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Nonsuicidal self-injury (NSSI) is a widespread behavior among adolescents and young adults. Although many individuals who self-injure do not seek treatment, there is evidence for web-based help-seeking through web-based communities and mobile peer support networks. However, few studies have rigorously tested the efficacy of such platforms on outcomes relevant for NSSI recovery.
The aim of this small-scale preregistered randomized controlled trial is to provide preliminary insight into the shorter- and longer-term efficacy of the use of a peer support app, TalkLife, in reducing NSSI frequency and urges and increasing readiness to change. In addition, we explore contact with informal support, interest in therapy, and attitudes toward professional help–seeking.
Individuals aged 16-25 years with current (within 3 months) and chronic (>6 episodes in the past year) NSSI history were eligible to participate in this study. After baseline assessments, the intervention group was instructed to use the app actively (eg, post or comment at least three times per week) and the control group received weekly psychoeducational materials through email, for 8 weeks. Follow-up was assessed at 1 month and 2 months. Linear mixed modeling was used to evaluate condition and time point effects for the primary outcomes of NSSI frequency and urges, readiness to change, contact with informal support, interest in therapy, and attitudes toward professional help–seeking.
A total of 131 participants were included in the analysis. We evidenced a significant effect of condition on NSSI frequency such that the participants using the peer support app self-injured less over the course of the study (mean 1.30, SE 0.18) than those in the control condition (mean 1.62, SE 0.18; P=.02;
Use of the peer support app was related to reduced NSSI frequency and greater confidence in one’s ability to change NSSI behavior over the course of the study period, but no effects on NSSI urges, contact with informal support, interest in therapy, or attitudes toward professional help–seeking were observed. The findings provide preliminary support for considering the use of mobile peer support apps as a supplement to NSSI intervention and point to the need for larger-scale trials.
Open Science Foundation; https://osf.io/3uay9
Nonsuicidal self-injury (NSSI)—“the deliberate damage of body tissue without suicidal intent” [
Web-based peer-to-peer communication regarding NSSI on social media websites and social support forums is highly prevalent. A robust body of work demonstrates the exchange of informational support, such as strategies to cope with symptoms, resources, advice on help-seeking, as well as emotional support, such as validation of shared struggles and empathetic responses on web-based NSSI forums [
At the same time, there are noted risks to participation on such web-based forums for individuals with a history of NSSI behavior. The types of information exchanged on the web are not always reliable or congruent with existing therapeutic or clinical recommendations [
Although qualitative work has set a foundation for understanding the likely effects of the exchange of peer support on NSSI behavior, few studies have examined this relationship in a controlled trial. Some social media research suggests that high levels of use of [
A growing body of research provides support for the efficacy of web-based and mobile apps in reducing various mental health symptoms [
For individuals who have unaddressed NSSI behaviors, web-based and mobile apps may provide some relief and serve as gateways for additional help. Young people report interest in, and acceptability of, digital interventions for NSSI [
Franklin et al [
Although extant research suggests the feasibility and acceptability of mobile apps for treating NSSI behaviors, few publicly available apps have been evaluated through efficacy trials. Most of the apps reviewed have focused on internet-based CBT, psychoeducation, or elements of
This study explores the efficacy of a mobile peer support app, TalkLife, in improving NSSI outcomes and informal support and formal help-seeking outcomes. This app is free and publicly available and designed to provide young people with immediate and informal mental health support. Preliminary research on this app shows that many young people use it to discuss NSSI and related mental health conditions [
Given the lack of prior work testing the effects of publicly available web-based and mobile platforms as resources for NSSI recovery, we sought to provide preliminary evidence of a treatment effect pursuant to future research and larger-scale trials. The broad aims of this small-scale trial are to assess the shorter- and longer-term efficacy of using the peer support app in mitigating NSSI frequency and urges, increasing contact with informal support and interest in therapy, and improving attitudes toward professional help–seeking. We present several hypotheses and research questions related to these primary outcomes. Please note that the hypotheses and research questions presented in this manuscript are part of a larger preregistered set. Because of power constraints, we did not include planned tests of mediation and reduced the number of variables explored in some cases (eg, H2). In addition, the ordering of these hypotheses differs from the study preregistration to assist in the logical flow of the results.
Specifically, we hypothesized that participation on this app would be associated with improvements in NSSI outcomes, readiness to change, and attitudes and behaviors related to support and help-seeking. Our hypotheses were guided by theory and existing literature—largely on perceived effects of web-based communities (from the vantage point of individuals with lived NSSI experience) and prior empirical support for the role of social support in NSSI recovery:
H1: Participation on the peer support app would lead to reductions in NSSI (i) frequency and (ii) urges, as well as increases in (iii) readiness to change compared with the control group.
H2: Participation on the peer support app would lead to increases in (i) informal conversations, (ii) satisfaction derived from these conversations, (iii) interest in therapy, and (iv) improved attitudes toward formal help-seeking compared with the control group.
We pose an exploratory research question of secondary outcomes that may be associated with participation on a web-based peer support platform based on prior qualitative research:
RQ1: Will participation on the peer support app lead to increases in (i) sense of belonging and (ii) social connectedness, as well as reductions in (iii) internalized stigma?
We also hypothesized a dose–response relationship among those in the peer support app treatment group, wherein greater engagement (sessions per week) would strengthen treatment effects:
H3: There would be a dose–response relationship between app use and the magnitude and durability of the effect of use on NSSI (i) frequency and (ii) urges.
Given that the peer support app is a relatively lightweight and nonprofessional intervention, we explored the durability of the postintervention effects:
RQ2: Will the effect of participation on the peer support app on NSSI (i) frequency and (ii) urges as well as (iii) readiness to change be maintained at 1-month and 2-month follow-up?
This study was supported by a small pilot program grant and was intended to serve as a small-scale trial that would allow us to explore the feasibility and necessary parameters required for a larger outcome trial. All study procedures were approved by the institutional review board at our university and the trial was preregistered at the Open Science Foundation. This was a 2-arm randomized controlled trial. Participants in the treatment group were invited to use the peer support app platform for a duration of 8 weeks. They were instructed to engage with the platform (publish posts or comments) at least three times per week. Although the trial was not deemed to elevate participant risk and was, in fact, intended to reduce risk, we were careful to minimize the likelihood of participant discomfort through careful consideration of inclusion and exclusion criteria, using a platform with strong in-app user protections, regularly reminding participants of available resources, and following up on anyone who expressed discomfort through communication with the research team.
To inform our decision regarding the amount of engagement that would be appropriate for participants using the app, we conducted preliminary analysis on a large sample of existing app users. A latent profile analysis of 105,504 users who had been flagged by self-injury classifiers or had posted within the self-injury thread suggested that moderate in-app engagement was associated with 3.35 posts and comments (combined) per week. These analyses also suggested that a 6-8-week trial duration would be ideal because this was well within the range of natural use.
Participants in the control group received weekly psychoeducational materials regarding NSSI through email. Psychoeducation is commonly a component of digital mental health interventions [
Participants aged 16-25 years with current (within 3 months) and chronic (>6 episodes in the past year) NSSI history were eligible to participate in this study. The exclusion criteria included recent history of psychosis (>2 weeks’ institutionalization in the past year) or current suicidality (operationalized as suicidal thoughts or plans at baseline). Potential participants were screened in a web-based eligibility survey. Upon completion of this eligibility survey, all eligible participants received an email from the research team providing them with key information regarding their participation and a web-based consent document. Participants were randomly assigned to the treatment or control condition upon consent, using a random number generator to avoid bias. The consent document for participants in the treatment condition informed them that the research team would have access to their use data on the mobile app for the duration of the study and follow-up period. All participants then received a welcome email containing several videos explaining expectations per week, how to register for the platform (where applicable), and details regarding how and when they would receive compensation.
Recruitment occurred through solicitations posted on (1) self-injury information clearing house websites and (2) through affiliated professional networks, social media outlets (such as Facebook or Twitter), and listservs, as well as (3) through the university recruitment system. Participants were eligible to receive a total of US $90 in the form of Amazon gift cards for completion of the study components (weekly surveys) throughout the study. Participants were compensated based on the number of weekly surveys they submitted. The trial ran from April 2019 to April 2020, with the last follow-up in June 2020.
The primary outcome variables were assessed at each time point throughout the study—a total of 8 time points (week 1-8) were considered, with the addition of 2 time points (1 month and 2 months after the intervention period) in follow-up analysis. Baseline measures on primary outcomes were controlled for in their respective analysis, as were demographics: gender and country of origin. On the basis of high comorbidity among individuals who engage in NSSI and the potential for this to affect the engagement and efficacy of treatment [
Participants completed a self-injury form checklist from the NSSI-AT [
Urges to self-injure were measured with two items adapted from the Alexian Brothers Urge to Self-Injure Scale [
Readiness to change was assessed with the Readiness Ruler—a simple tool used to help patients visualize their readiness to change. Participants indicated where they fell regarding their readiness to change, confidence in their ability to change, and importance of change on a scale of 1=
Informal support was operationalized as both (1) the number of conversations a participant reported having about self-injury and (2) the number of conversations that participants perceived as helpful. These were assessed through disclosure items from the NSSI-AT. Specifically, participants were asked if someone knew about their self-injury at baseline and if they had had a conversation about their self-injury in weekly surveys. If yes was selected, participants were asked to check boxes for the categories of people with whom they had had these conversations (eg, parent or guardian and friend). The number of boxes selected (or categories represented) were then summed weekly. If participants indicated that they had had a conversation with someone, they were also asked, “Have the conversations you’ve had with this person been helpful?” The response options were
NSSI-AT Treatment Experiences items were used to assess interest in therapy. Participants responded to “How interested are you in attending therapy in the next month?” at baseline and weekly. The response options were assessed on a 5-point scale ranging from 1=
Attitudes toward professional help–seeking were assessed through the Attitudes Toward Seeking Professional Psychological Help Scale [
Mental health stigma was measured through the Internalized Stigma of Mental Illness Scale [
Sense of belonging was measured through the belonging subscale of the short form version of the Interpersonal Support Evaluation checklist [
Participants responded to the Social Connectedness Scale developed by Lee and Robbins [
Data on participants’ mobile app activity were supplied with license from the platform and consent from participants. These data included the number of posts and comments participants published weekly over the course of the trial and follow-up periods and were used for a dose–response analysis.
Primary analyses were run on an intention-to-treat basis, with all participants randomized regardless of level of adherence. The relationship between survey completion as a continuous variable and demographics (gender, age, and region), indicators of mental health severity that may affect one’s ability to engage with the intervention (mental health diagnosis and trauma history), and attitudinal and motivational factors (eg, readiness to change, confidence in change, and importance of change) was also investigated through 1-way analysis of variance, where these predictors were independently regressed on survey completion. Missingness was not related to any of these variables. Finally, because some participants completed their week 8 and follow-up surveys during the COVID-19 pandemic, we ran parallel analyses that included and excluded data points that fell within the period in which most countries and states had formalized stay-at-home orders. Only 6.9% (9/131) of the participants completed their final intervention week (week 8) during the COVID-19 pandemic period (treatment=2 and control=7). Given this small sample, we observed no significant differences in the main analyses.
Linear mixed models (LMMs) were used to examine each of our primary outcome variables. Several estimators (maximum likelihood and restricted maximum likelihood) and covariance structures (first-order autoregressive process, compound symmetry, and unstructured) were compared before arriving at a combination that best fit our data: a maximum likelihood estimator with a first-order autoregressive covariance structure. All models included a random intercept for participant, fixed effects of condition, time point, a condition by time point interaction term, and relevant covariates. Models controlled for demographics (gender and country of origin), mental health history (trauma, mental health diagnoses, and lifetime NSSI), and the primary outcome variable at baseline. When the time point by condition interaction effect was not significant, it was removed from the final model before interpreting significant main effects. All analyses were performed using SPSS software (versions 25 and 27; IBM Corp).
A total of 131 participants were randomized into treatment and control conditions and completed baseline surveys. The flow of participants through the study is depicted in
Flow of participants.
Participant characteristics and key variables at baseline based on condition (N=131).
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Full sample (N=131) | Treatment (n=67) | Control (n=64) | Significance test | P value | |||||||||||||
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Chi-square ( |
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Age (years), mean (SD) | 20.32 (2.52) | 20.04 (2.24) | 20.61 (2.76) | –1.29 (129) | N/Aa | .20 | |||||||||||
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N/A | 2.4 (3) | .49 | ||||||||||||||
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Male | 24 (18.3) | 13 (19.4) | 11 (17.2) |
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Female | 89 (67.9) | 42 (62.7) | 47 (73.4) |
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Nonbinary | 15 (11.5) | 10 (14.9) | 5 (7.8) |
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Other | 3 (2.3) | 2 (3) | 1 (1.6) |
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N/A | 0.5 (2) | .78 | ||||||||||||||
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North America | 82 (62.6) | 40 (59.7) | 42 (65.6) |
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European Union | 24 (18.3) | 13 (19.4) | 11 (17.2) |
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United Kingdom | 25 (19.1) | 14 (20.9) | 11 (17.2) |
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N/A | 7.6 (4) | .11 | ||||||||||||||
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≤10 | 19 (14.5) | 11 (16.4) | 8 (12.5) |
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11-12 | 35 (26.7) | 11 (16.4) | 24 (37.5) |
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13-14 | 43 (32.8) | 25 (37.3) | 18 (28.1) |
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15-16 | 18 (13.7) | 10 (14.9) | 8 (12.5) |
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≥17 | 16 (12.2) | 10 (14.9) | 6 (9.4) |
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N/A | 1.3 (2) | .53 | ||||||||||||||
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2-3 times per week | 112 (85.7) | 59 (88.1) | 53 (82.8) |
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1 time per week | 10 (7.6) | 5 (7.5) | 5 (7.8) |
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1-3 times per month or less | 9 (6.9) | 3 (4.5) | 6 (9.4) |
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N/A | 1.9 (2) | .40 | ||||||||||||||
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4-20 times, n (%) | 8 (6.1) | 3 (4.5) | 5 (7.8) |
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21-50 times, n (%) | 28 (21.4) | 12 (17.9) | 16 (25) |
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More than 50 times, n (%) | 95 (72.5) | 52 (77.6) | 43 (67.2) |
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Urges: thoughts, mean (SD) | 50.43 (23.74) | 50.91 (26.81) | 49.93 (20.24) | 0.24 (130) | N/A | .81 | |||||||||||
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Urges: difficulty resisting, mean (SD) | 4.52 (1.46) | 4.37 (1.48) | 4.67 (1.43) | –1.17 (129) | N/A | .24 | |||||||||||
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Conversations (yes or no), n (%) | 112 (85.5) | 60 (89.6) | 52 (81.3) | N/A | 1.8 (1) | .18 | |||||||||||
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Number of roles, mean (SD) | 4.26 (2.17) | 4.07 (2.07) | 4.48 (2.27) | 0.32 (110) | N/A | .32 | |||||||||||
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Number of helpful conversations with roles, mean (SD) | 2.03 (1.42) | 2.03 (1.46) | 2.01 (1.39) | 0.05 (111) | N/A | .96 | |||||||||||
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Therapy (yes or no), n (%) | 105 (80.2) | 56 (83.6) | 59 (76.6) | N/A | 1.0 (1) | .38 | |||||||||||
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NSSI in therapy (yes or no)e, n (%) | 90 (85.7) | 49 (73.1) | 41 (83.7) | N/A | 0.3 (1) | .58 | |||||||||||
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Helpfulness of therapy overall (1=not at all helpful; 10=very helpful), mean (SD) | 5.89 (2.51) | 6.16 (2.59) | 5.60 (2.41) | 1.13 (102) | N/A | .26 | |||||||||||
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Helpfulness of therapy in stopping NSSI (1=not at all helpful; 5=very helpful), mean (SD) | 2.52 (1.43) | 2.35 (1.14) | 2.18 (1.34) | 0.76 (94) | N/A | .45 | |||||||||||
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Interest in therapy (scale: 1-5), mean (SD) | 2.84 (1.77) | 1.63 (1.43) | 3.04 (1.74) | –2.53 (72) | N/A | .01 | |||||||||||
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ATSPPHf (scale: 5-35), mean (SD) | 21.09 (7.36) | 25.53 (5.70) | 16.45 (5.91) | 8.95 (129) | N/A | <.001 | |||||||||||
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N/A |
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Importance of change | 7.14 (2.49) | 7.05 (2.54) | 7.22 (2.44) | –0.36 (129) |
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.72 | |||||||||||
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Readiness to change | 6.64 (2.68) | 6.49 (2.78) | 6.79 (2.58) | –0.65 (129) |
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.52 | |||||||||||
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Confidence in change | 5.68 (2.59) | 5.51 (2.52) | 5.85 (2.67) | –0.78 (129) |
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.44 | |||||||||||
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Internalized stigma, total | 2.88 (0.61) | 2.89 (0.523) | 2.86 (0.70) | 0.29 (129) |
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.83 | |||||||||||
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Stigma: stereotype | 2.20 (0.72) | 2.09 (0.633) | 2.33 (0.79) | –1.94 (129) |
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.05 | |||||||||||
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Stigma: alienation | 3.59 (0.74) | 3.68 (0.668) | 3.49 (0.80) | 1.45 (129) |
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.15 | |||||||||||
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Stigma: withdrawal | 2.83 (0.93) | 2.89 (0.843) | 2.77 (1.01) | 0.78 (129) |
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.44 | |||||||||||
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Belongingness | 14.40 (5.72) | 14.60 (6.03) | 14.19 (5.43) | 0.41 (129) |
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.68 | |||||||||||
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Social connectedness | 27.56 (10.82) | 31.21 (10.92) | 23.73 (9.37) | 4.19 (129) |
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<.001 | |||||||||||
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Trauma history (total traumatic events) | 3.52 (2.01) | 3.28 (1.93) | 3.77 (2.08) | –1.37 (129) |
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.17 | |||||||||||
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Mental health history (total mental health conditions) | 3.24 (1.82) | 3.24 (1.83) | 3.23 (1.92) | 0.014 (129) |
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.99 |
aN/A: not applicable.
bNSSI: nonsuicidal self-injury.
cThe last 2 categories were collapsed for nonsuicidal self-injury frequency 1-3 times per month and 1 time every month because of low cell sizes.
dThe first 3 categories were collapsed for lifetime nonsuicidal self-injury (4-5 times, 6-10 times, and 11-20 times) because of low cell sizes.
eOf those who reported attending therapy (n=105).
fATSPPH: Attitudes Toward Seeking Professional Psychological Help.
No significant time point by condition effects were observed in our analysis of primary outcomes, suggesting that patterns of change were not linear or equivalent across groups (see
Differences in outcomes by conditiona.
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Full sample, mean (SE) | Treatment, mean (SE) | Control, mean (SE) | P value |
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NSSI frequency | 1.46 (0.17) | 1.30 (0.18) | 1.62 (0.18) | 5.78 (1,129.91) | .02 | 0.02 |
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Urges: thoughts | 44.53 (3.79) | 42.69 (4.06) | 46.37 (4.09) | 1.53 (1,124.63) | .22 | 0.001 |
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Urges: difficulty resisting | 3.36 (0.24) | 3.31 (0.26) | 3.42 (0.26) | 0.314 (1,121.39) | .58 | 0.001 |
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Importance of change | 7.80 (0.35) | 8.03 (0.37) | 7.57 (0.38) | 3.21 (1,112.70) | .08 | 0.006 |
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Readiness to change | 6.69 (0.39) | 6.96 (0.43) | 6.42 (0.42) | 2.91 (1,126.20) | .09 | 0.01 |
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Confidence in change | 5.97 (0.38) | 6.28 (0.41) | 5.67 (0.41) | 4.27 (1,127.33) | .04 | 0.02 |
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Weekly informal conversations | 0.31 (0.12) | 0.28 (0.13) | 0.33 (0.13) | 0.35 (1,107.76) | .55 | 0.05 |
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Satisfaction derived from weekly conversations | 0.72 (0.24) | 0.73 (0.26) | 0.71 (0.26) | 0.02 (1,88.54) | .88 | 0.06 |
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Interest in therapy (scale: 1-5) | 2.93 (0.32) | 2.93 (0.38) | 2.94 (0.32) | 0.002 (1,63.31) | .97 | 0.03 |
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Attitudes toward professional help–seeking (scale: 5-35) | 25.95 (1.36) | 26.34 (1.48) | 25.56 (1.53) | 0.36 (1,127.06) | .55 | 0.01 |
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Internalized stigma: stereotype | 2.27 (0.13) | 2.30 (0.14) | 2.23 (0.14) | 0.39 (1,129.49) | .53 | 0.01 | |
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Internalized stigma: alienation | 3.51 (0.16) | 3.40 (0.17) | 3.62 (0.18) | 2.94 (1,128.81) | .09 | 0.08 | |
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Internalized stigma: withdrawal | 2.62 (0.16) | 2.55 (0.16) | 2.69 (0.17) | 1.68 (1,122.39) | .19 | 0.01 | |
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Sense of belonging | 15.19 (0.71) | 15.91 (0.75) | 14.44 (0.77) | 7.45 (1,128.83) | .007 | 0.06 | |
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Social connectedness | 29.21 (1.87) | 28.65 (2.08) | 29.77 (2.01) | 0.47 (1,121.12) | .49 | 0.02 |
aAll means reflect estimated marginal means from adjusted models.
bFor effect size
cCovariates include gender, region, trauma and mental health history, nonsuicidal self-injury frequency and lifetime nonsuicidal self-injury, and tested outcome at baseline. In addition, models control for time point and random effect of participant.
dNSSI: nonsuicidal self-injury.
Significant effects were observed for NSSI frequency (H1i) such that on average, participants in the peer support app condition injured themselves less over the course of the study (mean 1.30, SE 0.18) than participants in the control condition (mean 1.62, SE 0.18; P=.02; H1i). We did not observe any differences by condition for NSSI urges (H1ii) (see
A significant effect of treatment on confidence in one’s ability to change NSSI behaviors was observed (H1iii). Specifically, participants using the peer support app reported greater confidence in their ability to change their NSSI behavior (mean 6.28, SE 0.41) compared with control participants (mean 5.67, SE 0.41; P=.04). No significant effects were found for importance of changing NSSI behavior or readiness to change (see
No significant differences were evidenced between the groups or across time for any informal support or help-seeking outcomes (H2) including (i) informal conversations, (ii) satisfaction derived from these conversations, (iii) interest in therapy, and (iv) attitudes toward professional help–seeking (see
Exploratory analyses of internalized stigma, sense of belonging, and social connectedness as secondary variables (RQ1) revealed a significant condition effect for sense of belonging such that participants in the peer support app group reported greater sense of belonging (mean 15.91, SE 0.75) compared with those in the control group (mean 14.44, SE 0.77; P=.007). Time point was also significant for sense of belonging (P<.001), but the interaction between time point and condition did not reach significance (
To explore the potential for a dose–response relationship between app use and NSSI frequency and urges, log data from the platform were used (H3). Specifically, all participants’ posts and comments were summed at the week level. Several data points were observed at 3 times the IQR (21 data points from 10 participants). After inspection of participant trends and confirming normality in their responses on other study measures, they were deemed outliers. Winsorizing was selected to reduce the pull of these significant outliers while retaining their data [
The dose variable was entered as a predictor in the main LMMs, as described previously. No significant effects of dose were found for NSSI frequency (H3i;
Follow-up analyses (RQ2i-iii) were conducted to explore the durability of effects at 1 month and 2 months after the intervention period. We ran 2 LMMs that included all data during the intervention period (weeks 1-8) in addition to data at first follow-up (1 month) or all data during the intervention period in addition to data at first and second follow-up (1 month and 2 months). The results showed a decay in intervention effects at both follow-up periods. Given the similarities across both follow-up periods, we report statistics for the 2-month follow-up here.
At 2 months after the intervention period, the condition effect of NSSI frequency (H1i) remained significant (
Overall, our findings suggest that when compared with provision of web-based psychoeducational materials, use of the peer support platform was associated with reduced NSSI frequency over the course of the 8-week study period (H1i). Significance was sustained at both 1- and 2-month follow-up periods (RQ2i), with slight reductions in the magnitude of the effect at each reporting period. We also found a treatment effect for confidence in one’s ability to change NSSI behaviors. Participants in the treatment group reported greater confidence in their ability to change behaviors over the course of the study (H1iii) compared with those receiving psychoeducational materials. However, this effect was not sustained at the follow-up periods (RQ2iii).
Given that effect sizes were small for both treatment effects and this study was not fully powered to detect small effects, the results should be interpreted with appropriate caution. Digital interventions targeting mental health outcomes are often characterized by small to moderate treatment effects [
Counter to our expectations, there were no treatment effects on NSSI urges, contact with informal support, interest in therapy, or attitudes toward professional help–seeking. Urges are an important clinical feature of NSSI; however, not all individuals who engage in NSSI report urges [
Use of the peer support platform was not associated with increased offline conversations regarding their NSSI behaviors. Although models of web-based disclosure [
There was no evidence of a dose–response relationship in app use on any of the NSSI outcomes. Participants were instructed to engage on the platform at least three times (eg, publish 3 posts or comments) weekly. Although all participants engaged at this level for at least one week during the trial, we note variation in individual engagement across weeks. The mean number of posts and comments per week was 3.13 (SD 2.46), with an average of 8.43 (SD 9.36) sessions (log-ins) per week over the study period. The decision to prescribe 3 times of participative use per week was made to ensure that there was meaningful engagement beyond scrolling and based on past work suggesting that active use is more beneficial than passive use [
In terms of secondary variables, we did not find significant differences between the groups on internalized stigma or social connectedness; however, we did note a significant treatment effect for sense of belonging. Participants using the platform reported higher levels of belonging compared with the control group, and changes in sense of belonging were also trending toward significance over time. These findings are largely in line with research documenting sense of belonging and reduced loneliness as benefits of engagement in web-based communities [
Another lens that may explain some of the observed treatment effects but which was not explored in this study is social comparison. Prior work suggests that social comparison processes can play a negative role on peer-to-peer support platforms such that exposure to graphic content can trigger young people and drive competitiveness by making them feel as though their own NSSI behavior is not
Finally, although this was a small-scale trial with power limitations, we note that some of the small effects observed may be because the psychoeducational materials provided to the control participants were also regarded as efficacious (Kruzan et al, unpublished data, 2022) and seemed to exert some positive influence on several key outcome variables in this study (see
When interpreting the results, several limitations should be considered. First, the findings from this trial should be interpreted with appropriate caution, given that the study is underpowered to detect small effect sizes. There were few prior studies upon which we could base a priori assumptions and necessary parameters for sample size. Our study contributes some of these parameters for use in future research. Second, given the length of the trial and level of involvement requested of the participants, our sample may have been more motivated to engage in research (and thus with the intervention) than the average individual engaging in NSSI. Furthermore, we prescribed use of the platform, but natural use patterns may differ and this could affect outcomes. Future trials may wish to compare natural use to prescribed use. In addition, although we see an effect of app use on NSSI behavior, we were unable to explore possible mediators in this study. Future work should explore which elements of the experience on the platform drive the observed effect on NSSI frequency. Our findings suggest that sense of belonging may play an important role in this relationship. This trial did not control for a variety of other factors that may influence individuals’ NSSI behaviors over time, such as user expectancies, natural periodicity or the cyclical nature of NSSI, and other study procedures. We also note that our exclusion criteria affect the generalizability of our findings to individuals with more severe suicidality. Finally, although the need for this trial was in part informed by our prior work on the importance of social support in NSSI recovery [
To date, there are few studies that have formally explored the role of web-based peer support in reducing NSSI behaviors and other factors that may support NSSI recovery. The prevalence of NSSI among young people and the tendency for them to disclose it and seek help in web-based spaces such as mobile apps and social media highlight a need for research exploring efficacy and disentangling key mechanisms. This small-scale trial explored the potential efficacy of a mobile peer support app in reducing NSSI behaviors and urges, increasing readiness to change, and increasing contact with support. Although we found only small effects of the platform on NSSI frequency and confidence in one’s ability to change NSSI behaviors over the course of the study, we did find evidence for increased supportive conversations and interest in therapy, as well as improved attitudes toward help-seeking behaviors. Furthermore, we found suggestive evidence that sense of belongingness may play a critical role in benefits derived from platform use. Future work investigating the key mechanisms underlying the efficacy of this app and other platforms where individuals exchange peer support in reducing NSSI behaviors through fully powered randomized controlled trials is warranted.
Line graphs of primary outcomes over time.
CONSORT-eHEALTH checklist (V 1.6.1).
cognitive behavioral therapy
linear mixed model
nonsuicidal self-injury
Nonsuicidal Self-injury Assessment Tool
This work was supported by the USDA National Institute of Food and Agriculture, Hatch project 1004268 and the Cornell Center for Social Sciences. KPK received support from the National Institute of Mental Health (T32 MH115882) while completing final drafts of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
None declared.