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  • 1. Andersson, Gerhard
    et al.
    Bergström, Jan
    Buhrman, Monica
    Carlbring, Per
    Holländare, Fredrik
    Örebro University, School of Health and Medical Sciences.
    Kaldo, Viktor
    Nilsson-Ihrfelt, Elisabeth
    Paxling, Björn
    Ström, Lars
    Waara, Johan
    Development of a new approach to guided self-help via the Internet: The Swedish experience2008In: Journal of technology in human services, ISSN 1522-8835, E-ISSN 1522-8991, Vol. 26, no 2-4, p. 161-181Article in journal (Refereed)
    Abstract [en]

    This article describes the development and empirical status of guided Internet-delivered self-help. The treatment approach combines the benefits of bibliotherapy with book-length text materials and the support given online via web pages and e-mail. Interactive features such as online registrations, tests, and online discussion forums are also included. Cognitive behavior therapy (CBT) guided the research and clinical implementations of this approach, as it lends itself more easily to the self-help format compared with other presently available psychotherapy approaches. We include an overview of the research, current issues and research in service delivery, lessons learned through a program of research, and directions for future investigations

  • 2. Andersson, Gerhard
    et al.
    Bergström, Jan
    Holländare, Fredrik
    Örebro University, Department of Clinical Medicine.
    Carlbring, Per
    Kaldo, Viktor
    Ekselius, Lisa
    Internet-based self-help for depression: randomised controlled trial2005In: British Journal of Psychiatry, ISSN 0007-1250, E-ISSN 1472-1465, Vol. 187, p. 456-461Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Major depression can be treated by means of cognitive-behavioural therapy, but as skilled therapists are in short supply there is a need for self-help approaches. Many individuals with depression use the internet for discussion of symptoms and to share their experience.

    AIMS:

    To investigate the effects of an internet-administered self-help programme including participation in a monitored, web-based discussion group, compared with participation in web-based discussion group only.

    METHOD:

    A randomised controlled trial was conducted to compare the effects of internet-based cognitive-behavioural therapy with minimal therapist contact (plus participation in a discussion group) with the effects of participation in a discussion group only.

    RESULTS:

    Internet-based therapy with minimal therapist contact, combined with activity in a discussion group, resulted in greater reductions of depressive symptoms compared with activity in a discussion group only (waiting-list control group). At 6 months' follow-up, improvement was maintained to a large extent.

    CONCLUSIONS:

    Internet-delivered cognitive cognitive-behavioural therapy should be pursued further as a complement or treatment alternative for mild-to-moderate depression.

  • 3.
    Cato, Ville
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Cente.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Cente.
    Sellin Jönsson, Tabita
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Cente.
    Association between benzodiazepines and suicide risk: a matched case-control study2019In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 19, no 1, article id 317Article in journal (Refereed)
    Abstract [en]

    Background: It is unclear whether benzodiazepines increase the risk of suicide. The aim of this study was to test the hypothesis that benzodiazepines are associated with an increased risk of suicide, by comparing psychopharmacological interventions between psychiatric patients who committed suicide and a group of matched controls.

    Methods: The case group comprised 154 psychiatric patients (101 men, 53 women; age range: 13-96 years) who had committed suicide in orebro County, Sweden. Control psychiatric patients matched by age, sex, and main psychiatric diagnosis were selected for each case. Binary logistic regression was used to calculate odds ratios in unadjusted and adjusted models.

    Results: Benzodiazepine prescriptions were more common among cases than controls (65/154 [42.2%] versus 43/154 [27.9%], p = 0.009, odds ratio: 1.89 [95% CI: 1.17-3.03]). This association remained significant in a model adjusted for previous suicide attempts and somatic hospitalizations (odds ratio: 1.83 [95% CI: 1.06-3.14]). No statistically significant differences were seen between the groups in the use of any other subtype of psychopharmaceutical agent.

    Conclusions: These data indicate that benzodiazepine use may increase the risk of suicide. However, this study is limited by the potential for indication bias.

  • 4.
    Edlund, Sara M.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Fruzzetti, Alan E
    McLean Hospital & Department of Psychiatry, Harvard Medical School, Boston, USA.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Psychiatry.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Dialectical behavior therapy to augment stand-ard cognitive behavioral therapy for treatment-resistant anxi-ety disorders: A replicated single-subject pilot studyManuscript (preprint) (Other academic)
  • 5.
    Edlund, Sara
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Wurm, Matilda
    Örebro University, School of Law, Psychology and Social Work.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Psychiatry, Örebro University Hospital, Örebro, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Fruzzetti, Alan E.
    McLean Hospital & Department of Psychiatry, Harvard Medical School, Boston, USA.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Pain patients´ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity and treatment outcome2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 77-86Article in journal (Refereed)
    Abstract [en]

    Background and aims: Validating and invalidating responses play an important role in communication with pain patients, for example regarding emotion regulation and adherence to treatment. However, it is unclear how patients’ perceptions of validation and invalidation relate to patient characteristics and treatment outcome. The aim of this study was to investigate the occurrence of subgroups based on pain patients’ perceptions of validation and invalidation from their physicians. The stability of these perceptions and differences between subgroups regarding pain, pain interference, negative affectivity and treatment outcome were also explored.

    Methods: A total of 108 pain patients answered questionnaires regarding perceived validation and invalidation, pain severity, pain interference, and negative affectivity before and after pain rehabilitation treatment. Two cluster analyses using perceived validation and invalidation were performed, one on pre-scores and one on post-scores. The stability of patient perceptions from pre- to post-treatment was investigated, and clusters were compared on pain severity, pain interference, and negative affectivity. Finally, the connection between perceived validation and invalidation and treatment outcome was explored.

    Results: Three clusters emerged both before and after treatment: (1) low validation and heightened invalidation, (2) moderate validation and invalidation, and (3) high validation and low invalidation. Perceptions of validation and invalidation were generally stable over time, although there were individuals whose perceptions changed. When compared to the other two clusters, the low validation/heightened invalidation cluster displayed significantly higher levels of pain interference and negative affectivity post-treatment but not pre-treatment. The whole sample significantly improved on pain interference and depression, but treatment outcome was independent of cluster. Unexpectedly, differences between clusters on pain interference and negative affectivity were only found post-treatment. This appeared to be due to the pre- and post-heightened invalidation clusters not containing the same individuals. Therefore, additional analyses were conducted to investigate the individuals who changed clusters. Results showed that patients scoring high on negative affectivity ended up in the heightened invalidation cluster post-treatment.

    Conclusions: Taken together, most patients felt understood when communicating with their rehabilitation physician. However, a smaller group of patients experienced the opposite: low levels of validation and heightened levels of invalidation. This group stood out as more problematic, reporting greater pain interference and negative affectivity when compared to the other groups after treatment. Patient perceptions were typically stable over time, but some individuals changed cluster, and these movements seemed to be related to negative affectivity and pain interference. These results do not support a connection between perceived validation and invalidation from physicians (meeting the patients pre- and post-treatment) and treatment outcome. Overall, our results suggest that there is a connection between negative affectivity and pain interference in the patients, and perceived validation and invalidation from the physicians. Implications In clinical practice, it is important to pay attention to comorbid psychological problems and level of pain interference, since these factors may negatively influence effective communication. A focus on decreasing invalidating responses and/or increasing validating responses might be particularly important for patients with high levels of psychological problems and pain interference.

  • 6.
    Flygare, Anna-Lena
    et al.
    Centre for Clinical Research, Region Värmland, Karlstad, Sweden.
    Engström, Ingemar
    University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hasselgren, Mikael
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Jansson-Fröjmark, Markus
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Frejgrim, Rikard
    Centre for Clinical Research, Region Värmland, Karlstad, Sweden.
    Andersson, Gerhard
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Internet-based CBT for patients with depressive disorders in primary and psychiatric care: Is it effective and does comorbidity affect outcome?2020In: Internet Interventions, ISSN 2214-7829, Vol. 19, article id UNSP 100303Article in journal (Refereed)
    Abstract [en]

    Internet-based cognitive behavior therapy (ICBT) has proved effective in reducing mild to moderate depressive symptoms. However, only a few studies have been conducted in a regular healthcare setting which limits the generalizability of the results. The influence of psychiatric comorbidity on outcome is not well understood. In the current study, patients with mild to moderate depressive symptoms in primary and psychiatric care were interviewed using the SCID-I and SCID-II to assess psychiatric diagnoses. Those included were randomly allocated to ICBT (n = 48) or to an active control condition (n = 47). Both groups received therapist support. At post-treatment, ICBT had reduced depressive symptoms on the BDI-II more than the active control intervention (p = .021). However, the difference between groups was no longer significant at the 6-, 12- or 24-month followups. The within-group effect size after ICBT (BDI-II) was large (d = 1.4). A comorbid anxiety disorder didn't moderate the outcome, while the presence of a personality disorder predicted significantly less improvement in depressive symptoms. ICBT had a large effect on depressive symptoms in a sample from regular healthcare. It is possible to obtain a large effect from ICBT despite comorbid anxiety, however, including patients with a comorbid personality disorder in the current form of ICBT seems questionable.

  • 7.
    Forsell, Erik
    et al.
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Bendix, Marie
    Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Centre, Region Örebro County, Örebro, Sweden.
    von Schultz, Barbara Szymanska
    Department of Children and Women, Karolinska University Hospital, Huddinge, Sweden.
    Nasiell, Josefine
    Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden.
    Blomdahl-Wetterholm, Margareta
    Stockholms Läns Sjuvårdsområde (SLSO), Psychiatry Southwest, Stockholm, Sweden.
    Eriksson, Caroline
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Kvarned, Sara
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    van der Linden, Johanna Lindau
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Söderberg, Elin
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Jokinen, Jussi
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden.
    Wide, Katarina
    Department of Clinical Science, Intervention and Technology (CLINTEC), Department of Pediatrics, Karolinska Institutet, Stockholm, Sweden.
    Kaldo, Viktor
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Internet delivered cognitive behavior therapy for antenatal depression: A randomised controlled trial2017In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 221, p. 56-64Article in journal (Refereed)
    Abstract [en]

    Major depression occurs in 5-10% of pregnancies and is associated with many negative effects for mother and child, yet treatment options are scarce. To our knowledge, this is the first published randomised controlled trial on Internet delivered Cognitive Behavior Therapy (ICBT) for this group.

    Objective: To test the efficacy of a pregnancy adapted version of an existing 10-week ICBT-program for depression as well as assessing acceptability and adherence.

    Design: Randomised controlled trial.

    Setting: Online and telephone.

    Population or sample: Self-referred pregnant women (gestational week 10-28 at intake) currently suffering from major depressive disorder.

    Methods: 42 pregnant women (gestational week 12-28) with major depression were randomised to either treatment as usual (TAU) provided at their antenatal clinic or to ICBT as an add-on to usual care.

    Main outcome measures: The primary outcome was depressive symptoms measured with the Montgomery-Asberg depression rating scale-self report (MADRS-S). The Edinburgh Postnatal Depression Scale and measures of anxiety and sleep were used. Credibility, satisfaction, adherence and utilization were also assessed.

    Results: The ICBT group had significantly lower levels of depressive symptoms post treatment (p < 0.001, Hedges g = 1.21) and were more likely to be responders (i.e. achieve a statistically reliable improvement) (RR = 0.36; p = 0.004). Measures of treatment credibility, satisfaction, utilization, and adherence were comparable to implemented ICBT for depression.

    Limitations: Small sample size and no long-term evaluation.

    Conclusion: Pregnancy adapted ICBT for antenatal depression is feasible, acceptable and efficacious. These results need to be replicated in larger trials to validate these promising findings.

  • 8.
    Holländare, Fredrik
    Örebro University, School of Health and Medical Sciences.
    Managing depression via the Internet: self-report measures, treatment & relapse prevention2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Cognitive behaviour therapy (CBT) is an effective treatment for depression but access is limited. One way of increasing access is to offer CBT via the Internet. In Study I, guided Internet-based CBT was found to have a large effect on depressive symptoms compared to taking part in an online discussion group. Approximately two hours were spent on guiding each patient and the large effect found differs from previous studies that showed smaller effects, probably due to lack of guidance. The intervention had no effect on the participants’ quality of life but significantly decreased their level of anxiety.

    Internet-based versions of self-report measures can be more practical and efficient than paper versions. However, before implementation, evidence of psychometrical equivalence to the paper versions should be available. This was tested in Studies II and III for the Montgomery-Åsberg Depression Rating Scale – Self-rated (MADRS-S) and the Beck Depression Inventory – Second Edition (BDI-II). When the full scales were investigated, equivalent psychometric properties were found in the two versions of the MADRS-S and BDI-II. However, in the Internet-version of the BDI-II, a lower score was found for the question about suicidality and the difference was statistically significant. Although the difference was small, this indicates that suicidality might be underestimated when using the Internet-based BDI-II.

    As the long-term prognosis after treatment for depression is poor, in Study IV we investigated the possibility of delivering CBT-based relapse prevention via the Internet. The results revealed that fewer participants in the intervention group experienced a relapse compared to the control group and that the time spent on guiding each participant was approximately 2.5 hours. A trend towards a higher remission rate was found in the CBT group at the six-month follow-up and a reduction of depressive symptoms was associated with a lowered risk of relapse. CBT-based relapse prevention via the Internet can potentially be made available to large numbers of patients, thus improving their prognosis.

    The Internet increases the possibilities for health care providers in the management of depression.

    List of papers
    1. Internet-based self-help for depression: randomised controlled trial
    Open this publication in new window or tab >>Internet-based self-help for depression: randomised controlled trial
    Show others...
    2005 (English)In: British Journal of Psychiatry, ISSN 0007-1250, E-ISSN 1472-1465, Vol. 187, p. 456-461Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND:

    Major depression can be treated by means of cognitive-behavioural therapy, but as skilled therapists are in short supply there is a need for self-help approaches. Many individuals with depression use the internet for discussion of symptoms and to share their experience.

    AIMS:

    To investigate the effects of an internet-administered self-help programme including participation in a monitored, web-based discussion group, compared with participation in web-based discussion group only.

    METHOD:

    A randomised controlled trial was conducted to compare the effects of internet-based cognitive-behavioural therapy with minimal therapist contact (plus participation in a discussion group) with the effects of participation in a discussion group only.

    RESULTS:

    Internet-based therapy with minimal therapist contact, combined with activity in a discussion group, resulted in greater reductions of depressive symptoms compared with activity in a discussion group only (waiting-list control group). At 6 months' follow-up, improvement was maintained to a large extent.

    CONCLUSIONS:

    Internet-delivered cognitive cognitive-behavioural therapy should be pursued further as a complement or treatment alternative for mild-to-moderate depression.

    Keywords
    Adult, Cognitive Therapy/*methods, Depressive Disorder/*therapy, Female, Follow-Up Studies, Humans, Internet, Male, Middle Aged, Patient Compliance, Psychiatric Status Rating Scales, Self Care/*methods, Self-Help Groups, Telemedicine/*methods, Treatment Outcome
    National Category
    Medical and Health Sciences
    Research subject
    Medicine
    Identifiers
    urn:nbn:se:oru:diva-3578 (URN)10.1192/bjp.187.5.456 (DOI)16260822 (PubMedID)
    Available from: 2008-12-09 Created: 2008-12-09 Last updated: 2017-12-14Bibliographically approved
    2. Can the BDI-II and MADRS-S be transferred to online use without affecting their psychometric properties?
    Open this publication in new window or tab >>Can the BDI-II and MADRS-S be transferred to online use without affecting their psychometric properties?
    2008 (English)In: Electronic Journal of Applied Psychology, Vol. 4, no 2, p. 63-65Article in journal (Refereed) Published
    Abstract [en]

    The Internet has brought new possibilities to psychological assessment. Although there are several advantages to online assessment, there are also challenges. The aim of this study is to test the psychometric equivalence of the traditional paper versions and Internet adapted versions of the BDI-II and the MADRS-S. The 71 participants were recruited at a university campus, and filled out the BDI-II and MADRS-S on both Internet and paper. They were randomized to complete either the Internet versions or the paper versions first, and then complete the other version on the next day. For both the BDI-II and the MADRS-S the Chronbach’s alpha levels were similar in the two mediums of administration. No significant differences were found between the paper versions and the Internet versions and the scores from the two differing mediums correlated highly for both questionnaires. Therefore, it was concluded that the psychometric properties of the BDI-II and the MADRS-S remained unchanged after transformation to online use.

    Keywords
    Internet, questionnaires
    National Category
    Psychiatry
    Research subject
    Medicine
    Identifiers
    urn:nbn:se:oru:diva-16409 (URN)
    Available from: 2011-07-29 Created: 2011-07-29 Last updated: 2017-10-17Bibliographically approved
    3. A comparison of psychometric properties between internet and paper versions of two depression instruments (BDI-II and MADRS-S) administered to clinic patients
    Open this publication in new window or tab >>A comparison of psychometric properties between internet and paper versions of two depression instruments (BDI-II and MADRS-S) administered to clinic patients
    2010 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 12, no 5, article id e49Article in journal (Refereed) Published
    Abstract [en]

    Background: Self-report measures can guide clinical decisions and are useful when evaluating treatment outcomes. However, many clinicians do not use self-report measures systematically in their clinical practice. Internet-based questionnaires could facilitate administration, but the psychometric properties of the online version of an instrument should be explored before implementation. The recommendation from the International Test Commission is to test the psychometric properties of each questionnaire separately.

    Objective: Our objective was to compare the psychometric properties of paper-and-pencil versions and Internet versions of two questionnaires measuring depressive symptoms.

    Methods: The 87 participating patients were recruited from primary care and psychiatric care within the public health care system in Sweden. Participants completed the Beck Depression Inventory (BDI-II) and the Montgomery- Åsberg Depression Rating Scale—Self-rated (MADRS-S), both on paper and on the Internet. The order was randomized to control for order effects. Symptom severity in the sample ranged from mild to severe depressive symptoms.

    Results: Psychometric properties of the two administration formats were mostly equivalent. The internal consistency was similar for the Internet and paper versions, and significant correlations were found between the formats for both MADRS-S (r= .84) and the BDI-II (r= .89). Differences between paper and Internet total scores were not statistically significant for either questionnaire nor for the MADRS-S question dealing with suicidality (item 9) when analyzed separately. The score on the BDI-II question about suicidality (item 9) was significantly lower when administered via the Internet compared with the paper score, but the difference was small (effect size, Cohen’s [d] = 0.14). There were significant main effects for order of administration on both questionnaires and significant interaction effects between format and order. This should not, however, pose a problem in clinical use as long as the administration format is not changed when repeated measurements are made.

    Conclusions: The MADRS-S can be transferred to online use without affecting the psychometric properties in a clinically meaningful way. The full BDI-II also seems to retain its properties when transferred; however, the item measuring suicidality in the Internet version needs further investigation since it was associated with a lower score in this study. The use of online questionnaires offers clinicians a more practical way of measuring depressive symptoms and has the potential to save resources.

    Place, publisher, year, edition, pages
    Toronto, Canada: Journal of Medical Internet Research, 2010
    Keywords
    Questionnaires, psychometrics, Internet, depression
    National Category
    Medical and Health Sciences Psychiatry
    Research subject
    Medicine
    Identifiers
    urn:nbn:se:oru:diva-16410 (URN)10.2196/jmir.1392 (DOI)000285714300003 ()21169165 (PubMedID)2-s2.0-78651312500 (Scopus ID)
    Available from: 2011-07-29 Created: 2011-07-29 Last updated: 2018-04-23Bibliographically approved
    4. Randomized trial of Internet-based relapse prevention for partially remitted depression
    Open this publication in new window or tab >>Randomized trial of Internet-based relapse prevention for partially remitted depression
    Show others...
    2011 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 124, no 4, p. 285-294Article in journal (Refereed) Published
    Abstract [en]

    Objective:

    To investigate whether Internet-based cognitive behaviour therapy (CBT) can prevent relapse in persons with partially remitted major depression after previous treatment.

    Method:

    Seventy-one women and 13 men (N= 84) with partially remitted major depression after treatment were randomly assigned to either 10 weeks of Internet-based CBT or to a control group. Self-help material was used in combination with e-mail contact with a personal therapist. Monthly self-ratings of depressive symptoms were made, and diagnostic interviews were conducted before and after the treatment period, as well as 6 months later.

    Results:

    Significantly fewer participants in the CBT group experienced relapse (4⁄38 or 10.5%) compared with those in the control group (14⁄37 or 37.8%). The difference in relapse rates between groups occurred early in the study period and was still apparent after 6 months. A trend towards a larger reduction in depressive symptoms was observed at post-treatment in the participants who received CBT compared with controls. Reduction in depressive symptoms reduced the risk of relapse. A trend towards a higher remission rate was found in the CBT group at the 6 month follow-up.

    Conclusion:

    Internet-based CBT seems promising in preventing relapse in persons with partially remitted major depression after previous treatment.

    Place, publisher, year, edition, pages
    Wiley-Blackwell, 2011
    Keywords
    Depression, Internet, Relapse prevention
    National Category
    Psychiatry
    Research subject
    Medicine
    Identifiers
    urn:nbn:se:oru:diva-16408 (URN)10.1111/j.1600-0447.2011.01698.x (DOI)000294872900006 ()21401534 (PubMedID)2-s2.0-80052803455 (Scopus ID)
    Available from: 2011-07-29 Created: 2011-07-29 Last updated: 2018-05-03Bibliographically approved
  • 9.
    Holländare, Fredrik
    et al.
    Örebro University, School of Health and Medical Sciences.
    Andersson, Gerhard
    Dept Clin Neurosci, Sect Internet Psychiat, Karolinska Inst, Stockholm, Sweden; Linköping Univ, Linköping, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences.
    A comparison of psychometric properties between internet and paper versions of two depression instruments (BDI-II and MADRS-S) administered to clinic patients2010In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 12, no 5, article id e49Article in journal (Refereed)
    Abstract [en]

    Background: Self-report measures can guide clinical decisions and are useful when evaluating treatment outcomes. However, many clinicians do not use self-report measures systematically in their clinical practice. Internet-based questionnaires could facilitate administration, but the psychometric properties of the online version of an instrument should be explored before implementation. The recommendation from the International Test Commission is to test the psychometric properties of each questionnaire separately.

    Objective: Our objective was to compare the psychometric properties of paper-and-pencil versions and Internet versions of two questionnaires measuring depressive symptoms.

    Methods: The 87 participating patients were recruited from primary care and psychiatric care within the public health care system in Sweden. Participants completed the Beck Depression Inventory (BDI-II) and the Montgomery- Åsberg Depression Rating Scale—Self-rated (MADRS-S), both on paper and on the Internet. The order was randomized to control for order effects. Symptom severity in the sample ranged from mild to severe depressive symptoms.

    Results: Psychometric properties of the two administration formats were mostly equivalent. The internal consistency was similar for the Internet and paper versions, and significant correlations were found between the formats for both MADRS-S (r= .84) and the BDI-II (r= .89). Differences between paper and Internet total scores were not statistically significant for either questionnaire nor for the MADRS-S question dealing with suicidality (item 9) when analyzed separately. The score on the BDI-II question about suicidality (item 9) was significantly lower when administered via the Internet compared with the paper score, but the difference was small (effect size, Cohen’s [d] = 0.14). There were significant main effects for order of administration on both questionnaires and significant interaction effects between format and order. This should not, however, pose a problem in clinical use as long as the administration format is not changed when repeated measurements are made.

    Conclusions: The MADRS-S can be transferred to online use without affecting the psychometric properties in a clinically meaningful way. The full BDI-II also seems to retain its properties when transferred; however, the item measuring suicidality in the Internet version needs further investigation since it was associated with a lower score in this study. The use of online questionnaires offers clinicians a more practical way of measuring depressive symptoms and has the potential to save resources.

  • 10.
    Holländare, Fredrik
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Psychiatric Research Center, Örebro University Hospital, Region Örebro County, Örebro, Sweden.
    Anthony, Susanne A.
    School of Law, Psychology & Social Work, Örebro University, Örebro, Sweden.
    Randestad, Mia
    School of Law, Psychology & Social Work, Örebro University, Örebro, Sweden.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Carlbring, Per
    Stockholm Univ, Dept Psychology, Stockholm, Sweden.
    Andersson, Gerhard
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Two-year outcome of internet-based relapse prevention for partially remitted depression2013In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 51, no 11, p. 719-722Article in journal (Refereed)
    Abstract [en]

    The objective of the study was to investigate the long-term effects of internet-based relapse prevention for sufferers of partially remitted depression. Eighty-four individuals with partially remitted unipolar depression were randomized to either internet-based CBT (iCBT) or to a control group. After the ten week intervention period the participants were followed for 24 months and diagnostic interviews conducted to detect relapse. The intervention and monthly self-ratings of depressive symptoms were administered via an internet-based platform that ensured secure communication with all participants. Significantly fewer participants in the iCBT group had experienced a relapse compared with those in the control group two years after the internet-based intervention. The relapse rate in the iCBT group was 13.7% (CI 95% = 2.5-24.9) and in the control group it was 60.9% (CI 95% = 44.8-77). Furthermore, a significantly larger proportion of the iCBT group experienced remission two years after the intervention compared with the control group. Internet-based CBT seems promising for preventing relapse in sufferers of partially remitted depression. (C) 2013 Elsevier Ltd. All rights reserved.

  • 11.
    Holländare, Fredrik
    et al.
    Örebro University, School of Health and Medical Sciences.
    Askerlund, Anna-Maria
    Örebro University, School of Law, Psychology and Social Work.
    Nieminen, Anna
    Örebro University, School of Law, Psychology and Social Work.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences.
    Can the BDI-II and MADRS-S be transferred to online use without affecting their psychometric properties?2008In: Electronic Journal of Applied Psychology, Vol. 4, no 2, p. 63-65Article in journal (Refereed)
    Abstract [en]

    The Internet has brought new possibilities to psychological assessment. Although there are several advantages to online assessment, there are also challenges. The aim of this study is to test the psychometric equivalence of the traditional paper versions and Internet adapted versions of the BDI-II and the MADRS-S. The 71 participants were recruited at a university campus, and filled out the BDI-II and MADRS-S on both Internet and paper. They were randomized to complete either the Internet versions or the paper versions first, and then complete the other version on the next day. For both the BDI-II and the MADRS-S the Chronbach’s alpha levels were similar in the two mediums of administration. No significant differences were found between the paper versions and the Internet versions and the scores from the two differing mediums correlated highly for both questionnaires. Therefore, it was concluded that the psychometric properties of the BDI-II and the MADRS-S remained unchanged after transformation to online use.

  • 12.
    Holländare, Fredrik
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Eriksson, Annsofi
    Örebro University, Örebro, Sweden.
    Lövgren, Lisa
    Örebro University, Örebro, Sweden.
    Humble, Mats B.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Internet-Based Cognitive Behavioral Therapy for Residual Symptoms in Bipolar Disorder Type II: A Single-Subject Design Pilot Study2015In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 4, no 2, article id e44Article in journal (Refereed)
    Abstract [en]

    Background: Bipolar disorder is a chronic condition with recurring episodes that often lead to suffering, decreased functioning, and sick leave. Pharmacotherapy in the form of mood stabilizers is widely available, but does not eliminate the risk of a new depressive or (hypo) manic episode. One way to reduce the risk of future episodes is to combine pharmacological treatment with individual or group psychological interventions. However, access to such interventions is often limited due to a shortage of trained therapists. In unipolar depression there is now robust evidence of the effectiveness of Internet-based psychological interventions, usually comprising psychoeducation and cognitive behavioral therapy (CBT). Internet-based interventions for persons suffering from bipolar disorder could increase access to psychological treatment.

    Objective: The aim of this study was to investigate the feasibility of an Internet-based intervention, as well as its effect on residual depressive symptoms in persons diagnosed with bipolar disorder type II (BP-II). The most important outcomes were depressive symptoms, treatment adherence, and whether the patient perceived the intervention as helpful.

    Methods: A total of 7 patients diagnosed with bipolar disorder type II at a Swedish psychiatric outpatient clinic were offered the opportunity to participate. Of the 7 patients, 3 (43%) dropped out before treatment began, and 4 (57%) were treated by means of an online, Internet-based intervention based on CBT (iCBT). The intervention was primarily aimed at psychoeducation, treatment of residual depressive symptoms, emotion regulation, and improved sleep. All patients had ongoing pharmacological treatment at recruitment and established contact with a psychiatrist. The duration of BP-II among the treated patients was between 6 and 31 years. A single-subject design was used and the results of the 4 participating patients were presented individually.

    Results: Initiating treatment was perceived as too demanding under current life circumstances for 3 patients who consequently dropped out during baseline assessment. Self-ratings using the Montgomery-sberg Depression Rating Scale-Self-rated (MADRS-S) showed symptom reduction in 3 (75%) of the 4 treated cases during iCBT. In the evaluation of the treatment, 2 patients reported that they perceived that the treatment had reduced symptoms a little, 1 that it had reduced symptoms very much, and 1 not at all. Treatment adherence (ie, module completion) was fairly high in 3 cases. In general, the modules were perceived as fairly helpful or very helpful by the patients. In one case, there was a reliable change-according to the Reliable Change Index-in self-rated symptoms of depression and perseverative thinking.

    Conclusions: The treatment seemed to have acceptable feasibility. The iCBT intervention could be an effective way to treat residual symptoms in some patients with bipolar disorder type II. This should be investigated in a larger study.

  • 13.
    Holländare, Fredrik
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Psychiatric Research Centre, Örebro University Hospital, Örebro, Sweden.
    Gustafsson, Sanna Aila
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Berglind, Maria
    School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden.
    Grape, Frida
    School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden.
    Carlbring, Per
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Andersson, Gerhard
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Hadjistavropoulos, Heather
    Department of Psychology, University of Regina, Regina, Canada.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Therapist behaviours in internet-based cognitive behaviour therapy (ICBT) for depressive symptoms2016In: Internet Interventions, ISSN 2214-7829, Vol. 3, p. 1-7Article in journal (Refereed)
    Abstract [en]

    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.

  • 14.
    Holländare, Fredrik
    et al.
    Örebro University, School of Health and Medical Sciences.
    Johnsson, Susanne
    Örebro University, School of Law, Psychology and Social Work.
    Randestad, Mia
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Carlbring, Per
    Umeå universitet, Umeå, Sweden.
    Andersson, Gerhard
    Linköpings universitet, Linköping, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences.
    Randomized trial of Internet-based relapse prevention for partially remitted depression2011In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 124, no 4, p. 285-294Article in journal (Refereed)
    Abstract [en]

    Objective:

    To investigate whether Internet-based cognitive behaviour therapy (CBT) can prevent relapse in persons with partially remitted major depression after previous treatment.

    Method:

    Seventy-one women and 13 men (N= 84) with partially remitted major depression after treatment were randomly assigned to either 10 weeks of Internet-based CBT or to a control group. Self-help material was used in combination with e-mail contact with a personal therapist. Monthly self-ratings of depressive symptoms were made, and diagnostic interviews were conducted before and after the treatment period, as well as 6 months later.

    Results:

    Significantly fewer participants in the CBT group experienced relapse (4⁄38 or 10.5%) compared with those in the control group (14⁄37 or 37.8%). The difference in relapse rates between groups occurred early in the study period and was still apparent after 6 months. A trend towards a larger reduction in depressive symptoms was observed at post-treatment in the participants who received CBT compared with controls. Reduction in depressive symptoms reduced the risk of relapse. A trend towards a higher remission rate was found in the CBT group at the 6 month follow-up.

    Conclusion:

    Internet-based CBT seems promising in preventing relapse in persons with partially remitted major depression after previous treatment.

  • 15.
    Holländare, Fredrik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Tillfors, Maria
    Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden; Centre for Health and Medical Psychology, Örebro University, Örebro, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Björk, Tabita
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Are quantity and content of psychiatric interventions associated with suicide? A case-control study of a Swedish sample2020In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 20, no 1, article id 13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Research is required to identify those psychiatric interventions with a protective effect against suicide. The overarching aim of the current study was to examine whether completed suicide in psychiatric patients in a Swedish population was associated with the quantity and nature of previous medical and psychosocial treatment interventions.

    METHODS: This retrospective case-control study (n = 308) compared a group of deceased psychiatric patients with matched controls. For every case of suicide, a control was found within psychiatry that matched according to sex, age, and primary psychiatric diagnosis. A stepwise forward logistic regression model with suicide as the dependent outcome variable was used.

    RESULTS: Receiving pharmacotherapy combined with psychotherapy [OR: 0.44 (95% CI: 0.226-0.876), p = 0.019] and a higher number of outpatient visits in psychiatry [OR: 0.99 (95% CI: 0.982-0.999), p = 0.028] were negatively associated with suicide. These associations were still significant after controlling for previous serious suicide attempts and somatic comorbidity.

    CONCLUSIONS: Frequent visits and pharmacotherapy combined with psychotherapy seem to be important for preventing suicide in psychiatric patients. The reasons for not receiving such therapy are important issues for further study.

  • 16.
    Norell-Clarke, A.
    et al.
    Centre for Research on Child and Adolescent Mental Health, Karlstad University, Karlstad, Sweden.
    Tillfors, Maria
    Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden.
    Jansson-Fröjmark, Markus
    Centre for Psychiatry Research,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Centre.
    Engström, Ingemar
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Does Mid-Treatment Insomnia Severity Mediate between Cognitive Behavioural Therapy for Insomnia and Post-Treatment Depression?: An Investigation in a Sample with Comorbid Insomnia and Depressive Symptomatology2018In: Behavioural and Cognitive Psychotherapy, ISSN 1352-4658, E-ISSN 1469-1833, Vol. 46, no 6, p. 726-737Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Recent treatment studies with cognitive behavioural therapy for insomnia (CBT-I) have demonstrated effects on both sleep problems and depression. Two previous studies have indicated that the beneficial effect from CBT-I on depression may come through improved sleep, although insomnia severity during treatment had not previously been investigated as a mediator.

    AIMS: Our aim was to investigate if insomnia severity during treatment mediated between CBT-I and depression severity after treatment, in a sample with co-morbid insomnia and depressive symptomology. We also examined whether depressive severity during treatment mediated between CBT-I and insomnia after treatment.

    METHOD: The participants were recruited from advertisements and fulfilled criteria for insomnia diagnosis, and had depressive symptomatology (Beck Depression Inventory-second edition: BDI-II > 13). Two-thirds of the participants were diagnosed with major depressive disorder. The participants received four biweekly group sessions of CBT-I or relaxation training (active control). Insomnia severity (Insomnia Severity Index) and depressive severity (BDI-II) were measured at baseline, mid-treatment, post-treatment and 6-month follow-up. The mid-treatment measures were used as mediators.

    RESULTS: Mediational analyses demonstrated a significant reciprocal relationship between insomnia severity and depressive severity throughout CBT-I, although mid-treatment insomnia had a stronger effect on depression than mid-treatment depression had on insomnia. The results were similar for both post-treatment and follow-up.

    DISCUSSION: Some improvement in depressive severity after CBT-I is explained by improved sleep. The findings emphasize the importance of making comorbid insomnia a treatment focus in its own right.

  • 17.
    Norell-Clarke, Annika
    et al.
    Centre for Research on Child and Adolescent Mental Health, Karlstad University, Karlstad, Sweden.
    Jansson-Fröjmark, Markus
    Örebro University, School of Law, Psychology and Social Work. Department of Psychology, Stockholm University, Stockholm, Sweden.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Holländare, Fredrik
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. University Health Care Research Centre, Örebro, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. University Health Care Research Centre, Örebro, Sweden.
    Group cognitive behavioural therapy for insomnia: Effects on sleep and depressive symptomatology in a sample with comorbidity2015In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 74, p. 80-93Article in journal (Refereed)
    Abstract [en]

    Aim: To investigate the effects of group CBT for insomnia (CBT-I) on insomnia and depressive symptomatology in a comorbid sample through a randomised controlled trial with a 6 month follow-up.

    Methods: 64 participants were recruited through advertisements and randomised to receive CBT-I or an active control (relaxation training: RT) during four group sessions. Insomnia Severity Index and BDI-II were the primary outcome measures, assessed pre-treatment, post-treatment and at 6 month follow-up. Insomnia and depressive diagnoses, and functional impairment were assessed before and after treatment, whereas sleep diary data was gathered continuously from one week before treatment until after treatment.

    Results: CBT-I was more efficient than RT in reducing insomnia severity and equally effective in reducing depressive symptoms, although CBT-I was associated with a higher proportion of remitted persons than RT, regarding both insomnia and depression diagnoses. Also, CBT-I was associated with less functional impairment, shorter sleep onset latency and wake after sleep onset but both treatments had equal improvements of sleep quality, early morning awakenings and total sleep time.

    Conclusion: Group CBT-I is an efficient form of insomnia-treatment for people with insomnia comorbid with depressive symptomatology. The mixed results regarding depression outcomes warrants replication and further studies into treatment mechanisms. (C) 2015 Elsevier Ltd. All rights reserved.

  • 18.
    Norell-Clarke, Annika
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    TIllfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Jansson-Fröjmark, Markus
    Örebro University, School of Law, Psychology and Social Work. Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden.
    Holländare, Fredrik
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    An investigation of cognitive processes as outcomes and mediators of CBT-I for insomnia in a sample with insomnia and depressionManuscript (preprint) (Other academic)
    Abstract [en]

    Aim: CBT for insomnia (CBT-I) seems to affect both insomnia and depression in comorbid samples but there is a gap in the knowledge about how the treatment works. The aim was to gain a greater understanding of the relationship between insomnia-specific cognitive processes, insomnia, depressive symptoms and CBT-I in sample with insomnia comorbid with depressive problems.

    Methods: 64 participants were recruited through advertisements and randomised to receive either CBT-I or an active control (relaxation training: RT) in groups during four sessions over seven weeks. Insomnia, depressive severity, and cognitive processes were measured pre-, mid- and post-treatment.

    Results: All cognitive processes: sleep-related worry, dysfunctional beliefs, somatic arousal, selective attention and monitoring, and safety behaviours, lowered over the course of treatment. CBT-I was associated with greater reductions of safety behaviours and dysfunctional beliefs about sleep compared to RT. Mid-treatment dysfunctional beliefs aboutsleep mediated between CBT-I and outcomes on insomnia and depression severity.

    Conclusion: Dysfunctional beliefs may be a transdiagnostic process of both insomnia and depression. Clinical implications and further directions are discussed.

  • 19.
    Norell-Clarke, Annika
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Jansson-Fröjmark, Markus
    Örebro University, School of Law, Psychology and Social Work. Stockholm University, Stockholm, Sweden.
    Holländare, Fredrik
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Psychiat Res Ctr, Örebro, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Psychiat Res Ctr, Örebro, Sweden.
    An investigation of dysfunctional beliefs as a mediator of cognitive behavioural therapy for insomnia in a sample with insomnia and depression2014In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, Vol. 23, p. 217-217Article in journal (Other academic)
  • 20.
    Norell-Clarke, Annika
    et al.
    Centre for Research on Child and Adolescent Mental Health, Karlstad University, Karlstad, Sweden.
    Tillfors, Maria
    Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden.
    Jansson-Fröjmark, Markus
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Centre, Region Örebro County, Örebro, Sweden.
    Engström, Ingemar
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Region Örebro County, Örebro, Sweden.
    How does cognitive behavioral therapy for insomnia work?: An investigation of cognitive processes and time in bed as outcomes and mediators in a sample with insomnia and depressive symptomatology2017In: International Journal of Cognitive Therapy, ISSN 1937-1209, E-ISSN 1937-1217, Vol. 10, no 4, p. 304-329Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to gain a greater understanding of the five cognitive processes from the cognitive model of insomnia, negative automatic thoughts, and time in bed as outcomes and potential mediators of cognitive behavioral therapy for insomnia (CBT-I), in a sample with insomnia and depressive symptomatology. Sixty-four participants were randomized to receive either CBT-I or an active control (relaxation training: RT) in groups during four biweekly sessions. Insomnia, depressive severity, and the potential processes of change were measured pre-, mid-, and post-treatment. CBT-I was associated with greater reductions of dysfunctional beliefs about sleep, sleep-related safety behaviors, and time in bed compared to RT. Mid-treatment dysfunctional beliefs about sleep was the only process that mediated between CBT-I and outcomes on insomnia and depressive severity, respectively. The relationships were reciprocal. Dysfunctional beliefs about sleep may be a transdiagnostic process of both insomnia and depression.

  • 21.
    Sellin, T.
    et al.
    University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Psychiatric ward consumption before suicide: A case-control study2017In: European psychiatry, ISSN 0924-9338, E-ISSN 1778-3585, Vol. 41, p. S295-S296, article id EW0559Article in journal (Other academic)
  • 22.
    Wurm, Matilda
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Klein Strandberg, Ester
    Örebro University, School of Law, Psychology and Social Work.
    Lorenz, Caroline
    Buhrman, Monica
    Uppsala University, Uppsala, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Chronic pain and emotional problems: A replicated single case study of an internet based therapist guided treatment based on CBT principles and the Unified Protocol of transdiagnostic treatments2016Conference paper (Other academic)
  • 23.
    Wurm, Matilda
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Klein Strandberg, Ester
    Örebro University, School of Law, Psychology and Social Work.
    Lorenz, Caroline
    Private person.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Buhrman, Monica
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Centre, Region Örebro County, Örebro, Sweden.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Internet delivered transdiagnostic treatment with telephone support for pain patients with emotional comorbidity: a replicated single case study2017In: Internet Interventions, ISSN 2214-7829, Vol. 10, p. 54-64Article in journal (Refereed)
    Abstract [en]

    In pain patients, comorbid emotional problems have been linked to negative outcomes, including suboptimaltreatment gains. Developing parsimonious and accessible treatment options is therefore important. The overarchingaim of this study was to test an internet delivered therapist guided transdiagnostic treatment withtelephone support. An adapted version of the Unified Protocol for Transdiagnostic Treatments of EmotionalDisorders was used as an intervention for pain patients with residual pain problems and comorbid emotionalproblems after having received a multimodal pain rehabilitation. The study used a replicated AB single caseexperimental design (N =5; 3 females). Outcome measures were depressive and general anxiety symptoms, painintensity, pain coping problems, and diagnostic status. Feasibility measures (completion and compliance) andpatient satisfaction were also assessed. Scores on Nonoverlap of All Pairs (NAP) indicate a decrease of anxiety forthree participants and a decrease of depression for four participants. Decreases were small and did not alwaysreach statistical significance. Also, Tau-U scores could only confirm a reliable trend for one participant. Two outof four patients who were diagnosed with psychiatric disorders before treatment did no longer fulfill diagnosticcriteria posttreatment. No improvements could be seen on pain problems. The treatment was feasible and patientsatisfaction was high. Hence, while an internet delivered transdiagnostic treatment with telephone support maybe a feasible and accepted secondary intervention for pain patients with comorbid emotional problems, theeffects are unclear. The gap between high patient satisfaction and small changes in symptomatology should beexplored further.

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