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Background: Internet-based cognitive behavioral therapy (ICBT) has proven to be an effective treatment in improving patients' ability to cope with tinnitus. However, some patients prefer face-to-face therapy to ICBT, and a few studies have shown considerable dropout rates if the treatment is not guided. This renders it important to identify factors that contribute to the commencement and continuation of ICBT programs. Aims: Because treatment motivation and expectations are important factors in psychological treatment, the aim of our study was to investigate what leads tinnitus patients to seek out ICBT, what helps them to keep up with the treatment, and what (if any) impact these factors have on dropout rates and treatment outcomes. Method: 112 tinnitus patients taking part in ICBT for tinnitus responded to symptom-related questionnaires at three points in time (pre-treatment, post-treatment, and one-year-follow-up) and to a questionnaire consisting of open-ended questions about their treatment motivation and expectations before beginning treatment. Data were analyzed using qualitative content analysis, and the results were used to divide the participants into groups. The treatment outcomes of these groups were compared using t-tests, χ2-tests, and both one-factorial and mixed ANOVAs. Results: Four main categories emerged as factors conducive to starting treatment: 1) Targets participants wanted to address, 2) circumstances that led to participation, 3) attitudes towards the treatment, and 4) training features. Participants identified six facilitators for continuing the treatment: success, training, individual attitude, hope, evidence, and support. Naming specific tinnitus-associated problems as targets was associated with greater improvement from pre-treatment to 1-year-follow-up. Describing an active involvement in the treatment was related to increased improvement from post-treatment to follow-up. Conclusion: There are several motivational factors that tinnitus patients consider relevant for beginning and continuing ICBT. Particularly, focusing on specific targets that do not involve the tinnitus itself, and encouraging participants to take an active role in treatment may increase treatment effectiveness. However, further hypothesis-guided research is necessary to confirm our explorative results.

Chronic pain is a major health problem and behavioral based treatments have been shown to be effective. However, the availability of these kinds of treatments is scarce and internet-based treatments have been shown to be promising in this area. The objective of the present systematic review is to evaluate internet-based interventions for persons with chronic pain. The specific aims are to do an updated review with a broad inclusion of different chronic pain diagnoses and to assess disability and pain and also measures of catastrophizing, depression and anxiety. A systematic search identified 891 studies and 22 trials were selected as eligible for review. Two of the selected trials included children/youth and five included individuals with chronic headache and/or migraine. The most frequently measured domain reflected in the primary outcomes was interference/disability, followed by catastrophizing. Result across the studies showed a number of beneficial effects. Twelve trials reported significant effects on disability/interference outcomes and pain intensity. Positive effects were also found on psychological variable such as catastrophizing, depression and anxiety. Several studies (n = 12) were assessed to have an unclear level of risk bias. The attrition levels ranged from 4% to 54% where the headache trials had the highest drop-out levels. However, findings suggest that internet-based treatments based on cognitive behavioural therapy (CBT) are efficacious measured with different outcome variables. Results are in line with trials in clinical settings. Meta-analytic statistics were calculated for interference/disability, pain intensity, catastrophizing and mood ratings. Results showed that the effect size for interference/disability was Hedge's g = −0.39, for pain intensity Hedge's g = −0.33, for catastrophizing Hedge's g = −0.49 and for mood variables (depression) Hedge's g = −0.26.

Objectives: Audiologists provide professional contact and support between appointments to clients with hearing impairment using telephone and e-mail, but more advanced and flexible technological platforms are also possible. The present study aimed to evaluate the clinical application of an Internet-based support system for audiologists and their first-time hearing aid clients. Design: An Internet-based support system developed by Månsson et al. (2013) for psychologists and their clients was adapted for audiologic purposes. Three audiologic clinics in Sweden tested the support system with their clients. Study sample: Twenty-three clients managed by four audiologists used and evaluated the support system. In addition, five of the clients and all four audiologists were interviewed and their responses were analyzed using content analysis. Results: The clients and the audiologists reported positive experiences and overall satisfaction but audiologists reported that the support system did not address the needs of all clients. More positive experiences and greater satisfaction with the support system were associated with reductions on self-reported consequences of hearing loss and positive hearing aids outcomes. Conclusions: An Internet-based support system can be used in audiologic rehabilitation. Both audiologists and clients recognized the system's potential value to offer an online support to the provision of audiologic services.

Internet-based cognitive behaviour therapy (ICBT) is efficacious for treating depression, with therapist guidance identified as important for favourable outcomes. We have limited knowledge, however, about the fundamental components of therapist guidance in ICBT. The purpose of this study was to systematically examine therapist messages sent to patients during the course of ICBT for depressive symptoms in order to identify common “therapist behaviours” and the extent to which these behaviours correlate with completion of modules and improvements in symptoms at post-treatment, one- and two-year follow-up. A total of 664 e-mails from 5 therapists to 42 patients were analysed using qualitative content analysis. The most frequent behaviour was encouraging that accounted for 31.5% of the total number of coded behaviours. This was followed by affirming (25.1%), guiding (22.2%) and urging (9.8%). Less frequently the therapists clarified the internet treatment framework, informed about module content, emphasised the importance of patient responsibility, confronted the patient and made self-disclosures. Six of the nine identified therapist behaviours correlated with module completion. Three behaviours correlated with symptom improvement. Affirming correlated significantly (r = .42, p = .005) with improvement in depressive symptoms at post-treatment and after two years (r = .39, p = .014). Encouraging was associated with outcome directly after treatment (r = .52, p = .001). Self-disclosure was correlated with improvement in depressive symptoms at post-treatment (r = .44, p = .003). The study contributes to a better understanding of therapist behaviours in ICBT for depressive symptoms. Future directions for research are discussed.

BACKGROUND:Face-to-face brief interventions for problem drinking are effective, but they have found limited implementation in routine care and the community. Internet-based interventions could overcome this treatment gap. We investigated effectiveness and moderators of treatment outcomes in internet-based interventions for adult problem drinking (iAIs). METHODS AND FINDINGS:Systematic searches were performed in medical and psychological databases to 31 December 2016. A one-stage individual patient data meta-analysis (IPDMA) was conducted with a linear mixed model complete-case approach, using baseline and first follow-up data. The primary outcome measure was mean weekly alcohol consumption in standard units (SUs, 10 grams of ethanol). Secondary outcome was treatment response (TR), defined as less than 14/21 SUs for women/men weekly. Putative participant, intervention, and study moderators were included. Robustness was verified in three sensitivity analyses: a two-stage IPDMA, a one-stage IPDMA using multiple imputation, and a missing-not-at-random (MNAR) analysis. We obtained baseline data for 14,198 adult participants (19 randomised controlled trials [RCTs], mean age 40.7 [SD = 13.2], 47.6% women). Their baseline mean weekly alcohol consumption was 38.1 SUs (SD = 26.9). Most were regular problem drinkers (80.1%, SUs 44.7, SD = 26.4) and 19.9% (SUs 11.9, SD = 4.1) were binge-only drinkers. About one third were heavy drinkers, meaning that women/men consumed, respectively, more than 35/50 SUs of alcohol at baseline (34.2%, SUs 65.9, SD = 27.1). Post-intervention data were available for 8,095 participants. Compared with controls, iAI participants showed a greater mean weekly decrease at follow-up of 5.02 SUs (95% CI -7.57 to -2.48, p < 0.001) and a higher rate of TR (odds ratio [OR] 2.20, 95% CI 1.63-2.95, p < 0.001, number needed to treat [NNT] = 4.15, 95% CI 3.06-6.62). Persons above age 55 showed higher TR than their younger counterparts (OR = 1.66, 95% CI 1.21-2.27, p = 0.002). Drinking profiles were not significantly associated with treatment outcomes. Human-supported interventions were superior to fully automated ones on both outcome measures (comparative reduction: -6.78 SUs, 95% CI -12.11 to -1.45, p = 0.013; TR: OR = 2.23, 95% CI 1.22-4.08, p = 0.009). Participants treated in iAIs based on personalised normative feedback (PNF) alone were significantly less likely to sustain low-risk drinking at follow-up than those in iAIs based on integrated therapeutic principles (OR = 0.52, 95% CI 0.29-0.93, p = 0.029). The use of waitlist control in RCTs was associated with significantly better treatment outcomes than the use of other types of control (comparative reduction: -9.27 SUs, 95% CI -13.97 to -4.57, p < 0.001; TR: OR = 3.74, 95% CI 2.13-6.53, p < 0.001). The overall quality of the RCTs was high; a major limitation included high study dropout (43%). Sensitivity analyses confirmed the robustness of our primary analyses. CONCLUSION:To our knowledge, this is the first IPDMA on internet-based interventions that has shown them to be effective in curbing various patterns of adult problem drinking in both community and healthcare settings. Waitlist control may be conducive to inflation of treatment outcomes.

Background: Procrastination can be stressful and frustrating, but it seldom causes any major distress. However, for some people, it can become problematic, resulting in anxiety, lowered mood, physical complaints, and decreased well-being. Still, few studies have investigated the benefits of targeting procrastination. In addition, no attempt has previously been made to determine the overall efficacy of providing psychological treatments.Methods: A systematic review and meta-analysis was conducted by searching for eligible records in Scopus, Proquest, and Google Scholar. Only randomized controlled trials comparing psychological treatments for procrastination to an inactive comparator and assessing the outcomes by a self-report measure were included. A random effects model was used to determine the standardized mean difference Hedge's g at post-treatment. Furthermore, test for heterogeneity was performed, fail-safe N was calculated, and the risk of bias was explored. The study was pre-registered at Prospero: CRD42017069981.Results: A total of 1,639 records were identified, with 12 studies (21 comparisons, N = 718) being included in the quantitative synthesis. Overall effect size g when comparing treatment to control was 0.34, 95% Confidence Interval [0.11, 0.56], but revealing significant heterogeneity, Q(20) = 46.99, p < 0.00, and I2 = 61.14%, 95% CI [32.83, 84.24]. Conducting a subgroup analysis of three out of four studies using cognitive behavior therapy (CBT) found an effect size g of 0.55, 95% CI [0.32, 0.77], and no longer showing any heterogeneity, Q(4) = 3.92, p = 0.42, I2 = 0.00%, 95% CI [0.00, 91.02] (N = 236). Risk of publication bias, as assessed by the Egger's test was not significant, z = −1.05, p = 0.30, fail-safe N was 370 studies, and there was some risk of bias as rated by two independent researchers. In terms of secondary outcomes, the self-report measures were too varied to present an aggregated estimate.Conclusions: Psychological treatments seem to have small benefits on procrastination, but the studies displayed significant between-study variation. Meanwhile, CBT was associated with a moderate benefit, but consisted of only three studies. Recommendations for future research are provided, including the use of more valid and reliable outcomes and a screening interview at intake.

Psychological resources and risk factors influence risk of coronary heart disease. We evaluated whether inverted items in the Self-esteem, Mastery, and Center for Epidemiological Studies Depression scales compromise validity in the context of coronary heart disease. In a population-based sample, validity was investigated by calculating correlations with other scales ( n = 1004) and interleukin-6 ( n = 374), and by analyzing the relationship with 8-year coronary heart disease risk ( n = 1000). Negative items did not affect the validity of the resource scales. In contrast, positive items from Center for Epidemiological Studies Depression showed no significant relationships with biological variables. However, they had no major impact on the validity of the original scale.

Background: A burn is one of the most traumatic and painful injuries a child can experience and it is also a very stressful experience for the parents. Given the great psychological distress and perceived lack of multi-professional support experienced by the parents, there is a need for support during in-hospital treatment as well as during recovery. The aim of the study is to develop and evaluate an internet-based information and self-help program for parents of children who have been hospitalized for burn injury. The program aims to decrease parents' symptoms of stress. Methods: Participants will consist of parents of children treated for burns between 2009 and 2013 at either of the two specialized Swedish Burn centers. The study is a two-armed randomized controlled trial with a six-week intervention group and an inactive control group, with a pre- and post-assessment, as well as a 3- and 12-month follow-up. The main outcome is stress (post-traumatic stress, general perceived stress and parental stress). The data will be analyzed with the intention-to-treat principle. The intervention is based on Cognitive-Behavior Therapy (CBT) and is inspired by Acceptance and Commitment Therapy (ACT). It is psycho-educational and provides basic skills training in communication and stress management. Conclusion: We believe that this program will offer parents of children with burns information and support, decrease symptoms of stress, and that parents will perceive the program as useful. If the program is found to be beneficial, it could be implemented in burn care as it is accessible and cost-effective.

Background: Guided Internet-delivered cognitive behavioural therapy (ICBT) is an effective treatment of social anxiety disorder (SAD). However, the treatment is not effective for all. The amount and type of therapist contact have been highlighted as a possible moderator of treatment outcome. Objective: The aim of this study was to examine whether treatment effects of ICBT are enhanced with an initial 90 min face-to-face psychoeducation (PE) session for university students with SAD. Method: University students with SAD (N = 37) were randomized into one out of two conditions: 1) an initial therapist-led face-to-face PE session followed by guided ICBT, 2) guided ICBT without an initial PE session. Data was analysed with an intent-to-treat approach. Results: Eight participants (21.6%) dropped out of treatment. A statistically significant reduction in symptoms was found for all outcome measures for both groups. There were no significant additional effects of adding the initial face-to-face PE. Moderate to large within-group effect sizes on self-rated social anxiety symptoms were found at post-treatment (d = 0.70–0.95) and at a six month follow-up (d = 0.70–1.00). Nearly half of the participants were classified as recovered. Conclusions: Notwithstanding limitations due to the small sample size, the findings indicate that guided ICBT is an effective treatment for students with SAD. Adding an initial face-to-face PE session to the guided ICBT did not lead to enhanced outcomes in the present study.

This is the first study of adolescents suffering from anxiety disorder in Sweden to receive individually tailored internet-based treatment within a child and adolescent psychiatric clinic. The primary aim of this effectiveness study was to examine the effects of tailored internet-based cognitive behaviour therapy for adolescents. 11 adolescents, aged 15-19 years, were allocated to treatment after assessment. Screening consisted of online questionnaires followed by a diagnostic face-to-face interview at the clinic. Treatment consisted of individually prescribed cognitive behaviour therapy (CBT) text modules adapted for the age group. Therapist guidance was via an online platform along with telephone support and face-to-face sessions if needed. Statistically significant improvements were found on all dependent measures immediately following treatment for the 8 adolescents who completed treatment. The within-group effect size on the Beck Anxiety Inventory, the primary outcome measure, was d = 2.51 at post-treatment and 80 percent (4/5) adolescents no longer met DSM-IV criteria for their primary anxiety disorder as measured by the Anxiety Disorders Interview Schedule for DSM- IV: Child and Parent Versions. Based on the results from this pilot study the tentative conclusion might be that tailored internet delivered CBT could be useful for adolescents with anxiety disorders along with standard treatment delivered in child and adolescent psychiatric clinics.

The relationship between what a client writes when communicating with an online therapist and treatment outcome in internet-based cognitive behavior therapy (ICBT) is largely unknown. The aim of this study was to address if written correspondence from the client to the therapist correlates with outcome and treatment completion. A total of 29 participants with mild to moderate depression were included from an ongoing randomized controlled trial targeting depression. Content analysis involving ten categories was performed on all emails and module responses sent by the participants to their internet therapist. A total of 3756 meaning units were identified and coded. Significant positive correlations were found between change in depression and statements in the two categories “observing positive consequences” (r = .49) and “alliance” (r = .42). Treatment module completion correlated with seven categories. The result suggests that text dealing with alliance and observing positive consequences can be used as indicators of how the treatment is progressing. This study suggests that written correspondence from an online client can be divided into ten categories and the frequency of those can be used by internet therapists to individualize treatment and perhaps make ICBT more effective.

Many trials on Internet-delivered psychological treatments have had problems with nonadherence, but not much is known about the subjective reasons for non-adhering. The aim of this study was to explore participants' experiences of non-adherence to Internet-delivered psychological treatment. Grounded theory was used to analyze data from seven in-depth interviews with persons who had non-adhered to a study on Internet-delivered cognitive behavioral therapy for generalized anxiety disorder. The process of non-adherence is described as an interaction between patient factors and treatment factors. A working model theory was generated to illustrate the experience of nonadherence. The model describes a process where treatment features such as workload, text-content complexity and treatment process don't match personal prerequisites regarding daily routines, perceived language skills and treatment expectations respectively, resulting in the decision to nonadhere. Negative effects were also stated as a reason for non-adherence. Several common strategies used for increasing adherence to Internet-delivered therapy in general are by these non-completers regarded as factors directly related to their reason for non-adherence.

Objective: Internet-based cognitive behavioral self-help treatments (iCBT) have been shown to successfully reduce the distress associated with tinnitus. Despite this success, little is known about the mechanisms that make iCBT for tinnitus sufferers work. Availability of minimal therapeutic support is assumed to positively influence treatment outcome in iCBT, but the lower limit of required support is not known. In face-to-face therapy, patients' positive outcome expectations have demonstrated an advantageous effect on outcome. The first aim of our study was thus to investigate the role of ‘on demand’ therapeutic guidance vs. no therapeutic support on treatment outcome in an iCBT for tinnitus sufferers. Our second aim was to investigate whether positive outcome expectations can predict treatment outcome. Methods: A total of 112 tinnitus patients were randomly assigned to one of two groups (support-on-demand or non-support). Both groups received an established iCBT treatment for tinnitus. While participants in the support group (n = 56) could ask a therapist for additional support, those in the other (n = 56) received no therapeutic guidance. Tinnitus distress was assessed pre- and post-treatment via the Tinnitus Handicap Inventory (THI) and the Mini-Tinnitus Questionnaire (Mini-TQ). Pre-treatment outcome expectations were assessed using the Patient Questionnaire on Therapy Expectation and Evaluation (PATHEV). Results: We observed significantly less tinnitus distress in the THI (support: t(55) = 7.51, p ≤ .001; non-support: t(55) = 7.68, p ≤ .001) and Mini-TQ (support: t(55) = 8.24, p ≤ .001; non-support: t(55) = 8.46, p ≤ .001) in both groups from pre- to post-treatment, but no significant differences between the groups or interactions. The PATHEV subscale “Hope of Improvement” significantly predicted treatment outcome as measured by the THI (β = 0.28, p = .027). Conclusions: The iCBT self-help program is a good treatment option for tinnitus sufferers whether or not support-on-demand is provided. Furthermore, our results show the importance of outcome expectations to the efficacy of iCBT in tinnitus patients. Future research should focus on discovering further predictors of treatment outcome.

Studies on internet-administered cognitive behavior therapy (ICBT) frequently use several different sources of recruitment, yet no study has investigated whether different recruitment sources produce different clinical and demographic profiles among participants. Using data from a large sample (n = 982) seeking ICBT for depression, we compared these characteristics on the basis of self-reported recruitment source. Recruitment sources that imply more active treatment-seeking behaviors (Google searches, viewing postings on mental health websites) presented more severe depression and anxiety than those recruited through more passive sources of information (newspaper advertisements, referrals by friends and family). In addition, a number of demographic differences between groups were found. These findings have important implications for ICBT research projects and clinical programs who employ open recruitment procedures and multi-modal recruitment strategies, and who wish to recruit representative samples or target specific subgroups. Replications in other countries will however be required to establish cross-cultural patterns.

Recently, a number of studies have investigated treatments administered via smartphones showing that this treatment format has a potential to be effective. However, we still have limited knowledge of how patients experience this treatment format. The objective of this study was to explore participants' views of a smartphone-based behavioral activation treatment. In-depth interviews were conducted with 12 strategically (participants with different overall experiences) selected participants, suffering from major depression according to the DSM-IV. The interview data were processed with the aid of thematic analysis. The analysis generated the three main themes: Commitment, Treatment and Lack of important components, with attached subthemes. In conclusion, the findings from the current study correspond with existing knowledge in the field of internet-based treatment. Considering that this kind of treatment is still quite new, the need for further research and development is considerable. Nevertheless, its availability, assimilation into users' everyday lives and possible motivational qualities speak of its potential.

Background: Acceptance and Commitment Therapy (ACT) is an effective intervention for the treatment of chronic pain. Internet-based pain interventions might be an effective and cost-effective way to overcome treatment barriers of traditional face-to-face pain interventions such as the lack of availability and accessibility. However, little is known about the general (cost-)effectiveness of internet-based pain interventions and the specific (cost-) effectiveness of guided and unguided pain interventions. Therefore, the aim of this study is to investigate the effectiveness and cost-effectiveness of a guided and unguided ACT-based online intervention for persons with chronic pain (ACTonPain). Methods: ACTonPain is a pragmatic three-armed randomised controlled trial comparing ACTonPain with or without therapist guidance against a waitlist control group. Both active conditions differ only with regard to guidance provided by an eCoach, who sends feedback after each module. This study aims to include 300 participants. Randomisation and allocation will be performed using permuted block randomisation with variable block sizes. The intervention contains seven ACT-based modules with interactive exercises, and audio and video clips. Furthermore, the participants have the opportunity to receive daily text messages. Online self-assessments will take place at pre- and post-treatment, as well as at 6 month follow-up. The primary outcome is pain interference. Secondary outcomes include physical and emotional functioning, pain intensity, ACT-related variables as well as health-related quality of life. Moreover, a cost-effectiveness analysis will be conducted from a societal perspective. Demographic and medical variables will be assessed on the basis of self-reports in order to detect potential moderators or mediators of the effects. The data will be analysed on an intention-to-treat basis and also using per-protocol analyses. Discussion: This study will contribute to the evidence base of internet-based pain interventions and provide valuable information about the treatment success and cost-effectiveness regarding the intervention's level of guidance (self-help only vs. guided self-help). If ACTonPain is shown to be effective, investigations in different healthcare settings should follow, to examine possible ways of implementing ACTonPain into existing healthcare systems. The implementation of ACTonPain could help to shorten waiting times, expand access to pain treatment and, potentially, also reduce treatment costs.

Background: Studies have shown that certain Internet interventions can help alleviate depression. However, many such interventions contain personal support elements, making it difficult to ascertain whether the program or the support drives the effects. Studies are needed to investigate whether Internet interventions contribute to symptom reduction even when they are delivered without personal support, and even among severely depressed individuals who often receive other forms of treatment. Objective: This randomized controlled trial aimed to examine the effect of an Internet intervention that was deployed without personal support (“Deprexis”) among adults with initially severe depression symptoms. Methods: Adults recruited from a range of sources who had exceeded the threshold for severe depression (PHQ-9 ≥ 15) in a pre-screening assessment and met inclusion criteria were randomized (N = 163) to the intervention (3 months program access; n = 78) or care-as-usual/waitlist control (n = 85). A diagnostic screening interview was administered by telephone at baseline to all participants. Online assessments were administered at baseline, 3 months (post-treatment), and 6 months (follow-up). The main outcome was the Patient Health Questionnaire (PHQ-9) between baseline and post-treatment. Results: Eighty-two percent of randomized participants were reached for the post-treatment assessment. Results for the intention-to-treat (ITT) sample showed significant intervention effects on depression reduction between baseline and post-treatment (linear mixed model [MM], F1,155.6 = 9.00, p

OBJECTIVE: The primary purpose of this randomized controlled trial (RCT) was to evaluate the efficacy of internet-based problem-solving training (iPST) for employees in the educational sector (teachers) with depressive symptoms. The results of training were compared to those of a waitlist control group (WLC). METHODS: One-hundred and fifty teachers with elevated depressive symptoms (Center for Epidemiologic Studies Depression Scale, CES-D ≥16) were assigned to either the iPST or WLC group. The iPST consisted of five lessons, including problem-solving and rumination techniques. Symptoms were assessed before the intervention began and in follow-up assessments after seven weeks, three months, and six months. The primary outcome was depressive symptom severity (CES-D). Secondary outcomes included general and work-specific self-efficacy, perceived stress, pathological worries, burnout symptoms, general physical and mental health, and absenteeism. RESULTS: iPST participants displayed a significantly greater reduction in depressive symptoms after the intervention (d=0.59, 95% CI 0.26–0.92), after three months (d=0.37, 95% CI 0.05–0.70) and after six months (d=0.38, 95% CI 0.05–0.70) compared to the control group. The iPST participants also displayed significantly higher improvements in secondary outcomes. However, workplace absenteeism was not significantly affected. CONCLUSION: iPST is effective in reducing symptoms of depression among teachers. Disseminated on a large scale, iPST could contribute to reducing the burden of stress-related mental health problems among teachers. Future studies should evaluate iPST approaches for use in other working populations.

Background: Internet-administered cognitive behavioural therapy (iCBT) is an effective treatment of depression, yet much remains to be learned about the specific mechanisms influencing symptom reduction. Although previous research has consistently shown that therapist-guided iCBT is more effective than unguided iCBT, it is unknown whether the medium used for therapist-client communication has an impact on results. Methods: Thirty-eight subjects with major depression were recruited from the waiting list of another iCBT study and randomised to a guided iCBT program with therapist guidance either by telephone calls (n = 19) or e-mail correspondence (n = 19). Outcome measures were self-rated measures of depression, anxiety and quality of life. Results: At post-treatment, both groups showed significant and large symptom reductions yet did not differ from each other. Neither was there any between-group difference in client-rated therapeutic alliance or treatment engagement. Symptom reductions were maintained at a three-month follow-up. Conclusion: Therapist guidance by telephone does not appear to differ from therapist guidance by e-mail in iCBT for depression, although further research featuring larger samples is necessary to draw more definite conclusions. Trial registration: None

Stress is a major health problem in today's workplace. Recent studies suggest that acceptance and commitment therapy (ACT) is effective for reducing stress at work, specifically among managers. Moreover, smartphone-delivered treatments have been developed and increasingly used in research. The objective of our study was to evaluate the efficacy of an ACT-based smartphone treatment among middle managers at medium- and large-sized companies (>50 employees) in Sweden. A total of 73 participants were randomized to either receive the six-week stress intervention (n = 36) or to a waitlist control group (n = 37). Results showed small to moderate within-group effect sizes (Cohen's d range 0.37–0.62) for the treatment group, and small to moderate between group effects (Cohen's d range 0.41–0.50). In conclusion, the study indicates that a smartphone administered stress intervention based on ACT can reduce perceived stress and increase general health among Swedish middle managers in the private sector.

The current study is a qualitative follow-up of a study on guided internet-delivered cognitive behavior therapy (ICBT) for social anxiety disorder (SAD), conducted four years after treatment completion. The main aim was to capture participants' description of their experiences of the treatment, their view on treatment effects, memories of the treatment, and whether they continued using the gained knowledge after treatment. Sixty participants were selected from the original study's treatment group. A criterion based sampling approach was used based on the obtained treatment effect, and with a minimum of five completed treatment modules. E-mail invitations were sent, with information about the follow-up and the instruction to respond if interested in participating. Twelve semi-structured interviews were made and the material was analyzed using an approach based on grounded theory. The results showed that all participants found the treatment to have some effect, but they also found it to be demanding, difficult, and hard. Many appreciated to hear of the experiences of other participants in the online forum. Under the theme of memory, most could describe the setup of the treatment in general terms. The exposure module was mentioned by all, cognitive restructuring by most, and some also reported memories of the psychoeducation. A core process was identified which involved how the attained treatment effect was viewed over the time, and how this view changed from treatment completion to current time. The findings outlined in this study describe how treatment effects can be sustained via an active approach to the treatment and the symptoms of SAD.

Background: Research has shown that computerized cognitive behavior therapy (cCBT), including internet-delivered CBT), can be effective. However, less is known about clinicians' attitudes towards this mode of treatment delivery. The aim of this study was to explore the attitudes of clinicians within child- and adolescent psychiatry towards cCBT and to explore if attitudes differed depending on rurality or theoretical orientation. Methods: A random sample of Swedish child- and adolescent mental health services was selected for a survey study (N = 15). A total number of 156 surveys were collected. Results: Results showed a generally low knowledge of cCBT. A majority of clinicians were positive to cCBT as a prevention program (73%), and as treatment for mild to moderate problems (75%). More caution was reported with regard to more severe mental health problems. Treatment orientation, but not rurality, had a significant effect on several ratings. Thematic analyses showed concerns regarding for example lack of human support and the restricted usefulness of cCBT regarding age and complexity of symptoms. Perceived advantages were for example increased availability and possibility of an alternative way of communication. Conclusions: This study adds to the limited literature on attitudes towards cCBT. The emerging picture is of a mainly positive attitude and prerequisites for dissemination are promising.

Objective: This study (ID: NCT01205906) compared the impact of the working alliance between the therapist and the client on treatment outcome in a group and an Internet-based cognitive behavior therapy (GCBT vs. ICBT) for chronic tinnitus. Methods: The Working Alliance Inventory — Short Revised (WAI-SR, scale range: 1–5) was administered to 26 GCBT and 38 ICBT participants after treatment weeks 2, 5, and 9, and the Tinnitus Handicap Inventory (THI) before and after the treatment. Results: High alliance ratings were found in both ICBT (WAI-SR total scores at week 9: M = 3.59, SD = 0.72) and GCBT (WAI-SR total scores at week 9: M = 4.20, SD = 0.49), but significantly higher ratings occurred in GCBT on most WAI-SR scales (ps

Internet interventions have great potential for alleviating emotional distress, promoting mental health, and enhancing well-being. Numerous clinical trials have demonstrated their efficacy for a number of psychiatric conditions, and interventions delivered via the Internet will likely become a common alternative to face-to-face treatment. Meanwhile, research has paid little attention to the negative effects associated with treatment, warranting further investigation of the possibility that some patients might deteriorate or encounter adverse events despite receiving best available care. Evidence from research of face-to-face treatment suggests that negative effects afflict 5–10% of all patients undergoing treatment in terms of deterioration. However, there is currently a lack of consensus on how to define and measure negative effects in psychotherapy research in general, leaving researchers without practical guidelines for monitoring and reporting negative effects in clinical trials. The current paper therefore seeks to provide recommendations that could promote the study of negative effects in Internet interventions with the aim of increasing the knowledge of its occurrence and characteristics. Ten leading experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialog and reach an agreement. The authors discuss the importance of conducting research on negative effects in order to further the understanding of its incidence and different features. Suggestions on how to classify and measure negative effects in Internet interventions are proposed, involving methods from both quantitative and qualitative research. Potential mechanisms underlying negative effects are also discussed, differentiating common factors shared with face-to-face treatments from those unique to treatments delivered via the Internet. The authors conclude that negative effects are to be expected and need to be acknowledged to a greater extent, advising researchers to systematically probe for negative effects whenever conducting clinical trials involving Internet interventions, as well as to share their findings in scientific journals.

Internet-based interventions are effective in the treatment of various mental disorders and have already been integrated in routine health care in some countries. Empirical data on potential negative effects of these interventions is lacking. This study investigated side effects in an Internet-based treatment for Social Anxiety Disorder (SAD). A total of 133 individuals diagnosed with SAD took part in an 11-week guided treatment. Side effects were assessed as open formatted questions after week 2 and at post-treatment after week 11. Answers were independently rated by two coders. In addition, rates of deterioration and non-response were calculated for primary social anxiety and secondary outcome measures (depression and quality of life). In total, 19 participants (14%) described unwanted negative events that they related to treatment. The emergence of new symptoms was the most commonly experienced side effect, followed by the deterioration of social anxiety symptoms and negative well-being. The large majority of the described side effects had a temporary but no enduring negative effect on participants' well-being. At post-treatment, none of the participants reported deterioration on social anxiety measures and 0–7% deteriorated on secondary outcome measures. Non-response was frequent with 32–50% for social anxiety measures and 57–90% for secondary outcomes at post-assessment. Results suggest that a small proportion of participants in Internet-based interventions experiences negative effects during treatment. Information about potential side effects should be integrated in patient education in the practice of Internet-based treatments.

The aim of this randomized controlled trial was to investigate the effects of guided internet-based cognitive behavior therapy (ICBT) for posttraumatic stress disorder (PTSD). Sixty-two participants with chronic PTSD, as assessed by the Clinician-administered PTSD Scale, were recruited via nationwide advertising and randomized to either treatment (n = 31) or delayed treatment attention control (n = 31). The ICBT treatment consisted of 8 weekly text-based modules containing psychoeducation, breathing retraining, imaginal and in vivo exposure, cognitive restructuring, and relapse prevention. Therapist support and feedback on homework assignment were given weekly via an online contact handling system. Assessments were made at baseline, post-treatment, and at 1-year follow-up. Main outcome measures were the Impact of Events Scale — Revised (IES-R) and the Posttraumatic Stress Diagnostic Scale (PDS). Results showed significant reductions of PTSD symptoms (between group effect on the IES-R Cohen's d = 1.25, and d = 1.24 for the PDS) compared to the control group. There were also effects on depression symptoms, anxiety symptoms, and quality of life. The results at one-year follow-up showed that treatment gains were maintained. In sum, these results suggest that ICBT with therapist support can reduce PTSD symptoms significantly.

Background: Exercise is often used in the treatment of chronic neck and shoulder muscle pain. It is likely that psychological aspects have an impact on the results of exercise-based treatments. Objectives: (1) To examine the associations between psychological factors and the effect of a home-based physical exercise intervention. (2) To examine differences in psychological factors at baseline between (a) subjects who continued in the trial and those who did not and (b) subjects who completed the intervention and those who did not. Method: A total of 57 women with chronic neck and shoulder pain were included in a home-based exercise intervention trial. Pain intensity, disability, and psychological factors (anxiety and depression symptoms, catastrophizing, fear-avoidance beliefs, self-efficacy, and pain acceptance) were measured at baseline, after 4–6 months, and after 1 year of exercise. Associations between the psychological factors and changes in pain intensity and disability were analysed, as well as differences in psychological factors at baseline between subjects who continued in and completed the intervention, and those who did not. Results: Associations between positive changes in pain intensity and disability were found for low fear-avoidance beliefs and low-pain self-efficacy at baseline. In addition, fear-avoidance beliefs at baseline were higher in the subjects who dropped out of the intervention than in those who continued. Pain acceptance at baseline was higher in the subjects who completed the intervention at the end of the trial. Conclusion: Particularly, fear-avoidance beliefs and pain self-efficacy should be taken into consideration when implementing home-based physical exercise as treatment for chronic neck pain. In addition, high pain acceptance might improve the adherence to prescribed exercise.

Little is known about the individual factors that predict outcomes in Internet-administered psychological treatments. We hypothesized that greater cognitive flexibility (i.e. the ability to simultaneously consider several concepts and tasks and switch effortlessly between them in response to changes in environmental contingencies) would provide a better foundation for learning and employing the cognitive restructuring techniques taught and exercised in therapy, leading to greater treatment gains. Participants in three trials featuring Internet-administered psychological treatments for depression (n = 36), social anxiety disorder (n = 115) and tinnitus (n = 53) completed the 64-card Wisconsin Card Sorting Test (WCST) prior to treatment. We found no significant associations between perseverative errors on the WCST and treatment gains in any group. We also found low accuracy in the classification of treatment responders. We conclude that lower cognitive flexibility, as captured by perseverative errors on the WCST, should not impede successful outcomes in Internet-delivered psychological treatments.

Depression in elderly people is a major public health concern. As response to antidepressants is often unsatisfactory in this age group, there is a need for evidence-based non-pharmacological treatment options. Our objectives were twofold: firstly, to synthesize published trials evaluating efficacy, safety and cost-effectiveness of psychological treatment of depression in the elderly and secondly, to assess the quality of evidence.The electronic databases PubMed, EMBASE, Cochrane Library, CINAL, Scopus, and PsycINFO were searched up to 23 May 2016 for randomized controlled trials (RCTs) of psychological treatment for depressive disorders or depressive symptoms in people aged 65 years and over. Two reviewers independently assessed relevant studies for risk of bias. Where appropriate, the results were synthesized in meta-analyses. The quality of the evidence was graded according to GRADE (Grading of Recommendations Assessment, Development and Evaluation).Twenty-two relevant RCTs were identified, eight of which were excluded from the synthesis due to a high risk of bias. Of the remaining trials, six evaluated problem-solving therapy (PST), five evaluated other forms of cognitive behavioural therapy (CBT), and three evaluated life review/reminiscence therapy. In frail elderly with depressive symptoms, the evidence supported the efficacy of PST, with large but heterogeneous effect sizes compared with treatment as usual. The results for life-review/reminiscence therapy and CBT were also promising, but because of the limited number of trials the quality of evidence was rated as very low. Safety data were not reported in any included trial. The only identified cost-effectiveness study estimated an incremental cost per additional point reduction in Beck Depression Inventory II score for CBT compared with talking control and treatment as usual.Psychological treatment is a feasible option for frail elderly with depressive symptoms. However, important questions about efficacy, generalizability, safety and cost-effectiveness remain.

Research conducted during the last decades has provided increasing evidence for the use of psychological treatments for a number of psychiatric disorders and somatic complaints. However, by focusing only on the positive outcomes, less attention has been given to the potential of negative effects. Despite indications of deterioration and other adverse and unwanted events during treatment, little is known about their occurrence and characteristics. Hence, in order to facilitate research of negative effects, a new instrument for monitoring and reporting their incidence and impact was developed using a consensus among researchers, self-reports by patients, and a literature review: the Negative Effects Questionnaire. Participants were recruited via a smartphone-delivered self-help treatment for social anxiety disorder and through the media (N = 653). An exploratory factor analysis was performed, resulting in a six-factor solution with 32 items, accounting for 57.64% of the variance. The derived factors were: symptoms, quality, dependency, stigma, hopelessness, and failure. Items related to unpleasant memories, stress, and anxiety were experienced by more than one-third of the participants. Further, increased or novel symptoms, as well as lack of quality in the treatment and therapeutic relationship rendered the highest self-reported negative impact. In addition, the findings were discussed in relation to prior research and other similar instruments of adverse and unwanted events, giving credence to the items that are included. The instrument is presently available in eleven different languages and can be freely downloaded and used from www.neqscale.com.

[This corrects the article DOI: 10.1371/journal.pone.0079015.].

The aim of the current study was to test the hypothesis that adults experiencing hearing difficulties who are aware of their difficulties but have not taken any action would fall under contemplation and preparation stages based on the transtheoretical stages-of-change model. The study employed a cross-sectional design. The study was conducted in United Kingdom and 90 participants completed University of Rhode Island Change Assessment (URICA) scale as well as measures of self-reported hearing disability, self-reported anxiety and depression, self-reported hearing disability acceptance, and provided additional demographic details online. As predicted, the results indicate that a high percentage of participants (over 90%) were in the contemplation and preparation stages. No statistically significant differences were observed among groups of stage with highest URICA scores and factors such as: years since hearing disability, self-reported hearing disability, self-reported anxiety and depression, and self-reported hearing disability acceptance. Cluster analysis identified three stages-of-change clusters, which were named as: decision making (53% of sample), participation (28% of sample), and disinterest (19% of sample). Study results support the stages-of-change model. In addition, implications of the current study and areas for future research are discussed.

BackgroundThere is need for more cost and time effective treatments for depression. This is the first randomised controlled trial in which a blended treatment--including four face-to-face sessions and a smartphone application--was compared against a full behavioural treatment. Hence, the aim of the current paper was to examine whether a blended smartphone treatment was non-inferior to a full behavioural activation treatment for depression.MethodsThis was a randomised controlled non-inferiority trial (NCT01819025) comparing a blended treatment (n=46) against a full ten-session treatment (n=47) for people suffering from major depression. Primary outcome measure was the BDI-II, that was administered at pre- and post-treatment, as well as six months after the treatment.ResultsResults showed significant improvements in both groups across time on the primary outcome measure (within-group Cohen's d=1.35; CI [-0.82, 3.52] to d=1.47; CI [-0.41, 3.35]; between group d=-0.13 CI [-2.37, 2.09] and d=-0.10 CI [-2.53, 2.33]). At the same time, the blended treatment reduced the therapist time with an average of 47%.ConclusionsWe could not establish whether the blended treatment was non-inferior to a full BA treatment. Nevertheless, this study points to that the blended treatment approach could possibly treat nearly twice as many patients suffering from depression by using a smartphone application as add-on. More studies are needed before we can suggest that the blended treatment method is a promising cost-effective alternative to regular face-to-face treatment for depression.Trial registrationCognitive Behavioral Therapy Treatment of Depression With Smartphone Support NCT01819025.

Background and aimsInternet-based cognitive-behavioral therapy (iCBT) for social anxiety disorder has been found effective, as attested by independently conducted randomized controlled trials in four languages. The study aim is to test the efficacy of an iCBT program in a culture where it was not tested before (i.e. Romania).MethodsParticipants (n = 76) were recruited, screened and randomized to either a nine-week guided iCBT or a wait-list control group in April and May 2012. Self-report measures were collected before (April 2012) and after the intervention (July 2012), as well as six months later (January 2013). Although social anxiety was assessed with multiple measures, the Liebowitz Social Anxiety Scale - Self Report version (LSAS-SR) and Social Phobia Inventory (SPIN) were used as the primary outcome measures.ResultsA significant difference with a large between-group effect size in favor of iCBT was found (Cohen's d = 1.19 for LSAS-SR and d = 1.27 for SPIN). Recovery rates show that 36.8% (n = 14) in the treatment group score below the SPIN clinical cut-off compared to only 2.6% (n = 1) in the wait-list control group. Post-intervention clinical interviews also revealed that 34.2% (n = 13) of the treatment group was completely recovered (full remission) while additionally 36.8% (n = 14) retained some social anxiety symptoms (partial remission). However, an important study limitation is that post-intervention interviewers were not blinded to the study conditions. The program also effectively reduced depression and dysfunctional thinking (between-group Cohen's d = 0.84 for depression and d = 0.63 for dysfunctional thinking). Moreover, the iCBT intervention appears to have a long-term impact for participants' functioning, as the treatment gains were maintained six months later.ConclusionsInternet-delivered interventions display a high potential to quickly and widely disseminate effective evidence-based programs around the world. This study provides support for guided iCBT as a promising treatment approach in Romania.Trial registrationClinicalTrials.gov NCT01557894.

ObjectiveA central goal of health care is to improve patient outcomes. Although several studies have demonstrated the effectiveness of therapist guided internet-based cognitive behaviour therapy (ICBT) for social anxiety disorder (SAD), a significant proportion of patients do not respond to treatment. Consequently, the aim of this study was to identify individual characteristics and treatment program related factors that could help clinicians predict treatment outcomes and adherence for individuals with SAD.MethodThe sample comprised longitudinal data collected during a 4-year period of adult individuals (N = 764) treated for SAD at a public service psychiatric clinic. Weekly self-rated Liebowitz Social Anxiety Scale (LSAS-SR) scores were provided. Rates of symptomatic change during treatment and adherence levels were analysed using multilevel modelling. The following domains of prognostic variables were examined: (a) socio-demographic variables; (b) clinical characteristics; (c) family history of mental illness; and (d) treatment-related factors.ResultsHigher treatment credibility and adherence predicted a faster rate of improvement during treatment, whereas higher overall functioning level evidenced a slower rate of improvement. Treatment credibility was the strongest predictor of greater adherence. Having a family history of SAD-like symptoms was also associated with greater adherence, whereas Attention-Deficit/Hyperactivity Disorder (ADHD)-like symptoms, male gender, and family history of minor depression predicted lower adherence. Also, the amount of therapist time spent per treatment module was negatively associated with adherence.ConclusionsResults from a large clinical sample indicate that the credibility of ICBT is the strongest prognostic factor explaining individual differences in both adherence level and symptomatic improvement. Early screening of ADHD-like symptoms may help clinicians identify patients who might need extra support or an adjusted treatment. Therapist behaviours that promote adherence may be important for treatment response, although more research is needed in order to determine what type of support would be most beneficial.

BackgroundHealth anxiety can be viewed as a dimensional phenomenon where severe health anxiety in form of DSM-IV hypochondriasis represents a cut-off where the health anxiety becomes clinically significant. Three of the most reliable and used self-report measures of health anxiety are the Health Anxiety Inventory (HAI), the Illness Attitude Scales (IAS) and the Whiteley Index (WI). Identifying the optimal cut-offs for classification of presence of a diagnosis of severe health anxiety on these measures has several advantages in clinical and research settings. The aim of this study was therefore to investigate the HAI, IAS and WI as proximal diagnostic instruments for severe health anxiety defined as DSM-IV hypochondriasis.MethodsWe investigated sensitivity, specificity and predictive value on the HAI, IAS and WI using a total of 347 adult participants of whom 158 had a diagnosis of severe health anxiety, 97 had obsessive-compulsive disorder and 92 were healthy non-clinical controls. Diagnostic assessments were conducted using the Anxiety Disorder Interview Schedule.ResultsOptimal cut-offs for identifying a diagnosis of severe health anxiety was 67 on the HAI, 47 on the IAS, and 5 on the WI. Sensitivity and specificity were high, ranging from 92.6 to 99.4%. Positive and negative predictive values ranged from 91.6 to 99.4% using unadjusted prevalence rates.ConclusionsThe HAI, IAS and WI have very good properties as diagnostic indicators of severe health anxiety and can be used as cost-efficient proximal estimates of the diagnosis.

BackgroundInternet-based cognitive behavioural therapy (iCBT) is an effective and acceptable treatment for depression, especially when it includes guidance, but its treatment adherence has not yet been systematically studied. We conducted a meta-analysis, comparing the adherence to guided iCBT with the adherence to individual face-to-face CBT.MethodsStudies were selected from a database of trials that investigate treatment for adult depression (see www.evidencebasedpsychotherapies.org), updated to January 2013. We identified 24 studies describing 26 treatment conditions (14 face-to-face CBT, 12 guided iCBT), by means of these inclusion criteria: targeting depressed adults, no comorbid somatic disorder or substance abuse, community recruitment, published in the year 2000 or later. The main outcome measure was the percentage of completed sessions. We also coded the percentage of treatment completers (separately coding for 100% or at least 80% of treatment completed).ResultsWe did not find studies that compared guided iCBT and face-to-face CBT in a single trial that met our inclusion criteria. Face-to-face CBT treatments ranged from 12 to 28 sessions, guided iCBT interventions consisted of 5 to 9 sessions. Participants in face-to-face CBT completed on average 83.9% of their treatment, which did not differ significantly from participants in guided iCBT (80.8%, P = .59). The percentage of completers (total intervention) was significantly higher in face-to-face CBT (84.7%) than in guided iCBT (65.1%, P < .001), as was the percentage of completers of 80% or more of the intervention (face-to-face CBT: 85.2%, guided iCBT: 67.5%, P = .003). Non-completers of face-to-face CBT completed on average 24.5% of their treatment, while non-completers of guided iCBT completed on average 42.1% of their treatment.ConclusionWe did not find studies that compared guided iCBT and face-to-face CBT in a single trial. Adherence to guided iCBT appears to be adequate and could be equal to adherence to face-to-face CBT.

Personality traits have traditionally been viewed as stable, but recent studies suggest that they could be affected through psychological treatment. Internet-based cognitive behavior therapy (ICBT) for severe health anxiety (DSM-IV hypochondriasis) has been shown to be effective in reducing health anxiety, but its effect on measures of personality traits has not been investigated. The main aim of this study was to investigate the impact of ICBT on personality traits in the three broad dimensions--neuroticism, extraversion and aggression. We hypothesized that participants in ICBT would reduce their level of neuroticism compared to controls that did not receive the active treatment. No specific predictions were made regarding extraversion and aggression. Data from a randomized controlled trial were used in which participants were allocated to 12 weeks of ICBT (n = 40) or to a basic attention control condition (n = 41). Personality traits were assessed with the Swedish Universities Scales of Personality and the primary outcome of health anxiety was the Health Anxiety Inventory. There was a significant interaction effect of group and time on neuroticism-related scales, indicating larger pre- to post-treatment reductions in the Internet-based CBT group compared to the control condition. Analyses at 6-month follow-up showed that changes were stable. Traits relating to extraversion and aggression were largely unchanged. This study is the first to demonstrate that a brief ICBT intervention for severe health anxiety causes long-term changes in measures of personality traits related to neuroticism. The treatment thus has a broader impact than just reducing health anxiety.Clinicaltrials.gov (ID NCT00828152).

Objective. The main hypothesis, and the objective of the study, was to test if the participants allocated to the treatment group would show a larger reduction in depressive symptoms than those in the control group. Methods. This study was a randomized nine week trial of an Internet-administered treatment based on guided physical exercise for Major Depressive Disorder (MDD). A total of 48 participants with mild to moderate depression, diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders, were randomized either to a treatment intervention or to a waiting-list control group. The main outcome measure for depression was the Beck Depression Inventory-II (BDI-II), and physical activity level was measured using the International Physical Activity Questionnaire (IPAQ). The treatment program consisted of nine text modules, and included therapist guidance on a weekly basis. Results. The results showed significant reductions of depressive symptoms in the treatment group compared to the control group, with a moderate between-group effect size (Cohen’s d = 0.67; 95% confidence interval: 0.09–1.25). No difference was found between the groups with regards to increase of physical activity level. For the treatment group, the reduction in depressive symptoms persisted at six months follow-up. Conclusions. Physical activity as a treatment for depression can be delivered in the form of guided Internet-based self-help. Trial Registration. The trial was registered at ClinicalTrials.gov (NCT01573130).

Background. Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders.Methods. One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up.Results. Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen’s d = 0.77 (95% CI: 0.37–1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08–0.87) was found on the GAD-7. The number of patients who recovered (had no diagnoses of depression and anxiety, and had less than 10 on both the PHQ-9 and the GAD-7) were at post-treatment 52% in the treatment group and 24% in the control group. This difference was significant, χ2(N = 100, d f = 1) = 8.3, p < .01. From post-treatment to follow-up, treatment gains were maintained on the PHQ-9, and significant improvements were seen on the GAD-7.Conclusion. This study provides initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.

Background. Depression and anxiety disorders are major world-wide problems. There are no or few epidemiological studies investigating the prevalence of depression, generalized anxiety disorder and anxiety disorders in general in the Swedish population.Methods. Data were obtained by means of a postal survey administered to 3001 randomly selected adults. After two reminders response rate was 44.3%. Measures of depression and general anxiety were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). The PHQ-9 identified participants who had experienced clinically significant depression (PHQ-9 ≥ 10), and who had a diagnosis of major depression (defined by using a PHQ-9 scoring algorithm). Clinically significant anxiety was defined as having a GAD-7 score ≥ 8. To specifically measure generalized anxiety disorder, the Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV) was used with an established cut-off. Health-related quality of life was measured using the EuroQol (EQ-5D). Experiences of treatments for psychiatric disorders were also assessed.Results. Around 17.2% (95% CI: 15.1–19.4) of the participants were experiencing clinically significant depression (10.8%; 95% CI: 9.1–12.5) and clinically significant anxiety (14.7%; 95% CI: 12.7–16.6). Among participants with either clinically significant depression or anxiety, nearly 50% had comorbid disorders. The point prevalence of major depression was 5.2% (95% CI: 4.0–6.5), and 8.8% (95% CI: 7.3–10.4) had GAD. Among those with either of these disorders, 28.2% had comorbid depression and GAD. There were, generally, significant gender differences, with more women having a disorder compared to men. Among those with depression or anxiety, only between half and two thirds had any treatment experience. Comorbidity was associated with higher symptom severity and lower health-related quality of life.Conclusions. Epidemiological data from the Swedish community collected in this study provide point prevalence rates of depression, anxiety disorders and their comorbidity. These conditions were shown in this study to be undertreated and associated with lower quality of life, that need further efforts regarding preventive and treatment interventions.

Background. The Temperament and Character Inventory (TCI) by Cloninger is a widely used instrument to measure personality dimensions. Two dimensions of the TCI, Harm avoidance (HA) and Self-Directedness (SD), are known to be influenced by depressed mood. This study investigated changes in HA and SD after 10 weeks of Internet-delivered cognitive behavior therapy (ICBT) in a sample of clinically depressed subjects (N = 108). Differences in personality changes among treatment responders and non-responders were also investigated. Exploratory investigations on changes for other TCI dimensions, were also conducted.Methods. Depressed subjects were randomized either to ICBT or to a moderated online discussion group, which served as an active control group. The interventions lasted for 10 weeks. TCI was measured at baseline and after treatment. Depressive symptoms were assessed using the Beck Depression Inventory-II.Results. There were significant changes on HA and SD after ICBT. However, when comparing post-treatment HA and SD to the control, no differences were found. Among responders, larger changes compared to non-responders were found in HA and in SD, as well as in Cooperativeness.Conclusions. The study showed that HA and SD changed after ICBT. The changes in personality seem related to improvement in depression rather than a direct effect of ICBT.

Internet-based cognitive behaviour therapy (ICBT) can be equally effective as traditional face-to-face cognitive behaviour therapy (CBT) for treating panic disorder (PD). However, little is known about the predictors and moderators of outcome of ICBT when delivered in psychiatric outpatient settings. This study investigated a selection of outcome predictors and moderators of ICBT for panic disorder based on data from a randomised controlled trial where therapist-guided ICBT was compared with group CBT (GCBT) for panic disorder. Participants (N = 104) received 10 weeks of ICBT or GCBT and were assessed before and after treatment, and after six months. Multiple regression analyses were used to test for significant predictors of treatment outcome. Predictors of positive treatment response for both modalities were having low levels of symptom severity and work impairment. In addition, anxiety sensitivity was found to have a small negative relationship with treatment outcome, suggesting that anxiety sensitivity may slightly enhance treatment response. Treatment modality had a moderating effect on the relationship between domestic impairment and outcome and on the relationship between initial age of onset of panic symptoms and treatment outcome, favouring ICBT for patients having had an early onset of PD symptoms and for patients having a high domestic functional impairment. These results suggest that both ICBT and GCBT are effective treatment modalities for PD and that it is possible to predict a significant proportion of the long-term outcome variance based on clinical variables.

According to the cognitive behavioral model of severe health anxiety (hypochondriasis) four central maintaining mechanisms are how the individual perceives the risk of disease and how negative its consequences would be, attention to bodily sensations, and intolerance of uncertainty. The aim of the present study was to investigate the mediating role of these putative mechanisms in Internet-delivered CBT for severe health anxiety. We analyzed data from an RCT where participants were randomized to Internet-delivered CBT (n=40) or to a control condition (n=41). Mediators and outcome, i.e. health anxiety, were assessed weekly throughout the treatment, enabling fulfillment of the criterion of temporal precedence of changes occurring in the mediator in relation to the outcome to be met. The results showed that reduced perceived risk of disease, less attention to bodily symptoms, and reduced intolerance of uncertainty significantly mediated improvement in health anxiety. The study supports the validity of the cognitive behavioral model of health anxiety. The findings have theoretical and clinical implications as they indicate processes that may be causally related to the improvements observed after CBT for health anxiety.

The role of genetics for predicting the response to cognitive behavior therapy (CBT) for social anxiety disorder (SAD) has only been studied in one previous investigation. The serotonin transporter (5-HTTLPR), the catechol-o-methyltransferase (COMT) val158met, and the tryptophan hydroxylase-2 (TPH2) G-703T polymorphisms are implicated in the regulation of amygdala reactivity and fear extinction and therefore might be of relevance for CBT outcome. The aim of the present study was to investigate if these three gene variants predicted response to CBT in a large sample of SAD patients.Participants were recruited from two separate randomized controlled CBT trials (trial 1: n = 112, trial 2: n = 202). Genotyping were performed on DNA extracted from blood or saliva samples. Effects were analyzed at follow-up (6 or 12 months after treatment) for both groups and for each group separately at post-treatment. The main outcome measure was the Liebowitz Social Anxiety Scale Self-Report.At long-term follow-up, there was no effect of any genotype, or gene × gene interactions, on treatment response. In the subsamples, there was time by genotype interaction effects indicating an influence of the TPH2 G-703T-polymorphism on CBT short-term response, however the direction of the effect was not consistent across trials.None of the three gene variants, 5-HTTLPR, COMTval158met and TPH2 G-703T, was associated with long-term response to CBT for SAD.ClinicalTrials.gov (ID-NCT0056496).

Tinnitus is the experience of sounds without an appropriate external auditory source. These auditory sensations are intertwined with emotional and attentional processing. Drawing on theories of mental control, we predicted that suppressing an affectively negative sound mimicking the psychoacoustic features of tinnitus would result in decreased persistence in a mentally challenging task (mental arithmetic) that required participants to ignore the same sound, but that receiving a mindfulness exercise would reduce this effect. Normal hearing participants (N = 119) were instructed to suppress an affectively negative sound under cognitive load or were given no such instructions. Next, participants received either a mindfulness induction or an attention control task. Finally, all participants worked with mental arithmetic while exposed to the same sound. The length of time participants could persist in the second task served as the dependent variable. As hypothesized, results indicated that an auditory suppression rationale reduced time of persistence relative to no such rationale, and that a mindfulness induction counteracted this detrimental effect. The study may offer new insights into the mechanisms involved in the development of tinnitus interference. Implications are also discussed in the broader context of attention control strategies and the effects of emotional sound on task performance. The ironic processes of mental control may have an analog in the experience of sounds.

Biases in attention processes are thought to play a crucial role in the aetiology and maintenance of Social Anxiety Disorder (SAD). The goal of the present study was to examine the efficacy of a programme intended to train attention towards positive cues and a programme intended to train attention towards negative cues. In a randomised, controlled, double-blind design, the impact of these two training conditions on both selective attention and social anxiety were compared to that of a control training condition. A modified dot probe task was used, and delivered via the internet. A total of 129 individuals, diagnosed with SAD, were randomly assigned to one of these three conditions and took part in a 14-day programme with daily training/control sessions. Participants in all three groups did not on average display an attentional bias prior to the training. Critically, results on change in attention bias implied that significantly differential change in selective attention to threat was not detected in the three conditions. However, symptoms of social anxiety reduced significantly from pre- to follow-up-assessment in all three conditions (dwithin = 0.63-1.24), with the procedure intended to train attention towards threat cues producing, relative to the control condition, a significantly greater reduction of social fears. There were no significant differences in social anxiety outcome between the training condition intended to induce attentional bias towards positive cues and the control condition. To our knowledge, this is the first RCT where a condition intended to induce attention bias to negative cues yielded greater emotional benefits than a control condition. Intriguingly, changes in symptoms are unlikely to be by the mechanism of change in attention processes since there was no change detected in bias per se. Implications of this finding for future research on attention bias modification in social anxiety are discussed.ClinicalTrials.gov NCT01463137.

Background and aimsMajor depression can be treated by means of cognitive behavior therapy, delivered via the Internet as guided self-help. Individually tailored guided self-help treatments have shown promising results in the treatment of anxiety disorders. This randomized controlled trial tested the efficacy of an Internet-based individually tailored guided self-help treatment which specifically targeted depression with comorbid symptoms. The treatment was compared both to standardized (non-tailored) Internet-based treatment and to an active control group in the form of a monitored online discussion group. Both guided self-help treatments were based on cognitive behavior therapy and lasted for 10 weeks. The discussion group consisted of weekly discussion themes related to depression and the treatment of depression.MethodsA total of 121 participants with diagnosed major depressive disorder and with a range of comorbid symptoms were randomized to three groups. The tailored treatment consisted of a prescribed set of modules targeting depression as well as comorbid problems. The standardized treatment was a previously tested guided self-help program for depression.ResultsFrom pre-treatment to post-treatment, both treatment groups improved on measures of depression, anxiety and quality of life. The results were maintained at a 6-month follow-up. Subgroup analyses showed that the tailored treatment was more effective than the standardized treatment among participants with higher levels of depression at baseline and more comorbidity, both in terms of reduction of depressive symptoms and on recovery rates. In the subgroup with lower baseline scores of depression, few differences were seen between treatments and the discussion group.ConclusionsThis study shows that tailored Internet-based treatment for depression is effective and that addressing comorbidity by tailoring may be one way of making guided self-help treatments more effective than standardized approaches in the treatment of more severe depression.Trial registrationClinicaltrials.gov NCT01181583.

BACKGROUND: Guided internet-delivered cognitive behavior therapy (ICBT) has been tested in several trials on social anxiety disorder (SAD) with moderate to large effects. The aims of this study were threefold. First, to compare the effects of ICBT including online discussion forum with a moderated online discussion forum only. Second, to investigate if knowledge about SAD increased following treatment and third to compare the effects of inexperienced versus experienced therapists on patient outcomes. METHODS: A total of 204 participants with a primary diagnosis of SAD were included and randomized to either guided ICBT or the control condition. ICBT consisted of a 9-week treatment program which was guided by either psychology students at MSc level (n = 6) or by licensed psychologists with previous experience of ICBT (n = 7). A knowledge test dealing with social anxiety was administered before and after treatment. Measures of social anxiety and secondary outcomes dealing with general anxiety, depression, and quality of life were administered before and after treatment. In addition, a 1-year follow-up was conducted on the treated individuals. RESULTS: Immediately following treatment, the ICBT group showed superior outcome on the Liebowitz Social Anxiety Scale self-report version with a between group posttreatment Hedges g effect size of g = 0.75. In addition, significant differences on all the secondary outcomes were observed. Gains were well maintained one year later. Knowledge, as assessed by the knowledge test, increased following treatment with little gain in the control group. Therapist experience did not result in different outcomes, but experienced therapists logged in less frequently compared to the inexperienced therapists, suggesting that they needed less time to support patients. DISCUSSION: We conclude that guided ICBT reduce symptoms of SAD, increase knowledge about SAD and that therapist experience does not make a difference apart from the finding that experienced therapist may require less time to guide patients. TRIAL REGISTRATION: UMIN.ac.jp UMIN000001383.

Psychodynamic psychotherapy (PDT) is an effective treatment for major depressive disorder (MDD), but not all clients with MDD can receive psychotherapy. Using the Internet to provide psychodynamic treatments is one way of improving access to psychological treatments for MDD. The aim of this randomised controlled trial was to investigate the efficacy of an Internet-based psychodynamic guided self-help treatment for MDD.Ninety-two participants who were diagnosed with MDD according to the Mini-International Neuropsychiatric Interview were randomised to treatment or an active control. The treatment consisted of nine treatment modules based on psychodynamic principles with online therapist contact. The active control condition was a structured support intervention and contained psychoeducation and scheduled weekly contacts online. Both interventions lasted for 10 weeks. The primary outcome measure was the Beck Depression Inventory-II (BDI-II).Mixed-effects model analyses of all randomised participants showed that participants receiving Internet-based PDT made large and superior improvements compared with the active control group on the BDI-II (between-group Cohen's d = 1.11). Treatment effects were maintained at a 10-month follow-up.Internet-based psychodynamic guided self-help is an efficacious treatment for MDD that has the potential to increase accessibility and availability of PDT for MDD.Clinicaltrials.gov: NCT01324050.