Social anxiety and agoraphobia symptoms effectively treated by Prompt Mental Health Care versus TAU at 6‐ and 12‐month follow‐up: Secondary analysis from a randomized controlled trial

Background Prompt Mental Health Care (PMHC, Norwegian adaption of Improving Access to Psychological Therapies) has shown effects on symptoms of anxiety and depression compared to treatment as usual (TAU). In this secondary analysis, we examine the effectiveness of PMHC among clients presenting with symptoms of social anxiety disorder (SAD) and/or agoraphobia on core symptoms at 6- and 12-month follow-up. Methods Randomized controlled trial in two PMHC sites (70:30 ratio PMHC:TAU). Of participants, 61.3% (n = 472) scored at caseness for SAD and 47.7% (n = 367) for agoraphobia (40% both). Effects on SAD avoidance and physiological discomfort (SPIN-9), SAD cognitions (ATQ-SA), agoraphobic avoidance (MIA-8), and agoraphobic cognitions (ATQ-AP) were examined in piecewise growth models. Results The PMHC group showed substantially greater symptom reduction than the TAU group for all outcomes: At 6-month follow-up, the between-group effect sizes were d −0.60 (95% CI: −0.94 to −0.26) for SPIN-9, −0.45 (95% CI: −0.70 to −0.20) for ATQ-SA, −0.50 (95% CI: −0.87 to −0.13) for MIA-8, and −0.61 (95% CI: −0.92 to −0.31) for ATQ-AP. All effects were sustained at similar level at a 12-month follow-up. Conclusion PMHC effectively alleviated SAD and agoraphobia symptoms, and individuals struggling with such symptoms constituted a large proportion of clients. Although results should be interpreted with caution due to risk of attrition bias, they lend further support for a scale-up of PMHC and similar initiatives. Individuals struggling with SAD and/or agoraphobia stood out as relatively high burdened, whereas only one of five had sought help the last 12 months, underscoring the need for the PMHC service.publishedVersio

Process evaluation of Prompt Mental Health Care (PMHC): the Norwegian version of Improving Access to Psychological Therapies

Background: Prompt Mental Health Care (PMHC) is the Norwegian adaptation of Improving Access to Psychological Therapies (IAPT). Thus far, evaluations of PMHC have mostly focused on the effectiveness, rather than on contextual and implementation processes. Therefore, the objective of this study was to do a process evaluation and examine: 1) To what extent do the services follow guidelines provided by the Norwegian Directorate of Health (NDH), 2) what the therapists experienced as important barriers and facilitators in implementing the service, and 3) client treatment satisfaction and its associations with baseline variables. Method: The present study uses data from 526 clients who received PMHC treatment in the municipalities of Sandnes and Kristiansand. The therapists completed questionnaires about each client’s course of treatment. We conducted semi-structured interviews with the therapists and analysed them using thematic analysis. Data from client questionnaires were used to report descriptive sample statistics including symptom severity and treatment satisfaction. Linear regression was adopted to examine the associations between client treatment satisfaction and baseline characteristics. Results: Several aspects of PMHC were implemented in line with the guidelines provided by NDH. Importantly, both services reached out to the intended target group, and could further be characterized as low-threshold with relatively short waiting times (median waiting time between initial contact and treatment start was 27 days, IQR 18–39), no waiting lists, and frequent use of self-referral (33.3%). From the client perspective, results indicated a high degree of treatment satisfaction (Mean = 3.93 (SD = .71, range 1–5)), and this was true across demographic characteristics and symptom severity at baseline (all p > .05). Most notable challenges that came forward were; the low provision of guided self-help (received by only 1.0% of clients), the lack of focus on work participation (low to some degree of focus in 70.8% among sick-listed clients), the collaboration with other services (no collaboration in 85.3% of the clients), and some aspects regarding future development of the service. Conclusion: Both sites managed to implement key aspects of PMHC in line with the guidelines, but further development of the program is warranted. Discussion of challenges and future recommendations are presented.publishedVersio

Body-related concerns and participation in physical education among adolescent students: the mediating role of motivation

BackgroundThere is a need to understand better factors influencing participation in physical education (PE) and the mechanisms involved. The adolescent years are characterised by increasing levels of body-related concerns. In PE, the body is judged for its physical abilities and subject to social comparisons and body judgements. Grounded in the Self-Determination Theory, this study aimed to explore whether body-related factors were associated with adolescents’ involvement in PE and whether types of motivation mediated this relationship.MethodsThe study involved 2,140 (54.5% girls) secondary students (15–16-year-olds) from Norway participating in the nationally representative “Health Behaviour in School-aged Children (HBSC) study: a WHO collaborative cross-national study.” Body-related factors included Body Mass Index (BMI), health complaints, body perception and dietary behaviours. Gender, age, and socioeconomic status (family affluence) were control variables. Motivation for PE was assessed with the Perceived Locus of Causality (PLOCQ) scale measuring three distinct factors: autonomous motivation, controlled motivation and amotivation. PE involvement was self-reported as weekly participation in PE classes and time spent in moderate-to-vigorous physical activity (MVPA) during PE.ResultsGender (girl), family affluence, health complaints, not being on a diet but wanting to lose weight, and body perception (too fat) were negatively associated with weekly PE participation when adjusting for other variables. This association was largely explained by students’ autonomous motivation in the case of health complaints and partly in the case of dietary behaviour and body perception. Similar results were observed for MVPA during PE lessons. Additionally, gender was associated with MVPA through amotivation.ConclusionThe study adds new knowledge to the understanding of the relationship between body-related factors and PE, supporting that autonomous motivation is a central mechanism and an avenue for further research. The results should be considered in planning high-quality PE classes and suggest that an autonomous supportive learning climate sensitive to body-related concerns should be a priority to increase adolescent involvement in PE

A school based study of time trends in food habits and their relation to socio-economic status among Norwegian adolescents, 2001–2009

Background: In recent years, adolescents’ food habits have become a major source of concern, and substantial policy and intervention efforts have been made to influence adolescents to consume more fruit and vegetables and less sweets and soft drink. Particular attention has been devoted to the social gradient in food habits, aiming to reduce dietary inequality. However, few internationally published studies have evaluated trends in teenagers’ food habits, or investigated how dietary inequalities develop. Methods: We used Norwegian cross-sectional data from the international Health Behaviour in School-Aged Children (HBSC) study, collected via three nationally representative and comparable questionnaire surveys in 2001, 2005 and 2009. Food habits were identified by students’ consumption of fruit, vegetables, sweets and sugar rich soft drink. Socio-economic status (SES) was measured with the Family Affluence Scale (FAS). Multilevel logistic regression was used to analyze the data. Results: The analyses indicated an overall positive trend in food habits among adolescents in Norway. Students were more likely to consume fruit (OR 1.76, CI 1.61-1.92) and vegetables (OR 1.51, CI 1.37-1.66) daily in 2005 as compared to 2001, and were less likely to consume sweets (OR 0.58, CI 0.51-0.66 resp. OR 0.77, CI 0.67-0.90) and soft drink (OR 0.55, CI 0.49-0.62 resp. OR 0.84, CI 0.73-0.96) daily when comparing, respectively, 2005 with 2001 and 2009 with 2005. Across all survey years, students with higher SES were more likely to eat fruit (OR 1.47, CI 1.32-1.65) and vegetables (OR 1.40, CI 1.24-1.58) daily than did students with lower SES. Our analyses indicated that the socio-economic differences were stable in the period 2002 - 2010, with uniform improvement in fruit and vegetable consumption across all SES levels. No significant associations between SES and intake of sweets and sugar-added soft drink were found. Conclusion: The study identifies an overall improvement in diet among adolescents over a period characterized by onset of as well as ongoing initiatives targeting young people’s food habits. However, the observed socio-economic gradient in fruit and vegetable consumption remained unchanged

Exploring the temporal associations between avoidance behavior and cognitions during the course of cognitive behavioral therapy for clients with symptoms of social anxiety disorder

Objectives In cognitive behavioral therapy (CBT) for social anxiety disorder (SAD), avoidance behavior (AB) and cognitions (COG) are two important targets of intervention, but so far no studies have directly examined their relative importance. By means of cross-lagged panel models (CLPM), we examined their temporal associations and impacts on outcome in clients with symptoms of SAD while addressing typical methodological challenges. Method We used data from the first six therapy sessions in a sample of 428 primary care clients (mean [SD] age = 34.6 [12.2], 34.3% men), participating in the Prompt Mental Health Care trial. Session-by-session data was collected on AB, COG, depression and general anxiety. Competing multiple indicator CLPMs were tested. Results The Random Intercept-CLPM provided best fit, and indicated that AB predicted COG at subsequent time points (.39 ≤ β  ≤ .42 for T2–T5, p  < .05), but not vice versa. In addition, AB, but not COG, predicted clients’ general anxiety score at subsequent time points. Results were both robust to the inclusion of depressive symptoms as a within-level covariate, and sensitivity tests for stationarity and missing data assumptions. Conclusion Targeting avoidance behavior for primary care clients with symptoms of SAD may be more vital for the optimal effect of CBT than targeting cognitions. Methodological considerations and limitations of the study are discussed.publishedVersio

A school based study of time trends in food habits and their relation to socio-economic status among Norwegian adolescents, 2001–2009

Background: In recent years, adolescents&rsquo; food habits have become a major source of concern, and substantial policy and intervention efforts have been made to influence adolescents to consume more fruit and vegetables and less sweets and soft drink. Particular attention has been devoted to the social gradient in food habits, aiming to reduce dietary inequality. However, few internationally published studies have evaluated trends in teenagers&rsquo; food habits, or investigated how dietary inequalities develop. Methods: We used Norwegian cross-sectional data from the international Health Behaviour in School-Aged Children (HBSC) study, collected via three nationally representative and comparable questionnaire surveys in 2001, 2005 and 2009. Food habits were identified by students&rsquo; consumption of fruit, vegetables, sweets and sugar rich soft drink. Socio-economic status (SES) was measured with the Family Affluence Scale (FAS). Multilevel logistic regression was used to analyze the data. Results: The analyses indicated an overall positive trend in food habits among adolescents in Norway. Students were more likely to consume fruit (OR 1.76, CI 1.61-1.92) and vegetables (OR 1.51, CI 1.37-1.66) daily in 2005 as compared to 2001, and were less likely to consume sweets (OR 0.58, CI 0.51-0.66 resp. OR 0.77, CI 0.67-0.90) and soft drink (OR 0.55, CI 0.49-0.62 resp. OR 0.84, CI 0.73-0.96) daily when comparing, respectively, 2005 with 2001 and 2009 with 2005. Across all survey years, students with higher SES were more likely to eat fruit (OR 1.47, CI 1.32-1.65) and vegetables (OR 1.40, CI 1.24-1.58) daily than did students with lower SES. Our analyses indicated that the socio-economic differences were stable in the period 2002 - 2010, with uniform improvement in fruit and vegetable consumption across all SES levels. No significant associations between SES and intake of sweets and sugar-added soft drink were found. Conclusion: The study identifies an overall improvement in diet among adolescents over a period characterized by onset of as well as ongoing initiatives targeting young people&rsquo;s food habits. However, the observed socio-economic gradient in fruit and vegetable consumption remained unchanged.publishedVersio

Moderators of treatment effect of Prompt Mental Health Care compared to treatment as usual: Results from a randomized controlled trial

Background In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC). Methods Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7). Outcomes: change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation. Results Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment. Conclusion As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.publishedVersio

Associations between family structure and adolescents’ food habits

Objective: To investigate family structure differences in adolescents’ consumption of fruit, vegetables, sweets and sugar-added soft drinks with adjustments for socio-demographic and socio-economic variables. Design: Cross-sectional data from the Health Behaviour in School-aged Children survey. Setting: Norwegian primary and secondary schools. Participants: Adolescents (n 4475) aged 11, 13, 15 and 16 years. Results: After adjusting for covariates, living in a single-mother family was associated with lower vegetable consumption (OR 0·76, 95 % CI 0·63, 0·91) and higher soft drink consumption (OR 1·29, 95 % CI 1·06, 1·57). Living in a mother and stepfather family was negatively associated with fruit (OR 0·71, 95 % CI 0·54, 0·95) and vegetable (OR 0·72, 95 % CI 0·54, 0·97) consumption. Living in a single-father family was associated with lower sweets consumption (OR 0·48, 95 % CI 0·32, 0·72). No significant interactions were demonstrated between family structure and socio-demographic or socio-economic covariates. Conclusions: The study suggests that an independent association between family structure and adolescents’ food habits exists.publishedVersio

Long-term outcomes at 24- and 36-month follow-up in the intervention arm of the randomized controlled trial of Prompt Mental Health Care

Background: Whether long-term symptom improvement is maintained after treatment in services such as the Norwegian Prompt Mental Health Care (PMHC) and the English Improving Access to Psychological Therapies is not yet known. In this prospective study, we investigate whether improvements observed at 6-month follow-up are maintained at 24- and 36-month follow-up among clients who received PMHC. Method: Data from the treatment arm of the randomized controlled trial of PMHC were used (n = 459). The main outcomes were (reliable) recovery rate and symptoms of depression (PHQ-9) and anxiety (GAD-7). Primary outcome data at 24- and 36-months follow-up were available for 47% and 39% of participants, respectively. Secondary outcomes were work participation, functional status, health-related quality of life, and positive mental well-being. Sensitivity analyses with regard to missing data assumptions were conducted for the primary continuous outcomes. Results: Improvements were maintained at 24- and 36-month follow-up for symptoms of depression and anxiety, (reliable) recovery rate, and health-related quality of life. Small linear improvements since 6-month follow-up were observed for work participation, functional status, and positive mental well-being. Sensitivity analyses did not substantially alter the findings for symptoms of depression and anxiety mentioned above. Conclusions: Our findings support the long-term effectiveness of PMHC, but results should be interpreted with caution due to lacking follow-up data at 24- and 36-month in the control group, and substantial attrition.publishedVersio

Tracking of depressed mood from adolescence into adulthood and the role of peer and parental support: A partial test of the Adolescent Pathway Model

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