Long-term effects and mediating mechanisms of SELFIE, a transdiagnostic ecological momentary intervention for improving self-esteem in youth exposed to childhood adversity: findings from a randomized clinical trial

Introduction: This study examined 1) long-term effects of SELFIE, a transdiagnostic blended ecological momentary intervention (EMI) for improving self-esteem at 18- and 24-month follow-up, and 2) whether SELFIE’s effects on general psychopathology are mediated via self-esteem. Methods: A 2-arm, parallel-group, assessor-blinded, Dutch multi-center randomized controlled trial (RCT) was conducted between 2018-2022. Participants aged 12-26 years with prior exposure to childhood adversity and low self-esteem were randomized to a blended EMI (app-based and face-to-face) plus care as usual (CAU) or to CAU only. Measures included global, positive, and negative self-esteem, schematic self-beliefs, quality of life, general psychopathology, momentary self-esteem and affect, assessed at post-intervention, 6-month, 18-month, and 24-month follow-up. Results: 174 participants were randomized. 1) Across 18- and 24-month follow-up, participants in the experimental compared to control condition showed higher global self-esteem (B=2.12, 95% CI [0.80, 3.45], d=0.46). Small to moderate long-term effects were observed on positive and negative self-esteem, positive schematic self-beliefs, and social quality of life (18- and 24-month), as well as momentary self-esteem (18-month), and general psychopathology (24-month). 2) Effects on general psychopathology at post-intervention (B=-19.0, 95% CI [-31.6, -8.5], proportion mediated (PM)=86.8%) and 6-month follow-up (B=-15.1, 95% CI [-26.0, -6.2], PM=66.7%) were mediated via changes in global self-esteem. Additional mediators were positive and negative self-esteem, positive and negative schematic self-beliefs. Conclusion: Results demonstrate long-term efficacy signals of SELFIE on self-esteem, psychopathology, and quality of life. Short-term effects on general psychopathology were partly mediated via self-esteem. Further research on SELFIE’s implementation, scalability, and public health impact is warranted.