Emotion regulation refers to the processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions.
Effective emotion regulation involves managing emotional responses in a way that allows for adaptive functioning and goal-directed behavior.
People with depression and anxiety disorders (e.g., generalized anxiety or social anxiety) often struggle with emotion regulation, experiencing difficulties in identifying, understanding, and effectively managing their emotional responses.
This can lead to a vicious cycle where negative emotions become overwhelming and contribute to the maintenance of depressive and anxious symptoms.
Incorporating emotion regulation training into therapy may be important because it directly targets a key mechanism underlying these disorders. By helping individuals develop adaptive emotion regulation strategies, such training can enhance their ability to cope with negative emotions, reduce the intensity and duration of depressive and anxious states, and improve overall functioning.
Wisman, M. A., Emmelkamp, J., Dekker, J. J., & Christ, C. (2023). 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. Internet interventions, 31, 100596. https://doi.org/10.1016/j.invent.2022.100596
Key Points
- Internet-based emotion regulation training (ERT) added to cognitive behavioral therapy (CBT) appears feasible and acceptable for treating adolescents with depressive and anxiety disorders.
- Preliminary results indicate CBT + ERT may be more effective than CBT alone in reducing anxiety symptoms, depressive symptoms, maladaptive emotion regulation strategies, and increasing adaptive emotion regulation strategies at 6-month follow-up.
- The study design was feasible, but recruitment rates need improvement for a larger randomized controlled trial.
- The research took place during the COVID-19 pandemic which may have influenced results. The small sample size limited statistical power.
- Developing an improved internet-based ERT program in collaboration with adolescents and evaluating it in a larger trial is an important next step.
Rationale
Anxiety and depressive disorders are prevalent in adolescents and negatively impact functioning and quality of life (Essau et al., 2000; Jaycox et al., 2009).
CBT is an effective treatment but has limitations, such as lacking evidence for long-term benefits (James et al., 2020; Watanabe et al., 2007).
Dysfunctional emotion regulation is an important common factor underlying these disorders (Aldao et al., 2010; Compas et al., 2017).
Integrating emotion regulation training within a transdiagnostic framework shows promise for this population (Ehrenreich-May et al., 2017; Sakiris & Berle, 2019). Delivering ERT online may increase accessibility.
This pilot study examines the feasibility, acceptability, and preliminary effectiveness of internet-based ERT added to CBT for adolescents with depressive and anxiety disorders.
Method
Two-arm pilot randomized controlled trial with a parallel group design comparing CBT + ERT to CBT alone.
Procedure
Participants were randomly assigned to CBT + ERT or CBT after baseline assessment. Follow-up assessments occurred at 3 and 6 months.
CBT was provided face-to-face by psychologists. ERT consisted of 6 online sessions and 2 face-to-face/screen-to-screen sessions guided by a different psychologist.
Sample
39 participants aged 13-18 (mean=16.4) with depressive disorder (71.8%) or anxiety disorder (28.2%) recruited from a Dutch mental healthcare institution. 76.9% were female.
Measures
Depressive symptoms, anxiety symptoms, emotion regulation, internalizing problems, and severity of illness was assessed using the following measures:
- Children’s Depression Inventory (CDI-2): The CDI-2 measures the severity of depressive symptoms in children and adolescents.
- Screen for Child Anxiety Related Emotional Disorders (SCARED-NL): The SCARED-NL assesses the presence and severity of anxiety disorder symptoms in children and adolescents.
- Fragebogen zur Erhebung der Emotionsregulation bei Kindern und Jugendlichen (FEEL-KJ): The FEEL-KJ is a German-language questionnaire that measures the use of adaptive and maladaptive emotion regulation strategies in children and adolescents.
- Youth Self-Report (YSR) and Child Behavior Checklist (CBCL): The YSR (youth self-report) and CBCL (parent-report) assess a range of internalizing problems, such as anxiety, depression, and somatic complaints, in children and adolescents.
- Clinical Global Impression Scale (CGI): The CGI is a clinician-rated measure that assesses the overall severity of a patient’s mental illness and improvement over time.
Treatment adherence, satisfaction and system usability were also assessed.
Statistical Analysis
Linear mixed-model analyses evaluated treatment effects on primary and secondary outcomes. Multiple regression analyzed internalizing problems. Chi-square compared treatment response rates.
Results
CBT + ERT showed significantly larger reductions than CBT alone in self-reported depressive symptoms (d=0.70, p=.017), anxiety symptoms (d=0.62, p=.003), maladaptive emotion regulation (d=0.49, p=.014), and larger increases in adaptive emotion regulation (d=0.71, p=.008) at 6-month follow-up.
No significant differences were found for parent-reported outcomes or therapist-rated improvement.
Insights
This study provides initial evidence that adding internet-based ERT to CBT may enhance treatment for depressed and anxious adolescents by improving emotion regulation skills and reducing symptoms.
The online delivery increases accessibility. Results highlight emotion regulation as an important treatment target.
Future research should develop an optimized ERT program with adolescent input and evaluate it in a fully-powered trial across multiple centers.
Strengths
This study had several methodological strengths, including:
- This study is the first to examine the feasibility, acceptability, and preliminary effectiveness of an internet-based emotion regulation training (ERT) added to cognitive behavioral therapy (CBT) for adolescents with depressive and anxiety disorders.
- The study employed a randomized controlled design, which is the gold standard for evaluating treatment efficacy and allows for causal inferences.
- The use of validated outcome measures from multiple informants (patients, parents, and therapists) provides a comprehensive assessment of treatment effects and enhances the reliability and validity of the findings.
- The study had a limited loss to follow-up, with 79.5% of participants completing all assessments, which reduces the risk of attrition bias and increases confidence in the results.
- The 6-month follow-up period allows for an examination of the durability of treatment effects over time, which is important for understanding the long-term benefits of the intervention.
Limitations
Despite strengths, this study also had some limitations, including:
- The small sample size (N=39) limits the statistical power of the study to detect significant treatment effects and increases the risk of Type II errors (false negatives). This means that the study may have been underpowered to find smaller but potentially clinically meaningful differences between the treatment groups.
- The absence of an active control condition (e.g., CBT + supportive therapy) makes it difficult to determine whether the observed effects of CBT + ERT are specific to the emotion regulation training or simply due to the additional attention and support provided. This limits the ability to draw conclusions about the unique benefits of ERT.
- The study was conducted during the COVID-19 pandemic, which may have influenced the results in several ways. For example, the increased stress and social isolation associated with the pandemic may have exacerbated participants’ symptoms or made it more difficult for them to engage in treatment.
- The study was conducted at a single mental health institution in the Netherlands, which may limit the generalizability of the findings to other settings or populations with different cultural, socioeconomic, or clinical characteristics.
- The study relied on self-report and parent-report measures, which are subject to biases such as social desirability or recall bias. The use of objective measures (e.g., behavioral observations, physiological measures) could provide additional validity to the findings.
Implications
This pilot study suggests that adding internet-based emotion regulation training to CBT may enhance treatment outcomes for adolescents with depressive disorders, as well as those with anxiety disorders, such as in treatment for generalized anxiety or social anxiety, for instance.
If replicated in larger trials, this combined intervention could become a valuable treatment option, particularly given the potential for online delivery to increase access to care.
The study also highlights the importance of targeting emotion regulation skills in treating adolescent depression and anxiety, given the role of emotion regulation difficulties in these disorders.
The preliminary evidence for the feasibility and effectiveness of this specific emotion regulation training protocol could inform future research and clinical practice.
However, potential moderators and boundary conditions of these effects should be considered, such as symptom severity, treatment engagement, and therapeutic alliance. Future research should examine these moderators to identify which adolescents are most likely to benefit.
Lastly, the study underscores the need for continued research on innovative, accessible, and effective interventions for adolescent mental health problems.
Given the high prevalence and burden of depression and anxiety in this population, developing and evaluating new treatment approaches that meet the diverse needs of adolescents and their families is essential.
While this study represents an important step, further work is needed to improve the quality and reach of mental health care for young people.
References
Primary reference
Wisman, M. A., Emmelkamp, J., Dekker, J. J., & Christ, C. (2023). 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. Internet interventions, 31, 100596. https://doi.org/10.1016/j.invent.2022.100596
Other references
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). EmAldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical psychology review, 30(2), 217-237. https://doi.org/10.1016/j.cpr.2009.11.004
Compas, B. E., Jaser, S. S., Bettis, A. H., Watson, K. H., Gruhn, M. A., Dunbar, J. P., Williams, E., & Thigpen, J. C. (2017). Coping, emotion regulation, and psychopathology in childhood and adolescence: A meta-analysis and narrative review. Psychological Bulletin, 143(9), 939–991. https://doi.org/10.1037/bul0000110
Ehrenreich-May, J., Rosenfield, D., Queen, A. H., Kennedy, S. M., Remmes, C. S., & Barlow, D. H. (2017). An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in adolescents. Journal of Anxiety Disorders, 46, 46-55. https://doi.org/10.1016/j.janxdis.2016.10.006
Essau, C. A., Conradt, J., & Petermann, F. (2000). Frequency, comorbidity, and psychosocial impairment of anxiety disorders in German adolescents. Journal of anxiety disorders, 14(3), 263-279. https://doi.org/10.1016/s0887-6185(99)00039-0
James, A. C., Reardon, T., Soler, A., James, G., & Creswell, C. (2020). Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane database of systematic reviews, (11). https://doi.org/10.1002/14651858.CD013162.pub2
Jaycox, L. H., Stein, B. D., Paddock, S., Miles, J. N., Chandra, A., Meredith, L. S., Tanielian, T., Hickey, S., & Burnam, M. A. (2009). Impact of teen depression on academic, social, and physical functioning. Pediatrics, 124(4), e596-e605. https://doi.org/10.1542/peds.2008-3348
Sakiris, N., & Berle, D. (2019). A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clinical psychology review, 72, 101751. https://doi.org/10.1016/j.cpr.2019.101751
Watanabe, N., Hunot, V., Omori, I. M., Churchill, R., & Furukawa, T. A. (2007). Psychotherapy for depression among children and adolescents: a systematic review. Acta Psychiatrica Scandinavica, 116(2), 84-95. https://doi.org/10.1111/j.1600-0447.2007.01018.x
Keep Learning
Here are some potential discussion questions for a college class on this paper:
- How might the COVID-19 context have influenced the study results? What are the implications for interpreting and generalizing the findings?
- The study used both patient self-report and parent-report measures, which showed different results. Why might this be? How should we weigh and interpret these different perspectives?
- The ERT intervention was delivered online. What are the potential benefits and drawbacks of online vs. face-to-face delivery of psychological interventions for adolescents?
- Emotion regulation was a key treatment target and mechanism measured in this study. What is emotion regulation and why is it important in the context of adolescent anxiety and depression?
- This was a small pilot study. What additional research questions and design features would be important to include in a larger, definitive randomized controlled trial of this intervention?
