structured format and within a school setting. Objective: This study examines the feasibility of an online school-based positive psychology program delivered in a structured format over a 6-week period utilizing a workbook to guide students through website content and interactive exercises. Methods: Students from four high schools were randomly allocated by classroom to either the positive psychology condition, "Bite Back", or the control condition. The Bite Back condition consisted of positive psychology exercises and information, while the control condition used a series of non-psychology entertainment websites. Both interventions were delivered online for 6 hours over a period of 4-6 weeks during class time. Symptom measures and measures of well-being/flourishing and life satisfaction were administered at baseline and post intervention. Results: Data were analyzed using multilevel linear modeling. Both conditions demonstrated reductions in depression, stress, and total symptom scores without any significant differences between the two conditions. Both the Bite Back and control conditions also demonstrated significant improvements in life satisfaction scores post intervention. However, only the control condition demonstrated significant increases in flourishing scores post intervention. Conclusions: Results suggest that a structured online positive psychology program administered within the school curriculum was not effective when compared to the control condition. The limitations of online program delivery in school settings including logistic considerations are also relevant to the contradictory findings of this study. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN1261200057831; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362489 (Archived by Webcite at http://www.webcitation.org/6NXmjwfAy)

Preventing mental health symptoms in adolescents using dialectical behaviour therapy skills group: a feasibility study

Previous prevention programmes have largely focused on the emotion regulation strategy of cognitive reappraisal. The present study is a feasibility trial that evaluates a prevention programme that teaches cognitive reappraisal, acceptance and problem-solving strategies. Ninety-six Year 10 high school students were randomly allocated to either the intervention or control condition. All participants completed scales evaluating emotion regulation difficulties, depression, anxiety and anger at baseline, post-intervention and at 6-month follow-up. In addition, the intervention condition completed a workshop evaluation questionnaire at post-intervention that included qualitative items. Mixed models for repeated measures and content analysis were used to analyse the data. Results suggested there were no statistical differences between the conditions although effect sizes suggested a small advantage favouring the control condition. On the qualitative evaluation, however, most participants reported important benefits in relation to improved emotion regulation abilities. These contrasting results are discussed and suggestions made for future research

The Ins and Outs of an Online Bipolar Education Program: A Study of Program Attrition

Background: The science of eHealth interventions is rapidly evolving. However, despite Background: The science of eHealth interventions is rapidly evolving. However, despite positive outcomes, evaluations of eHealth applications have thus far failed to explain the high attrition rates that are associated with some eHealth programs. Patient adherence remains an issue, and the science of attrition is still in its infancy. To our knowledge, there has been no in-depth qualitative study aimed at identifying the reasons for nonadherence to-and attrition from-online interventions. Objective: This paper explores the predictors of attrition and participant-reported reasons for nonadherence to an online psycho-education program for people newly diagnosed with a bipolar disorder. Methods: As part of an ongoing randomized controlled trial (RCT) evaluating an online psycho-education program for people newly diagnosed with a bipolar disorder, we undertook an in-depth qualitative study to identify participants' reasons for nonadherence to, and attrition from, the online intervention as well as a quantitative study investigating predictors of attrition. Within the RCT, 370 participants were randomly allocated to 1 of 2 active interventions or an attention control condition. Descriptive analyses and chi-square tests were used to explore the completion rates of 358 participants, and standard regression analysis was used to identify predictors of attrition. The data from interviews with a subsample of 39 participants who did not complete the online program were analyzed using "thematic analysis" to identify patterns in reported reasons for attrition. Results: Overall, 26.5% of the sample did not complete their assigned intervention. Standard multiple regression analysis revealed that young age (P=.004), male gender (P=.001), and clinical recruitment setting (P=.001) were significant predictors of attrition (F7,330= 8.08, P<.001). Thematic analysis of interview data from the noncompleter subsample revealed that difficulties associated with the acute phases of bipolar disorder, not wanting to think about one's illness, and program factors such as the information being too general and not personally tailored were the major reasons for nonadherence. Conclusions: The dropout rate was equivalent to other Internet interventions and to face-to-face therapy. Findings from our qualitative study provide participant-reported reasons for discontinuing the online intervention, which, in conjunction with the quantitative investigations about predictors, add to understanding about Internet interventions. However, further research is needed to determine whether there are systematic differences between those who complete and those who do not complete eHealth interventions. Ultimately, this may lead to the identification of population subgroups that most benefit from eHealth interventions and to informing the development of strategies to improve adherence

Effects of adjunctive peer support on perceptions of illness control and understanding in an online psychoeducation program for bipolar disorder : a randomised controlled trial

Objectives: To examine the comparative effectiveness of an online psychoeducation program for people diagnosed with bipolar disorder within the previous 12 months, completed alone or with adjunctive peer support, on symptoms and perceived control over the illness. Method: Participants were randomly allocated to an eight-week online psychoeducation program (n=139), a psychoeducation program plus online peer support (n=134) or an attentional control condition (n=134). Results: Increased perceptions of control, decreased perceptions of stigmatisation and significant improvements in levels of anxiety and depression, from pre- to post-intervention were found across all groups. There were no significant differences between groups on outcome measures, although a small clinical difference was found between the supported and unsupported conditions in depression symptoms and in functional impairment at the six-month follow-up. Adherence to the treatment program was significantly higher in the supported intervention than in the unsupported program. Gender and age were also significant predictors of adherence, with females and those over the age of 30 showing greater adherence. Limitations: Mood state at study entry was measured by self-report rather than by clinical interview. Conclusions: The pattern of outcomes suggests a primary influence of non-specific or common therapeutic factors across all three intervention groups. A personally tailored intervention may be more suitable for individuals recently diagnosed with bipolar disorder, and longer term coaching may increase program adherence and long-term improvement in symptoms and functioning