Preventive and Personalized Digital Emotion Regulation Skills Intervention to Reduce Depression and Anxiety in Youths With Adverse Childhood Experiences (PREVENT-DERS)

In this active intervention arm, participants will undergo a 4-week (1 hour per session) online psychoeducation and skills training intervention focused on improving emotion regulation skills. We will tailor and personalize the 4-week intervention to each participant based on the Ecological Momentary Assessment-generated emotion regulation profiles at baseline. Emotion regulation profiles are mapped to 6 core areas (poor emotional awareness, poor emotional clarity, non-acceptance of emotional responses, difficulty in engaging in goal-directed behavior, impulsivity, and limited access to adaptive emotion regulation strategies) as outlined by the validated Difficulty in Emotion Regulation Scale (DERS) or DERS model.

The Active Intervention is a 4-week (1 hour per session) online psychoeducation and skills training intervention focused on improving emotion regulation skills. The Active Intervention includes personalized and non-personalized syllabus. The non-personalized intervention syllabus includes the following content: Session 1 (Enhancing emotional awareness and clarity), Session 2 (Accepting emotional responses), Session 3 (Reducing impulsivity and engaging in goal-directed behavior), and Session 4 (Accessing emotion regulation strategies). The personalized syllabus is based on each participant's Ecological Momentary Assessment (EMA)-generated emotion regulation profiles at baseline. In general, for weaker areas, we will reduce the difficulty in the type of skills taught and provide more skills practice. For stronger areas, we will teach more advanced skills for the participant to explore. Participants will undergo EMA self-monitoring of their emotions between each intervention session.

In this Active Comparator arm, participants will undergo a 4-week (1 hour per session) online psychoeducation intervention focused on learning healthy lifestyle strategies. The purpose of this arm is to support the blinding process, where both arms appear to receive similar interventions. Further, the lifestyle psychoeducation intervention is an evidence-based prevention intervention for depression and anxiety.

The Control Intervention is a 4-week (1 hour per session) online psychoeducation intervention focused on learning healthy lifestyle strategies. The first online session (Week 1) involves providing participants with a background of psychoeducation, adverse childhood experiences (ACEs), and mental health. The second online session (Week 2) involves teaching participants the importance of sleep hygiene. The third online session (Week 3) involves teaching participants the importance of a healthy diet. The fourth online session (Week 4) involves teaching participants the importance of exercise and providing an overview of outdoor activities in Singapore. Participants will undergo Ecological Momentary Assessment (EMA) self-monitoring of their emotions between each intervention session.

The 21-item Depression Anxiety and Stress Scales (DASS; Lovibond & Lovibond, 1995) will be used to screen for mild to moderate depression, anxiety, and stress symptoms. The DASS will also be administered at post-intervention and at the 3-month follow-up. Each item is rated on a 4-point Likert scale ranging from 0 (Did not apply to me) to 3 (Applied to me very much); higher scores indicate more severe depression, anxiety, and stress symptoms. Each subscale comprises 7 items and the subscale scores will be summed and multiplied by 2 as per scoring guidelines. Hence, each subscale score will range from 0 to 42.

The 18-item Difficulties with Emotion Regulation Scale Short-Form (DERS-SF; Kaufman et al., 2016) will be used to screen for elevated levels of global emotion dysregulation. Global emotion dysregulation has 6 subscales: poor emotional awareness, poor emotional clarity, non-acceptance of emotional responses, difficulty in engaging in goal-directed behavior, impulsivity, and limited access to adaptive emotion regulation strategies. These subscales correspond to the 6 dimensions of the DERS model. Each item is rated a 5-point Likert scale ranging from 1 (Almost never) to 5 (Almost always); higher scores will indicate more severe global emotion dysregulation (scores range from 18 to 90).

Ecological momentary assessment (EMA) of emotion dysregulation in the following two areas: Rumination and emotion regulation abilities. Two EMA items to assess rumination in response to recent stressors since the previous beep (How much were you focusing on the stressors? How much were you focusing on your emotions due to the stressors?). Both items are rated on a 100-point visual slider scale from 0 (not at all) to 100 (extremely). 21 EMA items to assess for emotion regulation abilities. Each item is rated on a 5-point Likert scale ranging from 1 (not at all) to 5 (completely).

The 10-item Ruminative Response Scale short-form (RRS; Treynor et al., 2003) will be used to screen for elevated levels of rumination. Each item is rated on a 4-point Likert scale ranging from 1 (Almost never) to 4 (Almost always); higher scores indicate more severe rumination (scores range from 10 to 40).

The 14-item Warwick Edinburgh Mental Wellbeing Scale (WEMWBS; Tennant et al., 2007) will be used to assess for subjective well-being. Each item is rated on a 5-point Likert scale ranging from 1 (None of the time) to 5 (All of the time); higher scores indicate better positive well-being.

The 20-item Urgency-Premeditation-Perseverance-Sensation Seeking-Positive Urgency scale (UPPS-P; Cyders et al., 2014) will be used to assess for multi-dimensional impulsivity and the subdomains include negative and positive urgency, lack of perseverance, lack of premeditation, and sensation-seeking. Each item is rated on a 4-point Likert scale ranging from 1 (Strongly Agree) to 4 (Strongly Disagree).