Publications by authors named "Gerhard Andersson"

565 Publications

Is Continued Improvement After Automated Virtual Reality Exposure Therapy for Spider Phobia Explained by Subsequent Exposure? A First Test of the Lowered Threshold Hypothesis.

Front Psychiatry 2021 20;12:645273. Epub 2021 May 20.

Department of Psychology, Stockholm University, Stockholm, Sweden.

Consumer Virtual Reality (VR) technology offers a powerful, immersive medium for scalable dissemination of mental health interventions. Decades of research has shown VR exposure therapy to be efficacious in the treatment of anxiety disorders and that the fear reduction generalizes to real-world stimuli. Many studies also report continued improvement over time, after discontinuing VR use. The lowered threshold hypothesis states that this continued improvement is moderated by lowering the threshold to conduct subsequent exposure. The current study is the first to formally test this hypothesis, using data from a recent trial on automated VR exposure therapy for spider phobia, in which participants ( = 49) were followed for 1 year, completing assessments 1 week, 3 and 12 months post-treatment. The assessment included validated self-report of phobia symptoms, a standardized behavioral approach test featuring a real spider, and a questionnaire for self-reporting frequency of exposures since last assessment. Number of exposures was found to be independently associated with greater symptom decrease in longitudinal outcome models. In sequential structural equation models, immediate post-treatment symptom reduction was associated with subsequent exposures, which in turn was associated with continued symptom reduction. However, this applied only to self-reported phobia symptoms (not behavioral avoidance) and no associations were found past 3 months. Our findings offer preliminary, partial support for the lowered threshold hypothesis, suggesting that VR exposure interventions may benefit from including explicit to transitioning components.
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http://dx.doi.org/10.3389/fpsyt.2021.645273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174706PMC
May 2021

Experiences of internet-based cognitive behavioural therapy for depression and anxiety among Arabic-speaking individuals in Sweden: a qualitative study.

BMC Psychiatry 2021 Jun 3;21(1):288. Epub 2021 Jun 3.

Department of Behavioural Sciences and Learning, Linköping University, SE-581 83, Linköping, Sweden.

Background: Internet-delivered cognitive behavioural therapy (ICBT) is a promising treatment for refugee and immigrant populations suffering from common mental disorders. The aim of the present study was to investigate experiences of participating in a guided ICBT program among resettled Arabic-speaking individuals suffering from symptoms of anxiety and depression.

Methods: Ten individuals who had previously received ICBT consented to participate and were interviewed using semi-structured telephone interviews. The interviews were conducted 10 months after treatment termination. Data were transcribed and analysed using a Thematic Analysis framework.

Results: The Thematic Analysis resulted in five overarching themes 1) The importance of being seen, 2) New ways of knowing and doing, 3) Treatment format not for everyone, 4) Changing attitudes towards mental health and help-seeking and 5) The healthcare system as a complex puzzle. Participants described varying levels of success in applying the new information learned from the treatment in their everyday lives. The results also indicate that participation in the ICBT program to some extent mitigated mental health stigma and acted as a precursor to other forms of treatment seeking.

Conclusions: The findings in the present study are largely in line with previous qualitative research studies on ICBT participants. Future research should investigate whether a more explicit focus on refugee-specific stressors and barriers to treatment engagement and implementation can increase adherence to ICBT programs in this population.
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http://dx.doi.org/10.1186/s12888-021-03297-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173836PMC
June 2021

Dismantling internet-based cognitive behavioral therapy for tinnitus. The contribution of applied relaxation: A randomized controlled trial.

Internet Interv 2021 Sep 12;25:100402. Epub 2021 May 12.

Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, USA.

Background: Internet-based cognitive behavioral therapy (ICBT) for tinnitus is an evidence-based intervention. The components of ICBT for tinnitus have, however, not been dismantled and thus the effectiveness of the different therapeutic components is unknown. It is, furthermore, not known if heterogeneous tinnitus subgroups respond differently to ICBT.

Aims: This dismantling study aimed to explore the contribution of applied relaxation within ICBT for reducing tinnitus distress and comorbidities associated with tinnitus. A secondary aim was to assess whether outcomes varied for three tinnitus subgroups, namely those with significant tinnitus severity, those with low tinnitus severity, and those with significant depression.

Methods: A parallel randomized controlled trial design ( = 126) was used to compare audiologist-guided applied relaxation with the full ICBT intervention. Recruitment was online and via the intervention platform. Assessments were completed at four-time points including a 2-month follow-up period. The primary outcome was tinnitus severity as measured by the Tinnitus Functional Index. Secondary outcomes were included for anxiety, depression, insomnia, negative tinnitus cognitions, health-related quality of life, hearing disability, and hyperacusis. Treatment engagement variables including the number of logins, number of modules opened, and the number of messages sent. Both an intention-to-treat analysis and completer's only analysis were undertaken.

Results: Engagement was low which compromised results as the full intervention was undertaken by few participants. Both the ICBT and applied relaxation resulted in large reduction of tinnitus severity (within-group effect sizes  = 0.87 and 0.68, respectively for completers only analysis), which were maintained, or further improved at follow-up. These reductions in tinnitus distress were greater for the ICBT group, with a small effect size differences (between-group  = 0.15 in favor of ICBT for completers only analysis). Tinnitus distress decreased the most at post-intervention for those with significant depression at baseline. Both ICBT and applied relaxation contributed to significant reductions on most secondary outcome measures, with no group differences, except for a greater reduction of hyperacusis in the ICBT group.

Conclusion: Due to poor compliance partly attributed to the COVID-19 pandemic results were compromised. Further studies employing strategies to improve compliance and engagement are required. The intervention's effectiveness increased with initial level of tinnitus distress; those with the highest scores at intake experienced the most substantial changes on the outcome measures. This may suggest tailoring of interventions according to tinnitus severity. Larger samples are needed to confirm this.
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http://dx.doi.org/10.1016/j.invent.2021.100402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141772PMC
September 2021

Development and Preliminary Evaluation of the Tinnitus Severity Short Form.

Am J Audiol 2021 Jun 24;30(2):404-415. Epub 2021 May 24.

Department of Psychological & Brain Sciences, Washington University in St. Louis, MO.

Purpose Tinnitus, or the perception of sounds that occur without an external sound source, is a prevalent condition worldwide. For a subset of adults, tinnitus causes significant distress and impairment. Several patient-reported outcome measures have been developed to assess severity of tinnitus distress. However, at present, the field lacks a brief measure that is sensitive to treatment change. The purpose of the current study was to develop and preliminarily validate a brief questionnaire for tinnitus severity from two existing measures of tinnitus-related distress, the Tinnitus Handicap Inventory (THI) and Tinnitus Functional Index (TFI). Method Using data from nine study samples in the United States and United Kingdom, we conducted exploratory and confirmatory factor analyses to identify a short measure with good psychometric properties. We also assessed sensitivity to treatment-related change by examining associations with change in the TFI and THI. Finally, we conducted a confirmatory factor analysis of the final short questionnaire in a new sample of adults seeking treatment for tinnitus-related distress. Results We identified 10 items from the THI and TFI that exhibited limited loadings on secondary factors. The resulting Tinnitus Severity Short Form achieved good to excellent fit, including in a unique sample of individuals seeking online treatment for tinnitus, and appeared sensitive to treatment-related change. Conclusions The Tinnitus Severity Short Form developed in the current study may be a useful tool for the assessment of subjective severity and distress associated with tinnitus, especially when patient burden is a concern. Further research is necessary to fully validate the questionnaire for the assessment of treatment-related change.
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http://dx.doi.org/10.1044/2021_AJA-20-00164DOI Listing
June 2021

Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data.

Lancet Psychiatry 2021 06 3;8(6):500-511. Epub 2021 May 3.

Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway.

Background: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom.

Methods: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683.

Findings: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components.

Interpretation: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package.

Funding: Japan Society for the Promotion of Science.
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http://dx.doi.org/10.1016/S2215-0366(21)00077-8DOI Listing
June 2021

Psychological distress in patients with cardiovascular disease: time to do something about it?

Eur J Cardiovasc Nurs 2021 May;20(4):293-294

Department of Health, Medicine and Caring Sciences, Linköping University, 602 21 Norrköping, Sweden.

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http://dx.doi.org/10.1093/eurjcn/zvab007DOI Listing
May 2021

Suggestions for shaping tinnitus service provision in Western Europe: Lessons from the COVID-19 pandemic.

Int J Clin Pract 2021 Apr 10:e14196. Epub 2021 Apr 10.

Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.

Background: Tinnitus severity has been exacerbated because of the COVID-19 pandemic and those with tinnitus require additional support. Such support should be informed by patient preferences and needs. The objective of this study was to gather information from individuals with tinnitus living in Europe to inform stakeholders of the (a) support they needed in relation to changes associated with the COVID-19 pandemic and (b) suggestions regarding tinnitus care for the future.

Methods: A cross-sectional mixed method study design was used using closed and open-ended questions via an online survey. Data were gathered from 710 adults experiencing tinnitus in Western Europe, with the majority living in The Netherlands, Belgium and Sweden. Data were analysed using qualitative content analysis and descriptive statistics.

Results: Those with tinnitus indicated the following support needs during the pandemic (a) support for tinnitus, (b) support for hearing-related difficulties, (c) social support and (d) pandemic-related support. Five directions for future tinnitus care were provided, namely, (a) need for understanding professional support and access to multidisciplinary experts, (b) greater range of therapies and resources, (c) access to more information about tinnitus, (d) prioritising tinnitus research and (e) more support for hearing protection and hearing loss prevention.

Conclusions: The findings point to the need for accessible (remote), patient-centred, suitable and evidence-based tinnitus care. Insights from the current study can be used by various stakeholders including clinical practitioners and tinnitus support services to ensure those with tinnitus have access to the help and support required in order to reduce service provision insufficiencies.
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http://dx.doi.org/10.1111/ijcp.14196DOI Listing
April 2021

Reasons for Discontinuing Active Participation on the Internet Forum Tinnitus Talk: Mixed Methods Citizen Science Study.

JMIR Form Res 2021 Apr 8;5(4):e21444. Epub 2021 Apr 8.

Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, Krems an der Donau, Austria.

Background: Tinnitus Talk is a nonprofit online self-help forum. Asking inactive users about their reasons for discontinued usage of health-related online platforms such as Tinnitus Talk is important for quality assurance.

Objective: The aim of this study was to explore reasons for discontinued use of Tinnitus Talk, and their associations to the perceptions of Tinnitus Talk and the age of users who ceased logging on to the platform.

Methods: Initially, 13,745 users that did not use Tinnitus Talk within the previous 2 months were contacted and the response rate was 20.47% (n=2814). After dataset filtering, a total of 2172 past members of Tinnitus Talk were included in the analyses. Nine predefined reasons for discontinued usage of Tinnitus Talk were included in the survey as well as one open question. Moreover, there were 14 predefined questions focusing on perception of Tinnitus Talk (usefulness, content, community, and quality of members' posts). Mixed methods analyses were performed. Frequencies and correlation coefficients were calculated for quantitative data, and grounded theory methodology was utilized for exploration of the qualitative data.

Results: Quantitative analysis revealed reasons for discontinued use of Tinnitus Talk as well as associations of these reasons with perceptions of Tinnitus Talk and age. Among the eight predefined reasons for discontinued use of Tinnitus Talk, the most frequently reported was not finding the information they were looking for (451/2695, 16.7%). Overall, the highest rated perception of Tinnitus Talk was content-related ease of understanding (mean 3.9, SD 0.64). A high number (nearly 40%) of participants provided additional free text explaining why they discontinued use. Qualitative analyses identified a total of 1654 specific reasons, more than 93% of which (n=1544) could be inductively coded. The coding system consisted of 33 thematically labeled codes clustered into 10 categories. The most frequent additional reason for discontinuing use was thinking that there is no cure or help for tinnitus symptoms (375/1544, 24.3%). Significant correlations (P<.001) were observed between reasons for discontinued usage and perception of Tinnitus Talk. Several reasons for discontinued usage were associated with the examined dimensions of perception of Tinnitus Talk (usefulness, content, community, as well as quality of members' posts). Moreover, significant correlations (P<.001) between age and reasons for discontinued use were found. Older age was associated with no longer using Tinnitus Talk because of not finding what they were looking for. In addition, older participants had a generally less positive perception of Tinnitus Talk than younger participants (P<.001).

Conclusions: This study contributes to understanding the reasons for discontinued usage of online self-help platforms, which are typically only reported according to the dropout rates. Furthermore, specific groups of users who did not benefit from Tinnitus Talk were identified, and several practical implications for improvement of the structure, content, and goals of Tinnitus Talk were suggested.
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http://dx.doi.org/10.2196/21444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063098PMC
April 2021

Internet-Based Cognitive Behavioral Therapy for Informal Caregivers: Randomized Controlled Pilot Trial.

J Med Internet Res 2021 Apr 7;23(4):e21466. Epub 2021 Apr 7.

Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.

Background: Caregiving for a family member can result in reduced well-being for the caregiver. Internet-delivered cognitive behavioral therapy (ICBT) may be one way to support this population. This is especially the case for caregivers in countries with limited resources, but high demand for psychological services.

Objective: In this study we evaluated the effects of a therapist-guided 8-week-long ICBT intervention for informal caregivers.

Methods: In total, 63 participants were recruited online and randomized either to the intervention or to the wait-list control group. The main study outcome was the Caregiver Burden Inventory (CBI). Secondary outcomes included measures of caregiver depression, anxiety, stress, and quality of life.

Results: Moderate between-group effect sizes were observed for the CBI measure, in favor of the intervention group, with a Cohen d=-0.70 for the intention-to-treat analysis. Analyses of the subscales of the CBI showed significant reductions on the subscales of Development and Physical Health. Moderate reductions were found for depression and anxiety scores as indicated by the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scores. Large between-group effects were observed for reduction in stress and increase in quality of life as indicated by the Perceived Stress Scale-14 (PSS-14), The Brunnsviken Brief Quality of Life Scale (BBQ), and The World Health Organization-Five Well-Being Index (WHO-5). In addition, participants experienced little to no difficulty in using the program and were mostly satisfied with the intervention's platform and the choice of content.

Conclusions: This is the first internet intervention study for informal caregivers in Lithuania. The results suggest that therapist-guided ICBT can be effective in reducing caregiver burden, anxiety, depression, stress, and improving quality of life.

Trial Registration: ClinicalTrials.gov NCT04052724; https://clinicaltrials.gov/ct2/show/NCT04052724.
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http://dx.doi.org/10.2196/21466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8060860PMC
April 2021

Disorder-specific internet-based cognitive-behavioral therapy in treating panic disorder, comorbid symptoms and improving quality of life: A meta-analytic evaluation of randomized controlled trials.

Internet Interv 2021 Apr 7;24:100364. Epub 2021 Jan 7.

Department of Behavioural Sciences and Learning, Linköping University, Sweden.

Compared to conventional face-to-face psychological treatments, internet-based cognitive-behavioral therapy (iCBT) presents an innovative alternative that has been found to be effective in the treatment of anxiety disorders. The current study provides a meta-analysis investigating the efficacy of disorder-specific guided self-help (Gsh) iCBT compared to various active and inactive control conditions, with focus on adult panic disorder sufferers with or without agoraphobia (PD/A). Systematic literature search yielded 13 randomized controlled trials (RCTs) ( = 1214) that met the eligibility criteria for this study. We found no statistically significant differences between Gsh iCBT and various active CBT interventions in reducing PD/A symptoms at both post-test ( = 0.015,  = 10) and follow-up ( = 0.113,  = 6) levels. Also, comorbid anxiety and depression were reduced equivalently at post-test ( = 0.004,  = 6) and follow-up ( = 0.004,  = 6). Quality of life was equally improved at post-test ( = -0.100,  = 5) and follow-up ( = 0.074,  = 2). When compared to inactive controls, we found large effect sizes in PD/A ( = -0.892,  = 9) and comorbid anxiety and depression ( = -0.723,  = 9) symptoms, and moderate change in quality of life ( = -0.484,  = 3) at post-test. There was no difference between Guided self-help iCBT and Self-help iCBT in PD/A ( = -0.025,  = 3) and comorbid anxiety and depression ( = -0.025,  = 3) at post-test. Baseline severity, country of original research and adherence to the treatment in form of initial uptake were identified as statistically significant moderators of the iCBT treatment.
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http://dx.doi.org/10.1016/j.invent.2021.100364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889983PMC
April 2021

Exploring tinnitus heterogeneity.

Prog Brain Res 2021 24;260:79-99. Epub 2020 Jul 24.

National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, University of Nottingham, Ropewalk House, Nottingham, United Kingdom; Hearing Sciences, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Nottingham Audiology Services, Nottingham University Hospitals, Nottingham, United Kingdom.

Introduction: Tinnitus experiences differ widely. A greater understanding of the core processes underlying these variations is needed. Moreover, meaningful definitions for different subgroups are required to better manage this heterogeneous population. The objective of the present research was to contribute toward the understanding of tinnitus heterogeneity by identifying factors that can predict tinnitus severity and to ascertain if distinct subgroups of tinnitus presentation can be identified.

Methods: This cross-sectional study consisted of 326 adults subdivided into subgroups of those with mild tinnitus (n=32; 10%), significant tinnitus (n=99; 30%) and severe tinnitus (n=195; 60%) according to their scores from the Tinnitus Functional Index. Multiple regression was used to identify factors associated with tinnitus severity. These factors included personal traits, tinnitus-related traits, treatment modalities and clinical comorbidities.

Results: Insomnia, hearing distress, and anxiety were the best predictors of tinnitus severity (explaining 53% of the variability). These comorbidities were stronger predictors than any demographical factors (that explained 11% of the variability). Distinct subgroups based on tinnitus severity (mild, significant, and severe) and anxiety levels were evident. Those with severe tinnitus had significantly more severe comorbidities compared with the mild and significant groups.

Conclusions: This study highlights that people with tinnitus could initially be grouped according to tinnitus severity to direct further management. Those with higher tinnitus severity should receive more immediate and intensive care. Due to the strong associations between tinnitus severity and tinnitus-related comorbidities (e.g., insomnia, hearing disability, and anxiety), tinnitus assessment and interventions should focus on these comorbidities.
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http://dx.doi.org/10.1016/bs.pbr.2020.05.022DOI Listing
July 2020

Tinnitus and tinnitus disorder: Theoretical and operational definitions (an international multidisciplinary proposal).

Prog Brain Res 2021 1;260:1-25. Epub 2021 Feb 1.

Department of Psychiatry and Psychotherapy, Bezirksklinikum, University of Regensburg, Regensburg, Germany.

As for hypertension, chronic pain, epilepsy and other disorders with particular symptoms, a commonly accepted and unambiguous definition provides a common ground for researchers and clinicians to study and treat the problem. The WHO's ICD11 definition only mentions tinnitus as a nonspecific symptom of a hearing disorder, but not as a clinical entity in its own right, and the American Psychiatric Association's DSM-V doesn't mention tinnitus at all. Here we propose that the tinnitus without and with associated suffering should be differentiated by distinct terms: "Tinnitus" for the former and "Tinnitus Disorder" for the latter. The proposed definition then becomes "Tinnitus is the conscious awareness of a tonal or composite noise for which there is no identifiable corresponding external acoustic source, which becomes Tinnitus Disorder "when associated with emotional distress, cognitive dysfunction, and/or autonomic arousal, leading to behavioural changes and functional disability.". In other words "Tinnitus" describes the auditory or sensory component, whereas "Tinnitus Disorder" reflects the auditory component and the associated suffering. Whereas acute tinnitus may be a symptom secondary to a trauma or disease, chronic tinnitus may be considered a primary disorder in its own right. If adopted, this will advance the recognition of tinnitus disorder as a primary health condition in its own right. The capacity to measure the incidence, prevalence, and impact will help in identification of human, financial, and educational needs required to address acute tinnitus as a symptom but chronic tinnitus as a disorder.
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http://dx.doi.org/10.1016/bs.pbr.2020.12.002DOI Listing
February 2021

Trajectories and associations between depression and physical activity in patients with cardiovascular disease during participation in an internet-based cognitive behavioural therapy programme.

Eur J Cardiovasc Nurs 2021 02;20(2):124-131

Department of Health, Medicine and Caring Sciences, Linköping University, Sweden.

Background: There is a lack of knowledge about internet-based cognitive behavioural therapy in patients with cardiovascular disease, and its effects on depressive symptoms and physical activity.

Aim: To examine trajectories of depressive symptoms and physical activity, and to explore if these trajectories are linked with the delivery of internet-based cognitive behavioural therapy.

Methods: A secondary-analysis of data collected in a randomised controlled trial that evaluated the effects of a 9-week internet-based cognitive behavioural therapy programme compared to an online discussion forum on depressive symptoms in cardiovascular disease patients. Data were collected at baseline, once weekly during the 9-week intervention period and at the 9-week follow-up. The Montgomery Åsberg depression rating scale - self-rating (MADRS-S) was used to measure depressive symptoms. Two modified items from the physical activity questionnaire measuring frequency and length of physical activity were merged to form a physical activity factor.

Results: After 2 weeks the internet-based cognitive behavioural therapy group had a temporary worsening in depressive symptoms. At 9-week follow-up, depressive symptoms (P<0.001) and physical activity (P=0.02) had improved more in the internet-based cognitive behavioural therapy group. Only in the internet-based cognitive behavioural therapy group, was a significant correlation (r=-0.39, P=0.002) between changes in depressive symptoms and changes in physical activity found. Structural equation analyses revealed that internet-based cognitive behavioural therapy decreased depressive symptoms, and that a decrease in depression, in turn, resulted in an increase in physical activity.

Conclusions: Internet-based cognitive behavioural therapy was more effective than an online discussion forum to decrease depressive symptoms and increase physical activity. Importantly, a decrease in depressive symptoms needs to precede an increase in physical activity.
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http://dx.doi.org/10.1177/1474515120947250DOI Listing
February 2021

The effect of nurse-led Internet-based cognitive behavioural therapy for insomnia on patients with cardiovascular disease: A randomized controlled trial with 6-month follow-up.

Nurs Open 2021 07 20;8(4):1755-1768. Epub 2021 Feb 20.

Department of Nursing Science, School of Health and Welfare, Jönköping University, Jönköping, Sweden.

Aim: To test the effect of nurse-led Internet-based cognitive behavioural therapy for insomnia (I-CBTI), tailored for patients with cardiovascular disease (CVD), with a 6-month follow-up.

Design: A two-arm parallel-group randomized controlled trial (RCT) registered at clinicaltrials.gov (NTC03938805) and reported according to the CONSORT checklist.

Methods: Forty-eight patients (mean age 72 years, 65% men) diagnosed with CVD and insomnia were randomized to either 9-week nurse-led I-CBTI with support, or an Internet-based self-study programme without support (control group). Insomnia Severity Index (ISI) and Short Form Health Survey (SF-12) were used as primary and secondary outcomes.

Results: ISI showed a significant treatment effect of I-CBTI compared to the control group at 9-week follow-up. The mean ISI score in the I-CBTI group at 9 weeks post-treatment was maintained at the 6-month follow-up. Patients' adherence to I-CBTI was associated with a better effect on both the ISI and SF-12.
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http://dx.doi.org/10.1002/nop2.817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186676PMC
July 2021

Patient alliance with the program predicts treatment outcomes whereas alliance with the therapist predicts adherence in internet-based therapy for panic disorder.

Psychother Res 2021 Feb 10:1-14. Epub 2021 Feb 10.

Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel.

Objective: This study examines relationships among different aspects of therapeutic alliance with treatment outcome, adherence and attrition in internet delivered cognitive behavioral therapy (ICBT) for panic disorder. We examined alliance-outcome relationships in ICBT ( = 74) using a newly developed self-report alliance measure that disentangles alliance with program content (Internet Patient's Experience of Attunement and Responsiveness with the program; I-PEARp) and with the therapist (I-PEARt). We compared ICBT outcomes of patient rated and therapist-rated alliance with conventional alliance scales (WAI-6 and WAI-T). Consistent with our hypothesis, I-PEARp and I-PEARt distinguished between different aspects of the alliance and predicted outcomes better than standard alliance scales. Furthermore, higher ratings of I-PEARp were associated with subsequent lower symptoms and lower symptoms were associated with higher subsequent alliance. In contrast, I-PEARt predicted adherence, but not symptoms. Although therapists' ratings of alliance (thI-PEAR) improved significantly during treatment, they did not predict subsequent symptoms, adherence, or dropout. Results indicate that the patient experience of the alliance in ICBT includes two aspects, each of which uniquely contributes to outcomes; patient connection to the program is related to symptom outcomes whereas the dyadic relationship with the therapist serves as the glue to allow the treatment to hold.
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http://dx.doi.org/10.1080/10503307.2021.1882712DOI Listing
February 2021

ICBT program for improving informal caregiver well-being: A qualitative study.

Internet Interv 2021 Mar 7;23:100361. Epub 2021 Jan 7.

Department of Behavioural Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Campus Valla, SE-581 83 Linköping, Sweden.

Background: Informal caregivers represent an important and vulnerable part of the society. They can experience negative psychological symptoms, such as depression and anxiety. Internet-based cognitive behavioural therapy (ICBT) is a promising psychological support option that could be effective in reducing informal caregiver burden as well as improving psychological well-being. Qualitative studies are valuable for gaining insights into participant experiences of using ICBT.

Objective: The main aim of this study was to explore informal caregiver experiences and hence acceptability and feasibility of the transdiagnostic ICBT program aimed at reducing informal caregiver burden and increasing the quality of life.

Methods: Following a strategic sampling procedure, 23 informal caregivers were recruited from previous randomized controlled trial for informal caregivers in Lithuania. Participants were interviewed over phone, using semi-structured interview questions. Interviews were analysed using a thematic analysis approach.

Results: Four themes and a total of 10 sub-themes were generated: I A program as a means of change (), II Suggestions for the program ( III Driving personal and situational forces ) and Hindering situational factors

Conclusions: Most of the informal caregivers were found to be satisfied with the program's format and materials as well as the communication with the therapist via a message function in the program. Some suggestions were made regarding implementation of the live support option. Also, suggestions regarding possibility for tailoring the program's content. Lastly, several personal and situational factors were identified as important in affecting informal caregiver well-being. We conclude that ICBT has potential in reducing informal caregiver burden and improving psychological health. Further research trials are warranted for evaluating both, the effectiveness and the feasibility of the program.
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http://dx.doi.org/10.1016/j.invent.2021.100361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811118PMC
March 2021

Therapygenetic effects of 5-HTTLPR on cognitive-behavioral therapy in anxiety disorders: A meta-analysis.

Eur Neuropsychopharmacol 2021 Mar 20;44:105-120. Epub 2021 Jan 20.

Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Frankfurt am Main, Germany; Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany.

There is a recurring debate on the role of the serotonin transporter gene linked polymorphic region (5-HTTLPR) in the moderation of response to cognitive behavioral therapy (CBT) in anxiety disorders. Results, however, are still inconclusive. We here aim to perform a meta-analysis on the role of 5-HTTLPR in the moderation of CBT outcome in anxiety disorders. We investigated both categorical (symptom reduction of at least 50%) and dimensional outcomes from baseline to post-treatment and follow-up. Original data were obtained from ten independent samples (including three unpublished samples) with a total of 2,195 patients with primary anxiety disorder. No significant effects of 5-HTTLPR genotype on categorical or dimensional outcomes at post and follow-up were detected. We conclude that current evidence does not support the hypothesis of 5-HTTLPR as a moderator of treatment outcome for CBT in anxiety disorders. Future research should address whether other factors such as long-term changes or epigenetic processes may explain further variance in these complex gene-environment interactions and molecular-genetic pathways that may confer behavioral change following psychotherapy.
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http://dx.doi.org/10.1016/j.euroneuro.2021.01.004DOI Listing
March 2021

Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis.

JAMA Psychiatry 2021 Apr;78(4):361-371

Benson Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts.

Importance: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them.

Objective: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information.

Data Sources: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019.

Study Selection: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization.

Data Extraction And Synthesis: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression.

Main Outcomes And Measures: Patient Health Questionnaire-9 (PHQ-9) scores.

Results: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9.

Conclusions And Relevance: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
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http://dx.doi.org/10.1001/jamapsychiatry.2020.4364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027916PMC
April 2021

Resource-Based Internet Intervention (Med-Stress) to Improve Well-Being Among Medical Professionals: Randomized Controlled Trial.

J Med Internet Res 2021 01 11;23(1):e21445. Epub 2021 Jan 11.

Department of Psychology, SWPS University of Social Sciences and Humanities, Warsaw, Poland.

Background: Medical professionals are exposed to multiple and often excessive demands in their work environment. Low-intensity internet interventions allow them to benefit from psychological support even when institutional help is not available. Focusing on enhancing psychological resources-self-efficacy and perceived social support-makes an intervention relevant for various occupations within the medical profession. Previously, these resources were found to operate both individually or sequentially with self-efficacy either preceding social support (cultivation process) or following it (enabling process).

Objective: The objective of this randomized controlled trial is to compare the efficacy of 4 variants of Med-Stress, a self-guided internet intervention that aims to improve the multifaceted well-being of medical professionals.

Methods: This study was conducted before the COVID-19 pandemic. Participants (N=1240) were recruited mainly via media campaigns and social media targeted ads. They were assigned to 1 of the following 4 groups: experimental condition reflecting the cultivation process, experimental condition reflecting the enabling process, active comparator enhancing only self-efficacy, and active comparator enhancing only perceived social support. Outcomes included 5 facets of well-being: job stress, job burnout, work engagement, depression, and job-related traumatic stress. Measurements were taken on the web at baseline (time 1), immediately after intervention (time 2), and at a 6-month follow-up (time 3). To analyze the data, linear mixed effects models were used on the intention-to-treat sample. The trial was partially blinded as the information about the duration of the trial, which was different for experimental and control conditions, was public.

Results: At time 2, job stress was lower in the condition reflecting the cultivation process than in the one enhancing social support only (d=-0.21), and at time 3, participants in that experimental condition reported the lowest job stress when compared with all 3 remaining study groups (ds between -0.24 and -0.41). For job-related traumatic stress, we found a significant difference between study groups only at time 3: stress was lower in the experimental condition in which self-efficacy was enhanced first than in the active comparator enhancing solely social support (d=-0.24). The same result was found for work engagement (d=-0.20), which means that it was lower in exactly the same condition that was found beneficial for stress relief. There were no differences between study conditions for burnout and depression neither at time 2 nor at time 3. There was a high dropout in the study (1023/1240, 82.50% at posttest), reflecting the pragmatic nature of this trial.

Conclusions: The Med-Stress internet intervention improves some components of well-being-most notably job stress-when activities are completed in a specific sequence. The decrease in work engagement could support the notion of dark side of this phenomenon, but further research is needed.

Trial Registration: ClinicalTrials.gov NCT03475290; https://clinicaltrials.gov/ct2/show/NCT03475290.

International Registered Report Identifier (irrid): RR2-10.1186/s13063-019-3401-9.
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http://dx.doi.org/10.2196/21445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834939PMC
January 2021

Internet-Based Support and Coaching With Complementary Clinic Visits for Young People With Attention-Deficit/Hyperactivity Disorder and Autism: Controlled Feasibility Study.

J Med Internet Res 2020 12 31;22(12):e19658. Epub 2020 Dec 31.

Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.

Background: Individuals with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) can experience obstacles in traditional health care situations due to difficulties associated with their impairment.

Objective: This controlled study aims to investigate the feasibility of an internet-based support and coaching intervention (IBSC), including 2 weekly chat sessions and 2 complementary clinic visits with coaches over the course of 8 weeks, for adolescents and young adults with ADHD and/or ASD in 2 naturalistic routine care settings.

Methods: Individuals with ADHD and/or ASD aged 15-32 years were recruited in 2 clinical settings, where they received either IBSC (n=24) or treatment as usual (TAU; n=20). Outcome measures included self-report questionnaires assessing quality of life (Manchester Short Assessment for Quality of Life), sense of coherence (Sense Of Coherence 29), self-esteem (Rosenberg Self-Esteem Scale), and anxiety and depressive symptoms (Hospital Anxiety and Depression Scale [HADS] and Montgomery-Åsberg Depression Rating Scale-Self-reported, respectively).

Results: Significant between-group effects were observed in measures of anxiety (HADS) at postintervention (P=.02) as well as at the 6-month follow-up (P=.004). Significant between-group effects were also noted for depressive symptoms (HADS) postintervention (P=.04). The between-group effects were partially explained by a deterioration in the TAU group. A significant increase in self-esteem (P=.04) as well as a decrease in anxiety (P=.003) at the 6-month follow-up was observed in the intervention group following IBSC. Findings from a qualitative study of the intervention are consistent with the results.

Conclusions: The findings from this study suggest that IBSC holds promise as a feasible complement or alternative to traditional face-to-face health care meetings.
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http://dx.doi.org/10.2196/19658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808894PMC
December 2020

Mitigating COVID-19 Impact on the Portuguese Population Mental Health: The Opportunity That Lies in Digital Mental Health.

Front Public Health 2020 16;8:553345. Epub 2020 Nov 16.

NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Lisbon, Portugal.

COVID-19 mitigation measures present unprecedented challenges in mental healthcare delivery, posing high risk to the mental health of at-risk populations, namely patients diagnosed with COVID-19, frontline healthcare providers, and those submitted to quarantine or isolation measures, as well as the general population. Ensuring safe and equitable access to mental healthcare by these groups entails resorting to innovative psychosocial intervention strategies, such as digital mental health. In this perspective piece, we describe the impact of COVID-19 on the Portuguese population's mental health, present an overview on initiatives developed to address the challenges currently faced by the Portuguese mental healthcare system, and discuss how the timely implementation of a comprehensive digital mental health strategy, coupling research, education, implementation, and quality assessment initiatives, might buffer COVID-19's impact on the Portuguese society.
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http://dx.doi.org/10.3389/fpubh.2020.553345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7701327PMC
December 2020

A large-scale experiment on New Year's resolutions: Approach-oriented goals are more successful than avoidance-oriented goals.

PLoS One 2020 9;15(12):e0234097. Epub 2020 Dec 9.

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

Despite the popularity of New Year's resolutions, current knowledge about them is limited. We investigated what resolutions people make when they are free to formulate them, whether different resolutions reach differing success rates, and whether it is possible to increase the likelihood of a resolution's success by administering information and exercises on effective goal setting. Participants (N = 1066) from the general public were randomized into three groups: active control, some support, and extended support. The most popular resolutions regarded physical health, weight loss, and eating habits. At a one-year follow-up, 55% of responders considered themselves successful in sustaining their resolutions. Participants with approach-oriented goals were significantly more successful than those with avoidance-oriented goals (58.9% vs. 47.1%). The group that received some support was exclusively and significantly more successful compared to the other two. This study reveals that New Year's resolutions can have lasting effects, even at a one-year follow-up.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234097PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725288PMC
January 2021

Changes in Tinnitus Experiences During the COVID-19 Pandemic.

Front Public Health 2020 5;8:592878. Epub 2020 Nov 5.

Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, United States.

The COVID-19 pandemic has disrupted delivery of healthcare, economic activity, and affected social interactions. Identifying and supporting those most affected by the pandemic is required. The purpose of this study was to determine the impact of the pandemic on individuals with tinnitus and to identify mediating factors. This is a mixed-methods exploratory cross-sectional study, using data collected via an online survey from 3,103 individuals with tinnitus from 48 countries. The greatest representation was from North America (49%) and Europe (47%) and other countries were only marginally represented. Although the study was aimed at those with pre-existing tinnitus, 7 individuals reported having COVID-19 initiated tinnitus. Having COVID-19 symptoms exacerbated tinnitus in 40% of respondents, made no change in 54%, and improved tinnitus in 6%. Other mediating factors such as the social and emotional consequences of the pandemic made pre-existing tinnitus more bothersome for 32% of the respondents, particularly for females and younger adults, better for 1%, and caused no change to tinnitus for 67%. Pre-existing tinnitus was significantly exacerbated for those self-isolating, experiencing loneliness, sleeping poorly, and with reduced levels of exercise. Increased depression, anxiety, irritability, and financial worries further significantly contributed to tinnitus being more bothersome during the pandemic period. These findings have implications for tinnitus management, because they highlight the diverse response both internal and external factors have on tinnitus levels. Clinical services should be mindful that tinnitus may be caused by contracting COVID-19 and pre-existing tinnitus may be exacerbated, although in the majority of respondents there was no change. Additional support should be offered where tinnitus severity has increased due to the health, social, and/or emotional effects of the COVID-19 pandemic. Tinnitus may be more bothersome for those experiencing loneliness, having fewer social interactions, and who are more anxious or worried.
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http://dx.doi.org/10.3389/fpubh.2020.592878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676491PMC
May 2021

Internet-based cognitive behavior therapy for depression, social anxiety disorder, and panic disorder: Effectiveness and predictors of response in a teaching clinic.

Behav Res Ther 2021 01 21;136:103767. Epub 2020 Nov 21.

Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. Electronic address:

Though therapist-guided Internet-based cognitive behavior therapy (ICBT) appears to be efficacious for depression, social anxiety disorder, and panic disorder, relatively little is known about real-world settings and predictors of treatment effects derived from cognitive-behavioral theory. We examined treatment effectiveness and predictors of improvement in a prospective cohort study where patients took part in 10 weeks of ICBT for depression (n = 114), social anxiety disorder (n = 150), or panic disorder (n = 106) at a teaching clinic. Patients self-reported symptoms before, during, and after treatment. Effect sizes were large for improvement in the primary symptom domain of each treatment group: depression (d = 1.48), social anxiety disorder (d = 1.01), and panic disorder (d = 1.15). In ICBT for depression, having no previous experience of psychological treatment (r = 0.21), and more frequent baseline negative automatic thoughts (r = 0.20) predicted larger improvement. In ICBT for panic disorder, having more baseline safety behaviors (r = 0.25) predicted larger improvement. Predictors remained significant when baseline symptoms were included in the statistical models. We conclude that ICBT can be effective in a real-world teaching clinic, and that patients with greater deficits at baseline benefit the most.
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http://dx.doi.org/10.1016/j.brat.2020.103767DOI Listing
January 2021

Addressing Healthcare Gaps in Sweden during the COVID-19 Outbreak: On Community Outreach and Empowering Ethnic Minority Groups in a Digitalized Context.

Healthcare (Basel) 2020 Nov 1;8(4). Epub 2020 Nov 1.

Department of Behavioural Sciences and Learning, Linköping University, 581 83 Linköping, Sweden.

Since its early stages, the COVID-19 pandemic has interacted with existing divides by ethnicity and socioeconomic statuses, exacerbating further inequalities in high-income countries. The Swedish public health strategy, built on mutual trust between the government and the society and giving the responsibility to the individual, has been criticized for not applying a dedicated and more diverse strategy for most disadvantaged migrants in dealing with the pandemic. In order to mitigate the unequal burden on the marginalized members of society, increasing efforts have been addressed to digital health technologies. Despite the strong potential of providing collective public health benefits, especially in a highly digitalized context as Sweden, need for a stronger cooperation between the public health authorities and migrant community leaders, representatives of migrant associations, religious leaders and other influencers of disadvantaged groups has emerged. Suggestions are presented on more culturally congruent, patient-centered health care services aimed to empower people to participate in a more effective public health response to the COVID-19 crisis.
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http://dx.doi.org/10.3390/healthcare8040445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712425PMC
November 2020

User characteristics and outcomes from a national digital mental health service: an observational study of registrants of the Australian MindSpot Clinic.

Lancet Digit Health 2020 11 19;2(11):e582-e593. Epub 2020 Oct 19.

MindSpot Clinic, Macquarie University, Sydney, NSW, Australia.

Background: Interest is growing in digital and telehealth delivery of mental health services, but data are scarce on outcomes in routine care. The federally funded Australian MindSpot Clinic provides online and telephone psychological assessment and treatment services to Australian adults. We aimed to summarise demographic characteristics and treatment outcomes of patients registered with MindSpot over the first 7 years of clinic operation.

Methods: We used an observational design to review all patients who registered for assessment with the MindSpot Clinic between Jan 1, 2013, and Dec 31, 2019. We descriptively analysed the demographics, service preferences, and baseline symptoms of patients. Among patients enrolled in a digital treatment course, we evaluated scales of depression (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder 7-Item Scale [GAD-7]), as primary measures of treatment outcome, from the screening assessment to post-treatment and a 3 month follow-up. The Kessler Psychological Distress 10-Item Plus Scale was also used to assess changes in general distress and disability, and course satisfaction was measured post-treatment.

Outcomes: A total of 121 652 screening assessments were started, of which 96 018 (78·9%) were completed. The mean age of patients was 35·7 years (SD 13·8) and 88 702 (72·9%) were women. Based on available assessment data, 36 866 (34·5%) of 106 811 participants had never previously spoken to a health professional about their symptoms, and most people self-reported symptoms of anxiety (88 879 [81·9%] of 108 494) or depression (78 803 [72·6%] of 108 494), either alone or in combination, at baseline. 21 745 patients started treatment in a therapist-guided online course, of whom 14 503 (66·7%) completed treatment (≥four of five lessons). Key trends in service use included an increase in the proportion of people using MindSpot primarily for assessment and information, from 52·6% in 2013 to 66·7% in 2019, while the proportion primarily seeking online treatment decreased, from 42·6% in 2013 to 26·7% in 2019. Effect sizes and percentage changes were large for estimated mean scores on the PHQ-9 and GAD-7 from assessment to post-treatment (PHQ-9, Cohen's d effect size 1·40 [95% CI 1·37-1·43]; and GAD-7, 1·45 [1·42-1·47]) and the 3 month follow-up (PHQ-9, 1·36 [1·34-1·38]; and GAD-7, 1·42 [1·40-1·44]); proportions of patients with reliable symptom deterioration (score increase of ≥6 points [PHQ-9] or ≥5 points [GAD-7]) were low post-treatment (of 13 058 respondents, 184 [1·4%] had symptom deterioration on the PHQ-9 and 282 [2·2%] on the GAD-7); and patient satisfaction rates were high (12 452 [96·6%] of 12 895 respondents would recommend the course and 12 433 [96·7%] of 12 860 reported the course worthwhile). We also observed small improvements in disability following treatment as measured by days out of role.

Interpretation: Our findings indicate improvement in psychological symptoms and positive reception among patients receiving online mental health treatment. These results support the addition of digital services such as MindSpot as a component in contemporary national mental health systems.

Funding: None.
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http://dx.doi.org/10.1016/S2589-7500(20)30224-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571905PMC
November 2020

Treating perfectionism using internet-based cognitive behavior therapy: A study protocol for a randomized controlled trial comparing two types of treatment.

Internet Interv 2020 Sep 27;21:100338. Epub 2020 Aug 27.

Department of Clinical Neuroscience, Karolinska Institutet, Sweden.

Perfectionism is characterized by setting high standards and striving for achievement, sometimes at the expense of social relationships and wellbeing. Despite sometimes being viewed as a positive feature by others, people with perfectionism tend to be overly concerned about their performance and how they are being perceived by people around them. This tends to create inflexible standards, cognitive biases, and performance-related behaviors that maintain a belief that self-worth is linked to accomplishments. Cognitive behavior therapy has been shown to be a viable treatment for perfectionism, both in terms of reducing levels of perfectionism and improving psychiatric symptoms. Furthermore, a number of recent studies indicate that it can be successfully delivered via the Internet, both with regular support and guidance on demand from a therapist. In the present study protocol, a clinical trial for perfectionism is described and outlined. In total, 128 participants will be recruited and randomized to either a treatment that has already been demonstrated to have many benefits, Internet-based Cognitive Behavior Therapy for perfectionism (iCBT-P), or an active comparison condition, Internet-based Unified Protocol (iUP), targeting the emotions underlying depression and anxiety disorders. The results will be investigated with regard to self-reported outcomes of perfectionism, psychiatric symptoms, self-compassion, and quality of life, at post-treatment and at six- and 12-month follow-up. Both iCBT-P and iUP are expected to have a positive impact, but the difference between the two conditions in terms of their specific effects and adherence are currently unknown and will be explored. The clinical trial is believed to lead to a better understanding of how perfectionism can be treated and the specificity of different treatments.
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http://dx.doi.org/10.1016/j.invent.2020.100338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481556PMC
September 2020

Knowledge gain and usage of knowledge learned during internet-based CBT treatment for adolescent depression - a qualitative study.

BMC Psychiatry 2020 09 10;20(1):441. Epub 2020 Sep 10.

Department of Behavioural Sciences and Learning, Linköping University, SE-58183, Linköping, Sweden.

Background: The role of explicit learning of treatment content in internet-based cognitive-behavioural treatment (ICBT) is an emerging field of research. The objective of this study was to explore clients experiences of their ICBT treatment for depression with a focus on knowledge gain and usage of knowledge learned during treatment.

Methods: A strategic sample of ten adolescents, aged between 15 and 19 years, who had received ICBT for major depression within a clinical controlled trial were recruited for the study. Semi-structured interviews were conducted 6 months following trial completion. Data were transcribed and analysed using thematic analysis. The participants had a general adherence rate of 6-8 opened modules out of 8 possible.

Results: Two main themes were identified; "Active agents of CBT" and "Passive agents of CBT", with each theme consisting of three and two sub-themes. Active agents of CBT reflect a tendency to specifically remember and actively apply specific CBT principles in present life situations. Passive agents of CBT reflect a tendency to remember CBT treatment principles vaguely and express a passive or reactive usage of learned therapy content.

Conclusion: The findings suggest that young clients can remember and apply CBT principles 6 months after their treatment. However, while experiencing benefits of treatment, clients recall and application of treatment strategies vary. The study emphasizes the importance of exploring client recall of CBT components and how valuable it is to explicitly remember contents of a treatment in order to improve and maintain improvement. Further studies on the role of knowledge and memory of ICBT for adolescent populations are warranted.
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http://dx.doi.org/10.1186/s12888-020-02833-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488317PMC
September 2020

Seeking neutral: A VR-based person-identity-matching task for attentional bias modification - A randomised controlled experiment.

Internet Interv 2020 Sep 14;21:100334. Epub 2020 Aug 14.

Department of Psychology, Stockholm University, Frescativägen, 114 19 Stockholm, Sweden.

Background: Attentional bias modification (ABM) aims to reduce anxiety by attenuating bias towards threatening information. The current study incorporated virtual reality (VR) technology and 3-dimensional stimuli with a person-identity-matching (PIM) task to evaluate the effects of a VR-based ABM training on attentional bias and anxiety symptoms.

Methods: One hundred participants with elevated social anxiety were randomised to four training groups. Attentional bias was assessed at pre- and post-training, and anxiety symptoms were assessed at pre-training, post-training, 1-week follow-up, and 3-month follow-up.

Results: Change in anxiety did not correlate with change in bias ( = -0.08). A repeated-measures ANOVA showed no significant difference in bias from pre- to post-ABM, or between groups. For anxiety symptoms, a linear mixed-effects model analysis revealed a significant effect of time. Participants showed reduction in anxiety score at each successive assessment ( < .001, Nagelkerke's pseudo  = 0.65). However, no other significant main effect or interactions were found. A clinically significant change analysis revealed that 4% of participants were classified as 'recovered' at 3-month follow-up.

Conclusions: A single session of VR-based PIM task did not change attentional bias. The significant reduction in anxiety was not specific to active training, and the majority of participants remained clinically unchanged.
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http://dx.doi.org/10.1016/j.invent.2020.100334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452567PMC
September 2020

Features, Functionality, and Acceptability of Internet-Based Cognitive Behavioral Therapy for Tinnitus in the United States.

Am J Audiol 2020 Sep 28;29(3):476-490. Epub 2020 Jul 28.

Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX.

Objective Although tinnitus is one of the most commonly reported symptoms in the general population, patients with bothersome tinnitus are challenged by issues related to accessibility of care and intervention options that lack strong evidence to support their use. Therefore, creative ways of delivering evidence-based interventions are necessary. Internet-based cognitive behavioral therapy (ICBT) demonstrates potential as a means of delivering this support but is not currently available in the United States. This article discusses the adaptation of an ICBT intervention, originally used in Sweden, Germany, and the United Kingdom, for delivery in the United States. The aim of this study was to (a) modify the web platform's features to suit a U.S. population, (b) adapt its functionality to comply with regulatory aspects, and (c) evaluate the credibility and acceptability of the ICBT intervention from the perspective of health care professionals and patients with bothersome tinnitus. Materials/Method Initially, the iTerapi ePlatform developed in Sweden was adopted for use in the United States. Functional adaptations followed to ensure that the platform's functional and security features complied with both institutional and governmental regulations and that it was suitable for a U.S. population. Following these adaptations, credibility and acceptance of the materials were evaluated by both health care professionals ( = 11) and patients with bothersome tinnitus ( = 8). Results Software safety and compliance regulatory assessments were met. Health care professionals and patients reported favorable acceptance and satisfaction ratings regarding the content, suitability, presentation, usability, and exercises provided in the ICBT platform. Modifications to the features and functionality of the platform were made according to user feedback. Conclusions Ensuring that the ePlatform employed the appropriate features and functionalities for the intended population was essential to developing the Internet-based interventions. The favorable user evaluations indicated that the intervention materials were appropriate for the tinnitus population in the United States.
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http://dx.doi.org/10.1044/2020_AJA-20-00002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842846PMC
September 2020