Individually tailored internet-based treatment for depression and comorbid conditions

Background: Depression is a large societal problem. People suffering from depression are heterogeneous and have a high degree of comorbid conditions. Pharmacological treatment is widespread, but not effective for all sufferers, and patients often have a preference for psychological treatment. There are effective psychological treatment alternatives, but access to treatment is low. Individually tailored internet-based treatment has the ability to target several conditions within the same treatment. It has shown promising effects on depression and anxiety but needs to be further evaluated against other interventions. The effects of specific treatment components also need to be explored. Aims: The aims of this thesis were to evaluate the effects and cost-effectiveness of individually tailored internet-based treatment compared to other treatment alternatives, to compare its effects to disorder-specific benchmark treatments, and to explore if compliance to treatment components for specific conditions predict reductions in the targeted symptoms. Methods: Study I-IV were based on the randomized trial REGASSA (n = 946) where an individually tailored internet-based treatment (TAIL) were compared to structured physical exercise (PE) and to treatment as usual in primary care (TAU). In Study I, the effects of TAIL and PE on depression symptoms were evaluated against TAU. Study II evaluated the cost- effectiveness of TAIL and PE against TAU. In Study III, TAIL was compared to similar, but disorder-specific, benchmark treatments for depression (n = 2358), panic disorder (n = 1176) and social anxiety disorder (n = 1335). In Study IV, the participants’ compliance to the different specific components in the TAIL-intervention were rated, and related to symptom reductions. Results: The effects of TAIL on depression symptoms were large (g = 1.47, 95% CI 1.29- 1.66), and there were significantly larger reductions in depression symptoms than in the TAU- group. There were no significant differences in effects on depression symptoms between TAIL and PE. TAIL and PE had 90 and 76 % probabilities respectively, of being cost-effective compared to TAU, given standard health care provider willingness to pay-thresholds. The effects of TAIL on depression symptoms were non-inferior to disorder-specific internet-based treatment. The effects of TAIL on panic or social anxiety symptoms however, could not be concluded to be non-inferior to disorder-specific treatment. Overall compliance with TAIL was strongly related to symptom reductions in depression, panic, social anxiety, stress and insomnia, weakly related to reductions in worry, but not related to reductions in pain symptoms. Compliance to specific components for social anxiety was related to reductions in specific social anxiety symptoms. Compliance to specific components for stress and insomnia were particularly important since they were related to both specific symptom reductions and reductions of depressive symptoms. Conclusions: The results in this thesis support that individually tailored internet-based treatment is an effective and cost-effective treatment alternative to be considered for implementation. It is as effective as the disorder-specific internet-based treatments for depression already used in routine care, but more comparisons are needed to conclude if it is as effective as disorder-specific anxiety treatments. Since specific treatment components for stress and insomnia were important for both specific and depressive symptom reductions, it is probable that individual tailoring for these conditions is worthwhile in the treatment of depression

Proceedings of the 13th annual conference of INEBRIA

CITATION: Watson, R., et al. 2016. Proceedings of the 13th annual conference of INEBRIA. Addiction Science & Clinical Practice, 11:13, doi:10.1186/s13722-016-0062-9.The original publication is available at https://ascpjournal.biomedcentral.comENGLISH SUMMARY : Meeting abstracts.https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-016-0062-9Publisher's versio

KBT-baserad vägledd självhjälp för samtidig insomni och depression – en randomiserad jämförande behandlingsstudie

Insomni och depression är två vanliga former av psykisk ohälsa som mycket ofta förekommer samtidigt. Psykologisk behandling med KBT i form av vägledd självhjälp är väl utprövat för dessa båda tillstånd var för sig. Endast ett fåtal behandlingsstudier har utvärderat någon form av psykologisk behandling för personer med samtidig insomni och depression. Vägledd självhjälp är inte utvärderad för denna grupp. I denna randomiserade studie jämfördes två KBT-baserade vägledda självhjälpsbehandlingar, den ena mot insomni (n=22), den andra mot depression (n=21), för personer med samtidig insomni och depression. Båda behandlingarna hade effekt på både insomnisymtom mätt med ISI och depressionssymtom mätt med MADRS-S. Effekterna var mindre än i tidigare studier av behandling för insomni respektive depression var för sig. Det var ingen skillnad i effekt mellan grupperna i något av utfallsmåtten. Att ingen skillnad kunde fastställas kan bero på för få deltagare

Practical and Emotional Problems Reported by Users of a Self-guided Digital Problem-solving Intervention During the COVID-19 Pandemic: Content Analysis

BackgroundTo better direct assessments and interventions toward the general population during both the ongoing COVID-19 pandemic and future crises with societal restrictions, data on the types of practical and emotional problems that people are experiencing are needed. ObjectiveThe aim of this study was to examine the types of practical and emotional problems that the general population is experiencing during the COVID-19 pandemic and to construct an empirically derived inventory based on the findings. MethodsA total of 396 participants, recruited among members of the general public in Sweden who were experiencing practical and/or emotional problems during the pandemic, accessed a self-guided digital problem-solving intervention for a period of 1 week to report and solve the problems they experienced. Prior to accessing the intervention, the participants completed a short self-assessment regarding symptoms of depression and anxiety. Content analysis was used to account for the types of problems participants reported. A set of items for an inventory was later proposed based on the problem categories derived from the analysis. ResultsA majority of participants had clinically relevant symptoms of either depression or anxiety. The problems reported were categorized as 13 distinct types of problems. The most common problem was difficulty managing daily activities. Based on the categories, a 13-item inventory was proposed. ConclusionsThe 13 types of problems, and the proposed inventory, could be valuable when composing assessments and interventions for the general population during the ongoing pandemic or similar crises with societal restrictions. The most common problem was of a practical nature, indicating the importance of including examples of such problems within assessments and interventions. Trial RegistrationClinicalTrials.gov NCT04677270; https://clinicaltrials.gov/ct2/show/NCT0467727

Internet-based cognitive behavioral therapy for depression and anxiety in Parkinson's disease — A pilot study

Background: Parkinson's disease (PD) is often associated with depression and anxiety. The availability of evidence-based psychological interventions is low. Objective: This pilot study investigates the feasibility and preliminary effect of internet-based cognitive behavioral therapy (ICBT) for depression and anxiety in PD. Methods: 9 patients with PD with comorbid symptoms on the relevant subscale of Hospital Anxiety and Depression Scale (HADS), of either depression (HADS-D > 7) or anxiety (HADS-A > 7) received 12 weeks of ICBT, specially adapted for depression and anxiety in PD. Primary outcome was change in depression and anxiety symptoms, measured with HADS total score. Effects on non-motor symptoms, PD specific health and quality of life and insomnia were explored, plus the participant's involvement, satisfaction, and subjective evaluation of the treatment. Results: Participants reported lower symptoms on HADS after ICBT (Cohen's d = 0.79, p < 0.05). However, levels of inactivity were rather high and questionnaires and comments from participants suggested that the treatment can be improved, for example by adding more therapist support. Conclusions: The results suggest that ICBT could be a feasible way to alleviate depression and anxiety in PD. However, a somewhat simplified treatment and different ways to provide support to enhance adherence and outcome are warranted

Exploring client messages in a therapist-guided internet intervention for alcohol use disorders – A content analysis

Background: There is a growing interest in offering therapist-guided internet interventions for alcohol use disorders (AUD) in regular addiction services. Elucidating the therapeutic processes during these interventions may help improve clinical delivery. The aim of this paper was to investigate written messages from client to therapist in a therapist-guided internet intervention for AUD. Methods: Data was extracted from the therapist-guided arm (n = 57) of a randomized trial of internet interventions for AUD. Qualitative content analysis was used to identify distinct categories of client behaviors in written messages to therapists. Coding was deductive (applying categories from past literature) as well as inductive (identifying new categories from the data). Subsequently, exploratory correlational and regression analyses were conducted to investigate whether identified client behaviors predicted module completion and drinking outcomes. Also, client questions posed in messages to therapists were categorized separately. Results: Eleven distinct behavior categories were identified, of which the two most common were alliance (26.6% of total categorizations) and identifying patterns and problem behaviors (22.8%). Confrontational alliance rupture was the least common category (0.4%). One new behavior category was identified inductively – alcohol-related setback (4.1%). In the exploratory analyses, no categories consistently predicted module completion or drinking outcomes. Client questions were most commonly posed to improve understanding or use of program content or skills. Discussion: The behavior categories, although not predictive of module completion or outcomes, may be of use for therapists, treatment developers and health care providers as a tool for understanding therapeutic processes in internet interventions for AUD

Changes in alcohol consumption after treatment for depression : A secondary analysis of the Swedish randomised controlled study REGASSA

Objectives Mental health problems and hazardous alcohol consumption often co-exist. Hazardous drinking could have a negative impact on different aspects of health and also negatively influence the effect of mental health treatment. The aims of this study were to examine if alcohol consumption patterns changed after treatment for depression and if the changes differed by treatment arm and patient sex. Methods This study of 540 participants was conducted in a large randomised controlled trial (RCT) that aimed to compare the effect of internet-based cognitive behavioural therapy, physical exercise and treatment as usual on 945 participants with mild-to-moderate depression. Treatment lasted for 12 weeks; alcohol consumption (Alcohol Use Disorder Identification Test (AUDIT)) and depression (Montgomery Åsberg Depression Rating Scale (MADRS)) were assessed at baseline and 12-month follow-up. Changes in alcohol consumption were examined in relation to depression severity, treatment arm and patient sex. Results The AUDIT distribution for the entire group remained unchanged after treatment for depression. Hazardous drinkers exhibit decreases in AUDIT scores, although they remained hazardous drinkers according to the cut-off scores. Hazardous drinkers experienced similar improvements in symptoms of depression compared with non-hazardous drinkers, and there was no significant relation between changes in AUDIT score and changes in depression. No differences between treatment arm and patient sex were found. Conclusion The alcohol consumption did not change, despite treatment effects on depression. Patients with depression should be screened for hazardous drinking habits and offered evidence-based treatment for hazardous alcohol use where this is indicated. Trial registration number DRKS00008745

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

High- versus low-intensity internet interventions for alcohol use disorders (AUD): A two-year follow-up of a single-blind randomized controlled trial

Alcohol Use Disorders (AUD) are widespread and have serious consequences, but are among the most undertreated mental disorders. Internet interventions have been found effective in treating AUD, but we know little about long-term outcomes, two years or more after treatment. This study explored 12- and 24-month outcomes in alcohol consumption following initial 6-month improvements after a therapist-guided high-intensity internet intervention and an unguided low-intensity internet intervention among individuals with alcohol use disorder. Between-group comparisons were analyzed, as well as within-group comparisons with (1) pre-treatment measurements (2) post-treatment measurements. Participants consisted of a general population sample of internet help-seekers in Sweden. A total of 143 adults (47% men) with a score of 14 (women)/16 (men) or more on the Alcohol Use Disorders Identification Test, alcohol consumption of 11 (women)/14 (men) or more standard drinks the preceding week and ≥ 2 DSM-5 alcohol use disorder (AUD) criteria based on a diagnostic interview were included. The high- and low-intensity internet interventions (n = 72 and n = 71 respectively) consisted of modules based on relapse prevention and cognitive-behavioral therapy. The primary outcome was self-reported alcohol consumption in the preceding week measured as (1) number of standard drinks and (2) number of heavy drinking days. Attrition from self-reported questionnaires was 36% at the 12-month follow-up and 53% at the 24-month follow-up. No significant between-group differences occurred in outcomes at either long-term follow-up. Regarding within-group differences, compared to pre-treatment, alcohol consumption was lower in both high- and low-intensity interventions at both long-term follow-ups [within-group standard drinks effect sizes varied between g = 0.38–1.04 and heavy drinking days effect sizes varied between g = 0.65–0.94]. Compared to post-treatment, within-group alcohol consumption in the high intensity intervention increased at both follow-ups; for the low-intensity intervention, within-group consumption decreased at 12-month follow-up, but did not differ compared to post-treatment at 24 months. Both high- and low-intensity internet interventions for AUD were thus associated with overall reductions in alcohol consumption at long term follow-ups, with no significant differences between the two. However, conclusions are hampered by differential and non-differential attrition

Increasing accessibility to iCBT for depression : A randomised controlled trial of condensed versus standard length treatment

Background: Research show that internet-based CBT (iCBT) is an effective treatment for depression. However, little is known about how length of treatment text material affect outcomes. Accessibility to treatment would improve if treatment could be presented with less text, especially for patients with ADHD symptoms and lower reading speed.Objective: The aim of this study was to test the hypothesis that a Condensed treatment would be non-inferior to a Full-length treatment. We further hypothesized that a Condensed treatment would be extra helpful for participants with a low reading speed and more ADHD symptoms. Method: A single-blind randomised controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; Full-length (60 000 words) and Condensed (30 000 words). Estimated between-group effect sizes and their confidence intervals were compared to a pre-determined non-inferiority margin (Cohen’s d = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted, as well as comparisons of treatment engagement and knowledge acquisition. Results: The Condensed version of iCBT was non-inferior at endpoint for depressive symptoms, anxiety symptoms, and quality of life compared to the Full-length version. There was a significant interaction effect between reading speed and treatment version. No significant differences between the treatment versions were found on measures of treatment engagement or knowledge acquisition. Conclusion: A condensed version of iCBT for depression can be used with non-inferior results. A condensed treatment might be extra helpful for patients with lower reading speed. Given a high degree of missing data, these results need to be replicated