Publications by authors named "Fabian Lenhard"

27 Publications

  • Page 1 of 1

KONTAKT® social skills group training for Australian adolescents with autism spectrum disorder: a randomized controlled trial.

Eur Child Adolesc Psychiatry 2021 May 30. Epub 2021 May 30.

School of Allied Health, Curtin University, Perth, WA, Australia.

While there is a large body of evidence drawn from randomised controlled trials supporting the efficacy of SSGT in autistic adolescents, the control arms of these studies are almost exclusively treated either as usual or waitlist. Addressing this limitation, 90 verbal autistic adolescents (70% male) aged 12-17 years (M = 13.77, SD = 1.6) with IQ > 70 participated in this pragmatic two-armed randomised controlled trial design study evaluating the efficacy of sixteen 90-min sessions of SSGT KONTAKT® (n = 46) in comparison to a manualised interactive group cooking programme (n = 44) of equal dosage controlling for the potentially confounding effects of exposure to a social group context. The primary outcome was the adolescents' progress towards achieving their personally meaningful social goals at follow-up. Secondary outcomes were changes in autistic traits, quality of life, facial emotion recognition skills, social anxiety, and loneliness. Assessments were conducted at baseline, post intervention and 12-week follow-up. The interaction between time point and group allocation was investigated through a random-effects regression model (linear mixed model) to examine changes in the dependent outcomes. While intention-to-treat analysis (N = 90) demonstrated that both SSGT (ES = 1.36, p < .001) and active control (ES = 1.10, p < .001) groups made progress towards their personally meaningful social goals at follow-up, KONTAKT® participants demonstrated greater progress in social goal attainment than their peers in the active control group (ES = 0.35, p = .04). Findings suggest that KONTAKT® is efficacious in supporting autistic adolescents to achieve their personally meaningful social goals compared to other prosocial group activities.Trial registration: (1) Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12617001117303, registered 31 July 2017, anzctr.org.au; (2) ClinicalTrials.gov: NCT03294668 registered 22 September 2017, https://clinicaltrials.gov .
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http://dx.doi.org/10.1007/s00787-021-01814-6DOI Listing
May 2021

Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety Disorder: A Randomized Clinical Trial.

JAMA Psychiatry 2021 May 12. Epub 2021 May 12.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.

Importance: Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited.

Objective: To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT).

Design, Setting, And Participants: This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study.

Interventions: ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist.

Main Outcomes And Measures: The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs.

Results: Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group.

Conclusions And Relevance: In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD.

Trial Registration: ClinicalTrials.gov Identifier: NCT03247075.
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http://dx.doi.org/10.1001/jamapsychiatry.2021.0469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117054PMC
May 2021

Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents: A Randomized Clinical Trial.

JAMA 2021 05;325(18):1863-1873

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.

Importance: In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.

Objective: To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder.

Design, Setting And Participants: A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020.

Interventions: Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment.

Main Outcomes And Measures: The primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS.

Results: Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, -∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).

Conclusions And Relevance: Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.

Trial Registration: ClinicalTrials.gov Identifier: NCT03263546.
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http://dx.doi.org/10.1001/jama.2021.3839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114140PMC
May 2021

ACT-enhanced group behavior therapy for trichotillomania and skin-picking disorder: A feasibility study.

J Clin Psychol 2021 May 3. Epub 2021 May 3.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden.

Objective: To evaluate the feasibility and efficacy of ACT-enhanced Group Behavior Therapy (AEGBT) for mixed diagnosis groups including patients with trichotillomania (TTM) and skin-picking disorder (SPD) in routine psychiatric care.

Method: Adult patients (N = 40) with TTM and/or SPD received 10 weeks of AEGBT followed by five booster sessions. The primary outcome measure for TTM was the Massachusetts General Hospital Hairpulling Scale (MGH-HPS) and for SPD the Skin Picking Scale-Revised (SPS-R), assessed at posttreatment and at booster sessions.

Results: Results showed significant reductions in hair pulling and skin-picking severity from baseline to posttreatment and large effect sizes at posttreatment. Improvements remained significant at the 12-month follow-up for patients with SPD, but not for patients with TTM. Group attendance was high and few patients dropped out from treatment. The group format enabled therapists to see 25% more patients compared with an individual format.

Conclusion: The results provide initial support for the feasibility and efficacy of an adapted treatment approach for TTM and SPD.
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http://dx.doi.org/10.1002/jclp.23147DOI Listing
May 2021

Quality of life in pediatric patients with obsessive-compulsive disorder during and 3 years after stepped-care treatment.

Eur Child Adolesc Psychiatry 2021 Apr 21. Epub 2021 Apr 21.

Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Denmark.

The present study aimed to investigate the long-term quality of life (QoL) in a large sample of pediatric obsessive-compulsive disorder (OCD) patients. The study included 220 pediatric OCD patients from the Nordic Long-term OCD Treatment Study (NordLOTS) who were evaluated at seven time points before, during, and after stepped-care treatment over a 3-year follow-up period. Data from three symptom severity trajectory classes formed the basis of the QoL evaluation: acute (n = 127, N = 147), slow (n = 46, N = 63), and limited responders (n = 47, N = 59). Patients' QoL was assessed using parent and child ratings of the revised Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). QoL was analyzed by trajectory class using a random mixed effects model. The association between pre-treatment factors and long-term QoL was investigated across classes in a multivariate model. Three years after treatment, the acute responder class had reached QoL levels from a general population, whereas the limited responder class had not. The slow responder class reached norm levels for the child-rated QoL only. Higher levels of co-occurring externalizing symptoms before treatment were associated with lower parent-rated QoL during follow-up, while adolescence and higher levels of co-occurring internalizing symptoms were associated with lower child-rated QoL during follow-up. For some patients, residual OCD symptoms in the years after treatment, even at levels below assumed clinical significance, are associated with compromised QoL. Co-occurring symptoms could be part of the explanation. Assessing QoL after OCD treatment, beyond the clinician-rated symptom severity, could detect patients in need of further treatment and/or assessment. Trial registry: Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com ; ISRCTN66385119.
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http://dx.doi.org/10.1007/s00787-021-01775-wDOI Listing
April 2021

Long-term outcomes of therapist-guided Internet-delivered cognitive behavior therapy for pediatric obsessive-compulsive disorder.

NPJ Digit Med 2020 23;3:124. Epub 2020 Sep 23.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, 171 77 Region Stockholm, Sweden.

Cognitive behavior therapy (CBT) is the recommended first-line intervention for children and adolescents with obsessive-compulsive disorder (OCD), but is not broadly accessible. Internet-delivered CBT (ICBT) with minimal therapist support is efficacious and cost-effective, at least in the short term. Whether the therapeutic gains of ICBT for OCD are sustained in the long run is unknown. In this study, 61 adolescents with OCD who participated in a randomized trial of ICBT were followed-up 3 and 12 months after treatment. The proportion of treatment responders and remitters remained stable from post-treatment to 3-month follow-up and increased significantly from 3-month to 12-month follow-up. This study suggests that the gains of ICBT for youth with OCD are not only maintained long-term, but that further improvements continue to occur during follow-up.
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http://dx.doi.org/10.1038/s41746-020-00327-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511358PMC
September 2020

Cross-Cultural Adaptation to Australia of the KONTAKT© Social Skills Group Training Program for Youth with Autism Spectrum Disorder: A Feasibility Study.

J Autism Dev Disord 2020 Dec;50(12):4297-4316

School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, WA, Australia.

This study investigated the feasibility and cultural validity of KONTAKT©, a manualised social skills group training, in improving the social functioning of adolescents with autism spectrum disorder (ASD). KONTAKT© was delivered to 17 adolescents (m = 14.09, SD = 1.43; 70% male) with ASD over sixteen 90 min sessions. A pre-test post-test design evaluated changes in personally meaningful social goals, symptom severity, quality of life, interpersonal efficacy, social anxiety, loneliness, and facial emotion recognition at pre, post and 3 months follow-up. Focus groups were conducted post intervention. Findings indicate that KONTAKT© may support Australian adolescents with ASD in achieving their personally meaningful social goals. This study resulted in finalisation of KONTAKT© in preparation for evaluation of its efficacy in a randomised controlled trial (Australian New Zealand Clinical Registry (ANZCTR): ACTRN12617001117303, ClinicalTrials.gov: NCT03294668).
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http://dx.doi.org/10.1007/s10803-020-04477-5DOI Listing
December 2020

Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Lessons from clinics in Sweden, United Kingdom and Australia.

Internet Interv 2020 Apr 27;20:100308. Epub 2020 Jan 27.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden.

Obsessive-compulsive disorder (OCD) can be successfully treated with cognitive behaviour therapy (CBT). However, as few patients have access to CBT, there is a strong push to develop and evaluate scalable and cost-effective internet-delivered interventions. BIP OCD is a therapist-guided online CBT intervention for pediatric OCD that has shown promise in trials conducted at a single site in Stockholm, Sweden. In this study, we evaluated if BIP OCD is an acceptable, feasible, and effective treatment in other countries and clinical contexts. Thirty-one patients were recruited at three different sites; a specialist OCD clinic in Gothenburg (Sweden), a specialist OCD clinic in London (United Kingdom), and a university-based clinic in Brisbane (Australia). Acceptability and feasibility measures included treatment adherence and feedback from therapists. Clinician assessments were conducted at baseline, post-treatment, and 3-month follow-up. The average module completion for the participants was 8.1/12 (SD = 3.2) and the majority of patients completed the BIP OCD treatment (100% in Gothenburg, and 55.6% in both London and Brisbane). Pooling data from the three sites, the within-group effect sizes from baseline to post-treatment on the Children's Yale-Brown Obsessive-Compulsive Scale were in the expected range (bootstrapped Cohen's  = 1.78; 95% CI 1.18-2.39), with an additional symptom reduction to the 3-month follow-up (bootstrapped Cohen's  = 0.27; 95% CI 0.02-0.51). Participating therapists identified both advantages and difficulties supporting patients in this digital format. The results of this study suggest that the treatment effects obtained in the original BIP OCD trials can be generalized to other clinical contexts nationally and internationally. Lessons learned provide important information for successful implementation of BIP OCD in regular healthcare contexts.
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http://dx.doi.org/10.1016/j.invent.2020.100308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019117PMC
April 2020

The Work and Social Adjustment Scale, Youth and Parent Versions: Psychometric Evaluation of a Brief Measure of Functional Impairment in Young People.

Child Psychiatry Hum Dev 2020 06;51(3):453-460

Centre for Psychiatry Research, Department of Clinical Neuroscience, CAP Research Centre, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Gävlegatan 22, 113 30, Stockholm, Sweden.

The Work and Social Adjustment Scale (WSAS) is a brief global measure of functional impairment that is widely used in adult health. We have adapted the WSAS for its use in youth, the WSAS-Youth version (WSAS-Y) and WSAS-Parent version (WSAS-P). This study evaluated the psychometric properties of the scale. The internal consistency, factor structure, convergent and divergent validity, test-retest reliability and sensitivity to change of the WSAS-Y/P were studied in 525 children and adolescents with obsessive-compulsive disorder and related disorders receiving treatment. The internal consistency of the WSAS-Y/P was excellent across diagnostic groups and time-points. Exploratory factor analysis extracted a single-factor of functional impairment, explaining in excess of 85% of the variance. The test-retest reliability was adequate. The WSAS-Y/P correlated more strongly with other measures of functional impairment than with measures of symptom severity, indicating good convergent/divergent validity. Finally, the WSAS-Y/P was highly sensitive to change after treatment.
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http://dx.doi.org/10.1007/s10578-020-00956-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235060PMC
June 2020

KONTAKT© for Australian adolescents on the autism spectrum: protocol of a randomized control trial.

Trials 2019 Dec 9;20(1):687. Epub 2019 Dec 9.

School of Occupational Therapy, Social Works and Speech pathology, Curtin University, Kent street, Bentley, Perth, WA, 6102, Australia.

Background: Individuals diagnosed with autism spectrum disorder (ASD) experience impairing challenges in social communication and interaction across multiple contexts. While social skills group training (SSGT) has shown moderate effects on various sociability outcomes in ASD, there is a need for (1) replication of effects in additional clinical and cultural contexts, (2) designs that employ active control groups, (3) calculation of health economic benefits, (4) identification of the optimal training duration, and (5) measurement of individual goals and quality of life outcomes.

Method/design: With the aim of investigating the efficacy and cost-effectiveness of a SSGT, KONTAKT©, a two-armed randomized control trial with adolescents aged 12-17 years (N = 90) with ASD and an intelligence quotient (IQ) of over 70 will be undertaken. Following stratification for centre and gender, participants will be randomly assigned to either KONTAKT© or to an active control group, a group-based cooking programme. Participants will attend both programmes in groups of 6-8 adolescents, over 16 one-and-a-half-hour sessions. The primary outcome examined is adolescent self-rated achievement of personally meaningful social goals as assessed via the Goal Attainment Scaling during an interview with a blinded clinician. Secondary outcomes include adolescent self-reported interpersonal efficacy, quality of life, social anxiety, loneliness, face emotion recognition performance and associated gaze behaviour, and parent proxy reports of autistic traits, quality of life, social functioning, and emotion recognition and expression. Cost-effectiveness will be investigated in relation to direct and indirect societal and healthcare costs.

Discussion: The primary outcomes of this study will be evidenced in the anticipated achievement of adolescents' personally meaningful social goals following participation in KONTAKT© as compared to the active control group. This design will enable rigorous evaluation of the efficacy of KONTAKT©, exercising control over the possibly confounding effect of exposure to a social context of peers with a diagnosis of ASD.

Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12617001117303. Registered on 31 July 2017. anzctr.org.au ClinicalTrials.gov, NCT03294668. Registered on 22 September 2017. https://clinicaltrials.gov.
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http://dx.doi.org/10.1186/s13063-019-3721-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902510PMC
December 2019

Stepped Care Internet-Delivered vs Face-to-Face Cognitive-Behavior Therapy for Pediatric Obsessive-Compulsive Disorder: A Trial Protocol for a Randomized Noninferiority Trial.

JAMA Netw Open 2019 10 2;2(10):e1913810. Epub 2019 Oct 2.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet.

Importance: Internet-delivered cognitive behavior therapy is an effective treatment for children and adolescents with obsessive-compulsive disorder and has the potential to markedly increase access to treatment for patients while being cost-effective for health care organizations.

Objective: To investigate whether internet-delivered cognitive behavior therapy implemented within a stepped care model is noninferior to, and cost-effective compared with, the gold standard of face-to-face cognitive behavior therapy for pediatric obsessive-compulsive disorder.

Design, Setting, And Participants: Multicenter, single-blind, randomized clinical noninferiority trial implemented at 2 specialist pediatric obsessive-compulsive disorder clinics in Stockholm and Gothenburg, Sweden. Participants are 152 children and adolescents aged 7 to 17 years with obsessive compulsive disorder, recruited through the 2 clinics and online self-referral. Patients will be randomized 1:1 to the stepped care intervention or face-to-face therapy. Blind evaluations will be conducted after treatment and at 3-month and 6-month follow-ups. At the 6-month follow-up (primary end point), noninferiority will be tested and resource use will be compared between the 2 treatment groups. Data will be analyzed according to intention-to-treat principles.

Intervention: Patients randomized to stepped care will first receive internet-delivered cognitive behavior therapy for 16 weeks; patients who are classified as nonresponders 3 months after treatment completion will receive additional face-to-face therapy. The control group will receive 16 weeks of face-to-face cognitive behavior therapy immediately following randomization and nonresponders at the 3-month follow-up will, as in the stepped care group, receive additional face-to-face therapy.

Main Outcomes And Measures: Noninferiority is defined as a 4-point difference on the primary outcome measure (Children's Yale-Brown Obsessive Compulsive Scale).

Discussion: Recruitment started October 6, 2017, and was completed May 24, 2019. Results from the primary end point will be available by May 2020. The naturalistic follow-ups (1, 2, and 5 years after the end of treatment) will continue to 2025. There are no interim analyses planned or stopping rules for the trial.

Trial Registration: ClinicalTrials.gov identifier: NCT03263546.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.13810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820063PMC
October 2019

The Internet Intervention Patient Adherence Scale for Guided Internet-Delivered Behavioral Interventions: Development and Psychometric Evaluation.

J Med Internet Res 2019 10 1;21(10):e13602. Epub 2019 Oct 1.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.

Background: Patient adherence is defined as the extent to which a patient complies with medical or health advice. At present, there is a lack of reliable and valid measures specifically designed to measure adherence to internet-delivered behavioral interventions.

Objective: The objective of this study was to develop and psychometrically evaluate a novel measure of adherence to guided internet-delivered behavioral interventions.

Methods: In collaboration with experienced clinicians and researchers in the field, a 5-item, clinician-rated internet intervention Patient Adherence Scale (iiPAS) was developed. The initial scale was tested in a sample of children and adolescents (N=50) participating in internet-delivered cognitive behavioral therapy (ICBT) studies. A revised version of the iiPAS was then administered to a larger sample of children and adolescents (N=148) with various behavioral problems participating in ICBT trials. The scale was evaluated according to a classical test theory framework.

Results: The iiPAS demonstrated excellent internal consistency. Factor analyses revealed one underlying factor, explaining about 80% of the variance, suggesting that the scale captures a homogeneous adherence construct. The iiPAS was strongly associated with objective measures of patient activity in ICBT (number of logins, number of written characters, and completed modules). Furthermore, mid- and posttreatment ratings of the iiPAS were significantly correlated with treatment outcomes. By contrast, objective measures of patient activity in the Web-based platform did not correlate with treatment outcomes.

Conclusions: The iiPAS could be a useful tool to measure adherence in a broad range of internet-delivered behavioral interventions.
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http://dx.doi.org/10.2196/13602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6774571PMC
October 2019

Cost-effectiveness of internet-delivered cognitive-behavioural therapy for adolescents with irritable bowel syndrome.

BMJ Open 2019 01 24;9(1):e023881. Epub 2019 Jan 24.

Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden.

Objective: To assess whether exposure-based internet-delivered cognitive-behavioural therapy (internet-CBT) is a cost-effective treatment for adolescents with irritable bowel syndrome (IBS) compared with a waitlist control, from a societal perspective, based on data from a randomised trial.

Design: Within-trial cost-effectiveness analysis.

Setting: Participants were recruited from the whole of Sweden via primary, secondary and tertiary care clinics reached through news media and advertising.

Participants: Adolescents (aged 13-17) with a diagnosis of IBS.

Interventions: Participants were randomised to either an exposure-based internet-CBT, including 10 weekly modules for adolescents and five modules for parents, or a waitlist.

Outcome Measures: The main health outcome was the quality-adjusted life-year (QALY) estimated by mapping Pediatric Quality-of-Life Inventory (PedsQL) scores onto EQ-5D-3L utilities. The secondary outcome was the point improvement on the PedsQL scale. Data on health outcomes and resource use were collected at baseline and 10 weeks post-treatment. Resource use was measured using the Trimbos and Institute of Medical Technology Assessment Cost Questionnaire for Psychiatry (TIC-P) . Incremental cost-effectiveness ratios (ICER) were calculated as the difference in average costs by the difference in average outcomes between groups.

Results: The base-case results showed that internet-CBT costs were on average US$170.24 (95% CI 63.14 to 315.04) more per participant than the waitlist. Adolescents in the internet-CBT group showed small QALY gains (0.0031; 95% CI 0.0003 to 0.0061), and an average improvement of 5.647 points (95% CI 1.82 to 9.46) on the PedsQL compared with the waitlist. Internet-CBT yielded an ICER of $54 916/QALY gained and a probability of cost-effectiveness of 74% given the Swedish willingness-to-pay threshold. The ICER for the outcome PedsQL was US$85.29/point improvement.

Conclusions: Offering internet-CBT to adolescents with IBS improves health-related quality of life and generates small QALY gains at a higher cost than a waitlist control. Internet-CBT is thus likely to be cost-effective given the strong efficacy evidence, small QALY gains and low cost.

Trial Registration Number: NCT02306369; Results.
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http://dx.doi.org/10.1136/bmjopen-2018-023881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347900PMC
January 2019

Long-Term Outcome of a Cluster-Randomized Universal Prevention Trial Targeting Anxiety and Depression in School Children.

Behav Ther 2019 01 19;50(1):200-213. Epub 2018 May 19.

Karolinska Institutet.

The present study concerns a 3-year follow-up of a universal prevention trial targeting anxiety and depressive symptoms in school children. In addition to evaluating the long-term effect of the prevention program, we also examined attrition and its effect on the outcome. High rates of attrition have commonly been observed in studies in the field. However, the role of attrition is not sufficiently understood regarding internal and external validity biases. The current study comprised 695 children (aged 8-11 at baseline) from 17 schools in Sweden. Schools were cluster-randomized to either the intervention or control condition. Children completed measures of anxiety and depressive symptoms and parents completed measures of their child's anxiety and general mental health. We found no evidence of long-term effects of the prevention program, except for a small effect regarding parent reports of child anxiety. However, that effect was not found to be of clinical significance. Regarding attrition, children with missing data at the 3-year follow-up displayed higher levels of psychiatric symptoms at baseline and increasing symptoms across time. Furthermore, children in the control condition with missing follow-up data were found to be significantly deteriorated across time compared to the corresponding children in the intervention condition regarding depressive symptoms and total difficulties. In other words, attrition served as a moderator of the effect, which suggests that the overall result was biased toward a null-result. Our study highlights that large and nonrandom attrition severely limits the validity of the results. Further, given the common problem of retaining participants in long-term evaluations of school-based prevention trials, previous studies may suffer from the same limitations as the current study.
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http://dx.doi.org/10.1016/j.beth.2018.05.003DOI Listing
January 2019

Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial.

Lancet Child Adolesc Health 2018 11 18;2(11):792-801. Epub 2018 Sep 18.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.

Background: Paediatric anxiety disorders are associated with substantial disability and long-term adverse consequences, but only a small proportion of affected children have access to evidence-based treatment. Internet-delivered cognitive behavioural therapy (ICBT) could help increase accessibility but needs further rigorous assessment. We aimed to assess the efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders.

Methods: We did a single-blind randomised controlled trial in a clinical research unit within the Child and Adolescent Mental Health Services in Stockholm (Sweden). Eligible participants were children aged 8-12 years with a diagnosis of a principal anxiety disorder (seperation anxiety disorder, generalised anxiety disorder, specific phobia, social anxiety disorder, or panic disorder) of at least moderate severity. We randomly allocated participants (1:1) to ICBT or internet-delivered child-directed play, an active comparator aimed to improve parent-child relationships and increase a child's self-esteem without directly targeting anxiety. Block sizes for the randomisation varied between four and six and were generated using a computer random-number generator, and the allocation was concealed from the researchers by opaque sealed envelopes. Both treatment programmes comprised 12 modules presented over 12 weeks with weekly asynchronous online therapist support, and consisted of texts, films, illustrations, and exercises. The primary outcome was severity rating of the principal anxiety disorder 12-weeks post-treatment, via the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders-IV (a rating of at least 4 corresponds to meeting the criteria for the principal diagnosis), assessed by clinicians masked to treatment allocation. All participants were included in the primary analysis (intention-to-treat). This trial is registered at ClinicalTrials.gov, number NCT02350257.

Findings: Between March 11, 2015, and Oct 21, 2016, 131 participants were recruited and allocated to either ICBT (n=66) or internet-delivered child-directed play (n=65). The clinician-assessed severity rating of the principal anxiety disorder improved significantly after the 12-weeks treatment period for participants in both ICBT (within-group effect size 1·22, 95% CI 0·78-1·65) and the active control (0·72, 0·44-1·00) groups. However, greater improvement was seen with ICBT than with the active control (estimated mean difference 0·79, 95% CI 0·42-1·16, p=0·002; between-group effect size 0·77, 95% CI 0·40-1·15). 29 (48%) participants in the ICBT group no longer had their principal diagnosis, compared to nine (15%) in the active control group (odds ratio 5·41, 95% CI 2·26 to 12·90, p<0·0001); the number needed to treat for ICBT to gain one additional participant in remission was three (95% CI 2·85 to 3·15). ICBT resulted in an average societal-cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported.

Interpretation: ICBT is an efficacious and cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care.

Funding: The Swedish Research Council for Health, Working Life and Welfare, and Stockholm County Council.
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http://dx.doi.org/10.1016/S2352-4642(18)30275-XDOI Listing
November 2018

Internet-delivered cognitive behavioural therapy for young children with obsessive-compulsive disorder: development and initial evaluation of the BIP OCD Junior programme.

BJPsych Open 2018 May 18;4(3):106-112. Epub 2018 Apr 18.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, and Stockholm Health Care Services, Stockholm County Council, Sweden.

Background: Internet-delivered cognitive behavioural therapy (ICBT) is a promising approach for increasing access to evidence-based treatments.

Aims: To develop and evaluate the feasibility and preliminary efficacy of an ICBT programme for young children with obsessive-compulsive disorder (OCD), named BIP OCD Junior.

Method: Eleven children aged 7-11 years were enrolled in a 12-week open trial of parent- and therapist-guided ICBT for OCD. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS).

Results: There was a significant improvement in OCD symptoms post-treatment, with a large within-group effect size on the CY-BOCS (Cohen's  = 1.86, 95% CI 0.83 to 2.86). Results were maintained at 3-month follow-up. Both children and parents rated the treatment as credible and were highly satisfied with the intervention.

Conclusions: BIP OCD Junior is a feasible and credible treatment option for young children with OCD. Randomised controlled trials are needed to further establish its efficacy and cost-effectiveness relative to gold standard face-to-face CBT.

Declaration Of Interest: None.
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http://dx.doi.org/10.1192/bjo.2018.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020306PMC
May 2018

One-Year Outcome for Responders of Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder.

J Am Acad Child Adolesc Psychiatry 2017 Nov 13;56(11):940-947.e1. Epub 2017 Sep 13.

Center for Child and Adolescent Psychiatry, Aarhus University Hospital, Risskov, Denmark.

Objective: This study describes 1-year treatment outcomes from a large sample of cognitive-behavioral therapy (CBT) responders, investigates age as a possible moderator of these treatment outcomes, and evaluates clinical relapse at the 1-year follow-up.

Method: This study is the planned follow-up to the Nordic Long-term OCD [obsessive-compulsive disorder] Treatment Study (NordLOTS), which included 177 children and adolescents who were rated as treatment responders following CBT for OCD. Participants were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at 6- and 12-month follow-up. Treatment response and remission were defined as CY-BOCS total scores ≤15 and ≤10, respectively. Linear mixed-effects models were used to analyze all outcomes.

Results: At 1 year, a total of 155 children and adolescents (87.6%) were available for follow-up assessment, with 142 of these (91.6%) rated below a total score of ≤15 on the CY-BOCS. At 1-year follow-up, 121 (78.1%) were in remission. On average, CY-BOCS total scores dropped by 1.72 points during the first year after terminating treatment (p = .001). A total of 28 participants (15.8%) relapsed (CY-BOCS ≥ 16) at either the 6- or 12-month assessment; only 2 patients required additional CBT.

Conclusion: Results suggest that manualized CBT in a community setting for pediatric OCD has durable effects for those who respond to an initial course of treatment; children and adolescents who respond to such treatment can be expected to maintain their treatment gains for at least 1 year following acute care. Clinical trial registration information- Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119.
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http://dx.doi.org/10.1016/j.jaac.2017.09.002DOI Listing
November 2017

Prediction of outcome in internet-delivered cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A machine learning approach.

Int J Methods Psychiatr Res 2018 03 28;27(1). Epub 2017 Jul 28.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.

Background: There are no consistent predictors of treatment outcome in paediatric obsessive-compulsive disorder (OCD). One reason for this might be the use of suboptimal statistical methodology. Machine learning is an approach to efficiently analyse complex data. Machine learning has been widely used within other fields, but has rarely been tested in the prediction of paediatric mental health treatment outcomes.

Objective: To test four different machine learning methods in the prediction of treatment response in a sample of paediatric OCD patients who had received Internet-delivered cognitive behaviour therapy (ICBT).

Methods: Participants were 61 adolescents (12-17 years) who enrolled in a randomized controlled trial and received ICBT. All clinical baseline variables were used to predict strictly defined treatment response status three months after ICBT. Four machine learning algorithms were implemented. For comparison, we also employed a traditional logistic regression approach.

Results: Multivariate logistic regression could not detect any significant predictors. In contrast, all four machine learning algorithms performed well in the prediction of treatment response, with 75 to 83% accuracy.

Conclusions: The results suggest that machine learning algorithms can successfully be applied to predict paediatric OCD treatment outcome. Validation studies and studies in other disorders are warranted.
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http://dx.doi.org/10.1002/mpr.1576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6877165PMC
March 2018

Cost-effectiveness of therapist-guided internet-delivered cognitive behaviour therapy for paediatric obsessive-compulsive disorder: results from a randomised controlled trial.

BMJ Open 2017 05 17;7(5):e015246. Epub 2017 May 17.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.

Objectives: To evaluate the cost-effectiveness of a therapist-guided internet-delivered cognitive behaviour therapy (ICBT) intervention for adolescents with obsessive-compulsive disorder (OCD) compared with untreated patients on a waitlist.

Design: Single-blinded randomised controlled trial.

Setting: A research clinic within the regular child and adolescent mental health service in Stockholm, Sweden.

Participants: Sixty-seven adolescents (12-17 years) with a Diagnostic and Statistical Manual of Mental Disorders Fifth Edition diagnosis of OCD.

Interventions: Either a 12-week, therapist-guided ICBT intervention or a wait list condition of equal duration.

Primary Outcome Measures: Cost data were collected at baseline and after treatment, including healthcare use, supportive resources, prescription drugs, prescription-free drugs, school absence and productivity loss, as well as the cost of ICBT. Health outcomes were defined as treatment responder rate and quality-adjusted life years gain. Bootstrapped mixed model analyses were conducted comparing incremental costs and health outcomes between the groups from the societal and healthcare perspectives.

Results: Compared with waitlist control, ICBT generated substantial societal cost savings averaging US$-144.98 (95% CI -159.79 to -130.16) per patient. The cost reductions were mainly driven by reduced healthcare use in the ICBT group. From the societal perspective, the probability of ICBT being cost saving compared with waitlist control was approximately 60%. From the healthcare perspective, the cost per additional responder to ICBT compared with waitlist control was approximately US$78.

Conclusions: The results suggest that therapist-guided ICBT is a cost-effective treatment and results in societal cost savings, compared with patients who do not receive evidence-based treatment. Since, at present, most patients with OCD do not have access to evidence-based treatments, the results have important implications for the increasingly strained national and healthcare budgets. Future studies should compare the cost-effectiveness of ICBT with regular face-to-face CBT.

Trial Registration Number: NCT02191631.
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http://dx.doi.org/10.1136/bmjopen-2016-015246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729979PMC
May 2017

Therapist-Guided, Internet-Delivered Cognitive-Behavioral Therapy for Adolescents With Obsessive-Compulsive Disorder: A Randomized Controlled Trial.

J Am Acad Child Adolesc Psychiatry 2017 01 25;56(1):10-19.e2. Epub 2016 Oct 25.

Center for Psychiatry Research, Karolinska Institutet, Stockholm, and Stockholm Health Care Services, Stockholm County Council, Sweden.

Objective: Cognitive-behavioral therapy (CBT) is the first-line treatment for young people with obsessive-compulsive disorder (OCD), but most patients do not have access to this treatment. Thus, innovative ways to increase the accessibility of CBT are needed. The objective of this trial was to evaluate the efficacy of therapist-guided internet-based CBT (ICBT) for adolescents with OCD.

Method: Sixty-seven adolescents (12-17 years old) with OCD were randomly assigned to a 12-week clinician- and parent-supported ICBT program (BiP OCD) or a waitlist condition. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by blinded assessors before and after the intervention. All patients were followed up 3 months after the intervention.

Results: In intention-to-treat analyses, BiP OCD was superior to waitlist on the CY-BOCS (time-by-group interaction, B = -4.53, z = -3.74, p < .001; Cohen's d = 0.69; 95% CI 0.19-1.18) and on most secondary outcome measurements. Patients randomized to BiP OCD also showed further improvement from post-treatment to 3-month follow-up, with a within-group pretreatment to follow-up effect size (Cohen's d) equal to 1.68 (95% CI 1.00-2.36). Patient satisfaction with BiP OCD was high. There were no relevant adverse events. Average clinician support time was 17.5 minutes per patient per week.

Conclusion: Therapist-guided ICBT is a promising low-intensity intervention for adolescents with OCD and has the potential to increase access to CBT. It might be particularly useful in a stepped-care approach, in which a large proportion of patients with moderately severe OCD could first be offered ICBT, thus freeing limited resources for more complex cases. Clinical trial registration information-Internet-Delivered CBT for Adolescents With OCD: A Randomized Controlled Study (BiPOCD); http://clinicaltrials.gov; NCT02191631.
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http://dx.doi.org/10.1016/j.jaac.2016.09.515DOI Listing
January 2017

Internet-Delivered Cognitive Behavior Therapy for Adolescents With Irritable Bowel Syndrome: A Randomized Controlled Trial.

Am J Gastroenterol 2017 01 15;112(1):152-162. Epub 2016 Nov 15.

Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.

Objectives: Few treatments have been able to effectively manage pediatric irritable bowel syndrome (IBS). Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure for abdominal symptoms is effective for adult IBS. The objective of this study was to evaluate the efficacy of Internet-CBT based on behavioral exposure for adolescents with IBS.

Methods: Adolescents with IBS fulfilling the Rome III criteria were randomized to either Internet-CBT or a wait-list control. The Internet-CBT was a 10-week intervention where the main component was exposure to IBS symptoms by reduction of avoidance of abdominal symptoms and instead stepwise provocation of symptoms. The primary outcome was total score on Gastrointestinal Symptoms Rating Scale for IBS (GSRS-IBS). Secondary outcomes included adolescent- and parent-rated quality of life and parent-rated gastrointestinal symptoms. Difference between groups was assessed from pretreatment to posttreatment and the Internet-CBT group was also evaluated at 6 months after treatment completion.

Results: A total of 101 adolescents with IBS (13-17 years of age) were included in this study. Dropout rates were low (6%) and all randomized patients were included in intent-to-treat analyses based on mixed effects models. Analyses showed a significant larger pretreatment to posttreatment change on the primary outcome GSRS-IBS (B=-6.42, P=0.006, effect size Cohen's d=0.45, 95% confidence interval (0.12, 0.77)) and on almost all secondary outcomes for the Internet-CBT group compared with the control group. After 6 months, the results were stable or significantly improved.

Conclusions: Internet-CBT based on exposure exercises for adolescents with IBS can effectively improve gastrointestinal symptoms and quality of life.
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http://dx.doi.org/10.1038/ajg.2016.503DOI Listing
January 2017

"On My Own, but Not Alone" - Adolescents' Experiences of Internet-Delivered Cognitive Behavior Therapy for Obsessive-Compulsive Disorder.

PLoS One 2016 6;11(10):e0164311. Epub 2016 Oct 6.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.

Introduction: Childhood Obsessive-Compulsive Disorder (OCD) is a prevalent and impairing condition that can be effectively treated with Cognitive Behavior Therapy (CBT). However, a majority of children and adolescents do not have access to CBT. Internet-delivered CBT (ICBT) has been suggested as a way to increase availability to effective psychological treatments. Yet, the research on ICBT in children and adolescents has been lagging behind significantly both when it comes to quantitative as well as qualitative studies. The aim of the current study was to describe the experience of ICBT in adolescents with OCD.

Method: Eight adolescents with OCD that had received ICBT were interviewed with qualitative methodology regarding their experiences of the intervention. Data was summarized into thematic categories.

Results: Two overarching themes were identified, autonomy and support, each consisting of three primary themes (self-efficacy, flexibility, secure self-disclosure and clinician support, parental support, identification/normalization, respectively).

Conclusions: The experiential hierarchical model that was identified in this study is, in part, transferrable to previous research. In addition, it highlights the need of further study of important process variables of ICBT in young patient populations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0164311PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5053512PMC
June 2017

Internet-delivered cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis.

Clin Psychol Rev 2016 12 20;50:1-10. Epub 2016 Sep 20.

Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.

Internet-delivered cognitive behavior therapy (ICBT) is a relatively novel treatment format with the potential to increase accessibility of evidence-based care. However, little is known about the feasibility and efficacy of ICBT in children and adolescents. We conducted a comprehensive systematic review and meta-analysis of ICBT for children and adolescents to provide an overview of the field and assess the efficacy of these interventions. A systematic literature search of six electronic databases was performed to identify ICBT intervention studies for children with a psychiatric condition, such as social anxiety disorder, or a somatic condition, such as chronic pain. Two reviewers independently rated study quality. Twenty-five studies, targeting 11 different disorders, were included in the review. Study quality and presentation of treatment variables, such as therapist time and treatment adherence, varied largely. Twenty-four studies (N=1882) were included in the meta-analysis and ICBT yielded moderate between-group effect sizes when compared with waitlist, g=0.62, 95% CI [0.41, 0.84]. The results suggest that CBT for psychiatric and somatic conditions in children and adolescents can be successfully adapted to an internet-delivered format.
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http://dx.doi.org/10.1016/j.cpr.2016.09.005DOI Listing
December 2016

Universal Prevention for Anxiety and Depressive Symptoms in Children: A Meta-analysis of Randomized and Cluster-Randomized Trials.

J Prim Prev 2015 Dec;36(6):387-403

Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden.

Although under-diagnosed, anxiety and depression are among the most prevalent psychiatric disorders in children and adolescents, leading to severe impairment, increased risk of future psychiatric problems, and a high economic burden to society. Universal prevention may be a potent way to address these widespread problems. There are several benefits to universal relative to targeted interventions because there is limited knowledge as to how to screen for anxiety and depression in the general population. Earlier meta-analyses of the prevention of depression and anxiety symptoms among children suffer from methodological inadequacies such as combining universal, selective, and indicated interventions in the same analyses, and comparing cluster-randomized trials with randomized trials without any correction for clustering effects. The present meta-analysis attempted to determine the effectiveness of universal interventions to prevent anxiety and depressive symptoms after correcting for clustering effects. A systematic search of randomized studies in PsychINFO, Cochrane Library, and Google Scholar resulted in 30 eligible studies meeting inclusion criteria, namely peer-reviewed, randomized or cluster-randomized trials of universal interventions for anxiety and depressive symptoms in school-aged children. Sixty-three percent of the studies reported outcome data regarding anxiety and 87 % reported outcome data regarding depression. Seventy percent of the studies used randomization at the cluster level. There were small but significant effects regarding anxiety (.13) and depressive (.11) symptoms as measured at immediate posttest. At follow-up, which ranged from 3 to 48 months, effects were significantly larger than zero regarding depressive (.07) but not anxiety (.11) symptoms. There was no significant moderation effect of the following pre-selected variables: the primary aim of the intervention (anxiety or depression), deliverer of the intervention, gender distribution, children's age, and length of the intervention. Despite small effects, we argue for the possible clinical and practical significance of these programs. Future evaluations should carefully investigate the moderators and mediators of program effects to identify active program components.
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http://dx.doi.org/10.1007/s10935-015-0405-4DOI Listing
December 2015

Effectiveness of cognitive behavior treatment for pediatric obsessive-compulsive disorder: acute outcomes from the Nordic Long-term OCD Treatment Study (NordLOTS).

Behav Res Ther 2015 Jan 21;64:15-23. Epub 2014 Nov 21.

Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway.

Objective: The purpose of this study was to examine the acute effectiveness of manualized exposure-based CBT with a family-based treatment, as an initial treatment for pediatric OCD delivered in regular community child and adolescents outpatient clinics. The report summarizes outcome of the first treatment step in the NordLOTS, which was conducted in Denmark, Sweden and Norway.

Method: 269 participants, age 7-17, with OCD, received treatment for 14 weekly sessions. Treatment response was defined as CY-BOCS score of ≤15 at post treatment.

Results: 241 participants (89.6%) completed all 14 weeks of treatment. Treatment response among the completers was 72.6% (95% CI 66.7%-77.9%). Mixed effects model revealed a statistically significant effect of time F(1,479) = 130.434. Mean symptom reduction on the CY-BOCS was 52.9% (SD = 30.9). The estimated within-group effect size between baseline and post treatment was 1.58 (95% CI: 1.37-1.80).

Conclusion: This study found that manualized CBT can be applied effectively in community mental health clinics. These findings underscore the feasibility of implementing exposure-based CBT for pediatric OCD in a regular child and adolescent mental health setting.

Clinical Trials Registration Information: This study was registered in Current Controlled Trials; Nordic Long-term Obsessive-compulsive disorder (OCD) Treatment Study (www.controlled-trials.com ISRCTN66385119).
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http://dx.doi.org/10.1016/j.brat.2014.11.005DOI Listing
January 2015

Internet-delivered cognitive behavior therapy for adolescents with obsessive-compulsive disorder: an open trial.

PLoS One 2014 20;9(6):e100773. Epub 2014 Jun 20.

Department of Clinical Neuroscience, Centre for Psychiatric Research and Education, Karolinska Institutet, Stockholm, Sweden.

Background: International guidelines recommend Cognitive Behavior Therapy (CBT) as the first line treatment for pediatric obsessive-compulsive disorder (OCD). However, a substantial proportion of patients do not have access to such treatment. We developed and tested the feasibility, efficacy and acceptability of a novel therapist-guided, Internet-delivered CBT (ICBT) platform for adolescents with OCD.

Methods: An interactive, age-appropriate ICBT platform ("BiP OCD") was developed. Twenty-one adolescents (12-17 years) with a DSM-IV diagnosis of OCD and their parents were enrolled in the study. All participants received 12 weeks of ICBT with therapist support. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Acceptability was assessed at post-treatment.

Results: Participants completed on average 8.29 (SD = 3.0) of the 12 treatment chapters. Treatment yielded significant improvements on all clinician-, parent- and most self-administered outcome measures, with a large effect size of d = 2.29 (95% CI 1.5-3.07) on the CY-BOCS. Patients continued to improve at follow-up. At 6-month follow-up, 71% were classified as responders (≥35% decrease on the CY-BOCS) and 76% as being in remission (CY-BOCS score ≤12). Average clinician support time was less than 20 minutes per patient per week. The majority of participants felt that BiP OCD was age-appropriate and rated the treatment as good or very good.

Conclusions: ICBT could be efficacious, acceptable, and cost-effective for adolescents with OCD. More rigorously controlled studies are needed to further evaluate the treatment.

Trial Registration: ClinicalTrials.gov; NCT01809990.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0100773PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4065049PMC
October 2015