“Light my fire” - Perspectives on Motivation, Helpfulness and Implementation of Guided Internet-based Cognitive Behavioral therapy.

Depression is common and imposes tremendous burdens for patients, their family and society. Implementation of internet-based cognitive behavioural therapy (ICBT) within general practice is recommended. Better results have been shown for treatment with ICBT when support is given, and therefore there is interest in exploring guided ICBT as an affordable alternative for treatment in the early stage after the onset of depression. General practitioners (GPs) have shown positive attitudes towards ICBT, although it is currently rarely used in regular care in general practice. This thesis is based on two studies: a patient study and a GP study. This has resulted in three papers that explore guided ICBT using an online intervention called MoodGYM combined with short module follow-up consultations. This treatment approach was designed to be compatible with general practice in Norway. The patient study was embedded in a randomized controlled trial that investigated the effects of the programmer on the symptoms of depression. Semi-structured interviews and a phenomenological–hermeneutical approach enabled us to explore in depth how the 14 patients gave meaning to their lived experience from both working with an online intervention and being supported with short consultations in-between the online modules. Paper one explores the patients’ motivation and identifies a sense of relatedness as the most important aspect. The need for relatedness was satisfied if the patient could identify with the online material, achieve feelings of being valued by an important others and feel connected to the therapist. Paper two explored those aspects perceived by patients to be helpful. The findings indicated the importance of MoodGYM as a structured approach to working with the patient’s depression and the patient as an active agent. The patients valued a trusted professional to whom they could self-disclose feelings and from whom they could receive feedback. In the GP study, GPs were provided with a training package in guided ICBT, and they were asked to implement guided ICBT into regular care. Eleven GPs were interviewed. We used a thematic approach to investigate their experiences. Paper three presents the patterns identified in the interviews. GPs valued ICBT as a structured approach for supplementing their treatment of depression. They also valued ICBT as a tool for enabling patients to become an active agent in their own health care. This was coherent with their role of recommending ICBT, but module follow-ups were difficult. The most important aspects in treatment for depression were to open up for patients and allow them to ventilate their feelings and to sustain a trusting relationship. GPs did not find strategies to combine these human aspects with module follow-ups, and they instead returned to standard treatment. Overall, the two studies that explored the treatment of depression from the perspective of patients and GPs show that a theory-based online supplement is perceived as positive because it adds structure to the consultation and engages patients. However, it is also important that the therapeutic setting provides patients with the opportunity to self-disclose and ventilate their feelings about their problems and a relationship with the GP built on engagement in the patient as a unique person. I suggest that treatment of depression in general practice would benefit from a flexible approach in which GPs recommend self-help while continuing to use the patients’ stories as a starting point for dialogue. This would benefit both patients and GPs

Patients’ Experiences of Helpfulness in Guided Internet-Based Treatment for Depression: Qualitative Study of Integrated Therapeutic Dimensions

Background: Quantitative research on Internet-based cognitive behavioral therapy (ICBT) has collected substantial evidence for the effectiveness of this treatment approach on health outcomes. Less is known about how patients find ICBT to be generally meaningful and helpful for treating depression. Objective: To explore patients’ experiences of being in ICBT treatment with a focus on the treatment dimensions that they considered helpful. Methods: Choosing a phenomenological-hermeneutical approach, 14 patients were interviewed with semistructured qualitative interviews to elicit their understanding of using ICBT. The patients took part in a clinical trial using ICBT with MoodGYM, which also featured brief consultations with a clinical psychologist. The interviews were transcribed and analyzed according to the chosen methodology and organized into significant themes. Results: The phenomenological-hermeneutical analysis identified 5 themes relating overall to the meaning of this mode of treatment in terms of helpfulness. Two related to treatment in general: (1) taking action to address one’s problems and (2) the value of talking to a professional. The next two themes specifically addressed guided self-help using the MoodGYM program: (3) acquiring relevant knowledge, and (4) restructuring the new knowledge acquired through ICBT. A fifth theme concerned (5) actual changes in patients’ perceptions and interactions, related to either the self-help material or the face-to-face consultations with the therapist. Conclusions: Three important dimensions were made explicit: the active engagement of the patient, the guidance of the therapist, and the content of the treatment program. The findings pointed to (1) the role of MoodGYM as a source of new knowledge providing patients with a structured approach to work with their depression, (2) the patient’s role as the primary agent of change through adapting relevant knowledge from MoodGYM to their situation, and (3) the dialogue with the therapist as a trusting relationship in which to share thoughts and feelings, receive feedback and advice, and to assist the patient in making use of the MoodGYM content

Norwegian General Practitioners’ Perspectives on Implementation of a Guided Web-Based Cognitive Behavioral Therapy for Depression: A Qualitative Study

BACKGROUND: Previous research suggests that Internet-based cognitive behavioral therapy (ICBT) has a positive effect on symptoms of depression. ICBT appears to be more effective with therapist support, but it is unclear what this support should comprise. General practitioners (GPs) have positive attitudes toward ICBT. However, ICBT is rarely used in regular care in general practice. More research is warranted to integrate the potential of ICBT as part of regular care. OBJECTIVE: The aim of this study was to explore aspects perceived by GPs to affect the implementation of guided ICBT in daily practice. Understanding their perspectives may contribute to improving the treatment of depression in the context of general practice. METHODS: A training package (3-day course) introducing a Norwegian translation of the ICBT program MoodGYM was developed and presented to GPs in Norway. Following training, GPs were asked to include guided ICBT in their regular care of patients with symptoms of depression by providing brief, face-to-face follow-up consultations between modules. We interviewed 11 GPs who had taken the course. Our interview guide comprised open questions that encouraged GPs to frame their responses using examples from their experiences when implementing ICBT. Thematic analysis was chosen to explore patterns across the data. RESULTS: An overall belief that ICBT would benefit both the patients’ health and the GPs’ own work satisfaction prompted the GPs to take the ICBT course. ICBT motivated them to invest time and effort in improving treatment. The most important motivating aspects in MoodGYM were that a program based on cognitive behavioral therapy could add a structured agenda to their consultations and empower depressed patients. Organizational aspects, such as a lack of time and varied practice, inhibited the use of ICBT. Inadequate knowledge, recalling the program, and changing own habits were also challenging. The GPs were ambivalent about whether ICBT had a negative impact on the doctor–patient interaction in the module follow-ups. Generally, GPs made an effort to recommend MoodGYM, but the expected module follow-ups were often not provided to patients and instead the GPs returned to standard treatment. CONCLUSIONS: GPs’ feedback in the present study contribute to our understanding of the challenges of changing treatment for depression. Our findings indicated that recommending ICBT could add to the GP’s toolkit. Offering training and highlighting the following aspects may increase recommendation of ICBT by GPs: (1) ICBT is theory-based and credible, (2) ICBT increases the GPs’ work satisfaction by having a tool to offer, and (3) ICBT facilitates empowerment of patients in their own health. In addition, the present study also indicated that complex aspects must be accommodated before module follow-ups can be incorporated into GPs’ treatment of depression

Symptom burden and follow-up of patients with neck and back complaints in specialized outpatient care: a national register study

Abstract Back and neck pain are common in the population, especially among immigrants. In Norway's specialist care system, treating these patients typically involves a multidisciplinary approach based on the biopsychosocial model. However, language and cultural differences may create barriers to participation. Immigrants are often underrepresented in clinical studies, but a register-based approach can enhance their participation in research. This study aimed to compare both the symptom burden, and treatment, among Norwegians, non-Norwegians, and patients requiring translator service for back and neck pain within the Norwegian specialist care system. The Norwegian neck and back registry is a National Quality Register, established in 2012 and fully digitized in late 2020. The baseline data includes demographics and patient recorded outcome measures including Oswestry Disability Index, Fear-Avoidance Beliefs, pain rating on a numeric rating scale, Hopkins Symptom Checklist and EuroQol five-dimensional questionnaire on health related quality of life. During the two-year study period, a total of 14,124 patients were invited, and 10,060 (71%) participated. Norwegian patients reported less pain, better function assessed by Oswestry Disability Index, lower fear avoidance beliefs, less emotional distress, and higher health related quality of life compared to non-Norwegians. We found that patients with female gender, who were younger, more educated and exhibited fear-avoidance behavior were significantly more likely to receive multidisciplinary treatment. We found no difference in the proportion of Norwegian and non-Norwegian patients receiving multidisciplinary treatment [odds ratio (OR) 1.02 (95% confidence interval (CI) 0.90–1.16)]. However, patients needing a translator were less likely to receive multidisciplinary treatment compared to those who didn't require translation [OR 0.41 (95% CI (0.25–0.66)]. We found that non-Norwegian patients experience a higher symptom burden compared to Norwegian. We found that both non-Norwegians and patient in need of translator were to a greater extent recommended treatment in primary health care. The proportion of non-Norwegians patients receiving multidisciplinary treatment was similar to Norwegians, but those needing a translator were less likely to receive such treatment

Motivation to persist with internet-based cognitive behavioural treatment using blended care: a qualitative study.

The prevalence of depression is high and results in huge costs for society. Internet-based cognitive behavioural treatment (ICBT) has been suggested for use in primary care and has been shown to be more effective when combined with human support. However, non-completion rates remain a challenge. Current recommendations state that steps to improve persistence with ICBT should be determined and the impact of therapist support on persistence explored. A few earlier studies have explored motivations to persist with ICBT without face-to-face therapist support. The present study explored the motivation to persist as experienced by a group of patients who sought help in primary care and used “blended care”, i.e. ICBT supported by short face-to-face consultations. To elucidate motivation in an everyday context and the meaning of patients’ experiences we chose a phenomenological hermeneutical approach. We interviewed participants in the intervention group of a randomized controlled trial that evaluated the efficacy of an ICBT programme called MoodGYM, an eHealth intervention used to treat depression. Fourteen participants, both completers and non-completers, went through individual, semi-structured interviews after they ended their treatment. Hope of recovery and a desire to gain control of one’s life were identified as intrinsic motivators. The feeling of being able to freely choose how, when and where to complete the ICBT modules was identified as an important supporting condition and satisfied the participants’ need for autonomy. Furthermore, the importance of a sense of belonging towards partners, friends or family was essential for motivation as was the ability to identify with ICBT content. Another supporting condition was the experience of connectedness when met with acknowledgement, flexibility and feedback from a qualified therapist in the face-to-face consultations. A key finding was that participants were motivated to persist with ICBT when their overall need for relatedness was satisfied. This was achieved through a sense of belonging towards partners, friends and family. Connectedness with the therapist and the participant’s ability to identify with the ICBT modules also gave a sense of relatedness. Improving these motivational aspects may increase patients’ persistence with ICBT

Does childcare work promote cardiorespiratory fitness and health? A cross‐sectional study of Danish childcare workers based on accelerometry and heart rate measurements

Childcare workers are reported to have poor cardiorespiratory fitness and health. The Goldilocks Work Principle argues that productive work should be designed with the right composition, intensity and alternations of physical behaviors so that workers get fit and healthy. The purpose of this study was to investigate: (1) composition, (2) intensity and (3) alternations of physical behaviors during work and leisure among childcare workers. Data were collected using accelerometers and heart rate monitors over five workdays among 51 childcare workers at five Danish childcare institutions. Workers mainly spent their work time sedentary (43.0%), spent little time (0.7%) at sufficiently high cardiometabolic intensity to increase cardiorespiratory fitness and often alternated between physical behaviors (67.0% occurred in bouts of <5 min). These findings indicate that the workers have a composition of behaviors at work dominated by sedentary time, little time with high cardiometabolic intensity, and frequent alternations between behaviors. During leisure, workers spent more time sedentary (59.4%), more time at high cardiometabolic intensity (3.4%) and less time occurred in bouts <5 min (38.7%). We see a potential for promoting cardiorespiratory fitness and health of childcare workers by redesigning the way they play with the children, so that work time with high cardiometabolic intensity is increased