Psychological self-care in chronic conditions : development of digital interventions in type 1 diabetes and atopic dermatitis

Background: Psychological interventions for somatic conditions have a long history with many successful examples, often based on cognitive behavioural therapy (CBT) However, psychologists are not commonly found in somatic healthcare. Therefore, it is of interest to develop self-guided interventions based on CBT for somatic disorders, for easy dissemination in regular healthcare. In this thesis, intervention in different stages of development were investigated for people with type 1 diabetes mellitus (T1DM) and for people with atopic dermatitis (AD) in both cases based on CBT. Aims: The overall aim in this thesis was to document the development of self-guided psychological interventions for somatic conditions, by a novel intervention for T1DM and a shortened and adapted intervention for AD. Method: The interventions developed for T1DM were inspired by earlier CBT research on T1DM and other somatic conditions. The self-guided intervention for AD was adapted from an evaluated clinician-guided intervention. Study I was a case report describing the treatment of two patients with T1DM who finished an early version of a 10-week CBT programme. Study II was a feasibility study in the setting of a diabetes clinic. Eight participants used two digital tools, focused on problem solving and exposure for four weeks. Study III was a feasibility study about a self-guided CBT-based intervention for AD with 21 participants. Study IV was a report on the secondary outcomes of study III. Study V was a randomised clinical non-inferiority trial with 168 participants randomised to a self-guided intervention for AD or to a clinician-guided intervention. Results: In study I, the 2 participants reported clinically significant improvements. Case 1 reported reduced blood glucose levels and improvements in his health behaviours. Case 2 reported clinically significant improvements in fear of hypoglycaemia. Both cases reported high satisfaction with their treatments and reported no adverse events. In study II, the results did not unreservedly support feasibility. All participants used the problem-solving tool, and three out of eight participants had used the exposure tool. No serious adverse events were reported. Results on feasibility were inconsistent, with credibility generally rated low, and usability below cut-off. However, some participants reported small improvements in outcome measures. As an additional tentative finding, a preliminary analysis of participant’s comments and reported problems suggested two types of users: One that may have more use for a problem-solving tool and one with fear of hypoglycaemia, that may be more helped by exposure. In study III, participants had a significant decrease on AD symptoms at post measurement immediately after intervention with a moderate within-group effect size (d=0.61 95% CI 0.11-1.12) which had improved to a moderate to large within-group effect size at 3-month follow up (d=0.84 95% CI 0.38-1.37) No serious adverse events were reported. The revised intervention consisted of 16 726 words, shortened from 111 142 words. In study IV, secondary outcomes on study III were reported. The intervention was feasible in all measures, except that system usability was rated 67 on average on the System Usability scale (range 0-100), below the scale’s authors’ cutoff of 70. At 3-month follow-up, within-group effect sizes on secondary outcomes were moderate to large. In study V, no significant differences were found between the groups. The estimated mean difference in change of 0.36 points (1-sided 97.5 % CI, −∞ to 1.75) which was lesser than the 3-point noninferiority margin. A clinician administering the clinician-guided group spent on average 50 minutes compared to 16 minutes for the self-guided group. Conclusions: Digital self-guided tools for people with T1DM may work for some people but would need improvements before a larger randomised trial. It’s possible that a general intervention based on problem-solving, and a specific intervention based on exposure for fear of hypoglycaemia would be a way to move forward in the development of interventions for T1DM. A self-guided CBT based intervention for AD was found feasible and effective and could be easily implemented in primary or specialist care. The results also support the feasibility of adapting an existing clinician-guided intervention into a self-guided variant. Self-guided interventions may have the advantage of less time spent by clinicians and therefore less use of resources. An additional possible advantage may be the less time spent by patients on reading written material

Transforming guided internet interventions into simplified and self-guided digital tools – Experiences from three recent projects

Introduction: Therapist-guided internet interventions are often more efficacious than unguided ones. However, the guidance itself requires clinician time, and some research suggests that self-guided interventions could potentially be equally effective. The concept of digital psychological self-care, self-guided internet interventions based on the use of digital tools and provided within a structured clinical process, is presented. Methods: Three new self-care interventions, a sleep diary-based intervention for insomnia, an alcohol diary-based intervention for problematic alcohol use and an intervention with exposure and mindfulness tools for atopic dermatitis (eczema), were developed. Newly developed digital self-care interventions were compared to the earlier therapist-guided interventions they were based on, using published results from three feasibility trials (n's = 30, 36 and 21) and three randomized trials (n's = 148, 166 and 102). The comparison included type of content, duration, length of written material and within-group effect-sizes. Results: In comparison to the guided interventions, clinician time was greatly reduced and the new interventions involved much less reading for participants. The digital self-care tools also showed within-group effect sizes and response rates on par with the more comprehensive guided internet interventions. Discussion: Preliminary results suggest that some guided internet interventions can be transformed into self-guided digital tools. These three examples show that digital psychological self-care, if provided with telephone interviews before and after the intervention, can be viable alternatives to more comprehensive guided internet interventions. Although these examples are promising, further studies, including randomized experiments, are needed to compare treatment efficacies, and to identify which groups of patients may need more comprehensive guided internet interventions

Brief self-guided digital intervention versus a comprehensive therapist-guided online cognitive behavioural therapy for atopic dermatitis: a trial protocol for a randomised non-inferiority trial

Introduction Our aim is to investigate whether a shortened digital self-care intervention is non-inferior to, and cost-effective compared with, a comprehensive and therapist-guided cognitive behavioural therapy treatment for atopic dermatitis (AD).Methods and analysis This is a single-blind, randomised clinical non-inferiority trial at Karolinska Institutet, a medical university in Stockholm, Sweden. We will recruit 174 adult participants with AD through self-referral. Participants will be randomised 1:1 to the two experimental conditions. Participants randomised to guided care will receive internet-delivered cognitive behavioural therapy for 12 weeks. Participants randomised to digital self-care will have access to this self-guided intervention for 12 weeks. At post-treatment (primary endpoint), non-inferiority will be tested and resource use will be compared between the two treatment groups. Cost-effectiveness will be explored at 1-year follow-up. Potential mediators will be investigated. Data will be analysed intention to treat. We define non-inferiority as a three-point difference on the primary outcome measure (Patient-oriented Eczema Measure). Recruitment started in November 2022.Ethics and dissemination This study is approved by the Swedish ethics authority (reg. no 2021-06704-01) and is preregistered at ClinicalTrials.gov. The study will be reported according to the Consolidated Standards of Reporting Trials statement for non-pharmacological trials. The results of the study will be published in peer-reviewed scientific journals and disseminated to patient organisations and media.Trial registration number NCT05517850

Psychological treatments for irritable bowel syndrome: a comprehensive systematic review and meta-analysis

A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a.Funding Agencies|Region Stockholm [ALF project]; Swedish Research Council [521-2013-2846]; Jane and Dan Olsson foundation [4-1559/2013]; Swedish Research Council for Health, Working life and Welfare [2014-4052]</p