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  • 1.
    Andersson, Erik
    et al.
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Wikström, Maja
    Karolinska Institutet.
    Elveling, Elin
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Kaldo, Viktor
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    Cost-effectiveness of internet-based cognitive behavior therapy for obsessive-compulsive disorder: results from a randomized controlled trial2015In: Journal of Obsessive-Compulsive and Related Disorders, ISSN 2211-3649, E-ISSN 2211-3657, Vol. 4, p. 47-53Article in journal (Refereed)
    Abstract [en]

    Obsessive-compulsive disorder (OCD) is a common and disabling disorder. Although evidence-based psychological treatments exists, such as cognitive behavior therapy (CBT), the cost-effectiveness of CBT has not been properly investigated. In this trial, we used health economic data from a recently conducted randomized controlled trial, where 101 OCD patients were allocated to either internet-based CBT (ICBT) or control condition (online support therapy). We analyzed treatment effectiveness in relation to costs, using both a societal- (including all direct and indirect costs) and a health care unit perspective (including only the direct treatment costs). Bootstrapped net benefit regression analyses were also conducted, comparing the difference in costs and effects between ICBT and control condition, with different willingness-to-pay scenarios. Results showed that ICBT produced one additional remission for an average societal cost of $931 and this figure was even lower ($672) when narrowing the perspective to treatment costs only. The cost-utility analysis also showed that ICBT generated one additional QALY to an average price of $7186 from a societal perspective and $4800 when just analyzing the treatment costs. We conclude that ICBT is a cost-effective treatment and the next step in this line of research is to compare the cost-effectiveness of ICBT with face-to-face CBT. (C) 2014 Elsevier Inc. All rights reserved.

  • 2.
    Andersson, Erik
    et al.
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Enander, Jesper
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Lindefors, Nils
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    Predictors and moderators of Internet-based cognitive behavior therapy for obsessive-compulsive disorder: Results from a randomized trial2015In: Journal of Obsessive-Compulsive and Related Disorders, ISSN 2211-3649, E-ISSN 2211-3657, Vol. 4, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Internet-based cognitive behavior therapy (ICBT) for obsessive-compulsive disorder (OCD) has shown efficacy in randomized trials but many patients do not respond to the treatment, we therefore need to find predictors and moderators of treatment response. In this study, we analyzed predictors of ICBT response using both post-treatment as well as 24-month outcome data. As half of the participants were randomized to receive an Internet-based booster program as an adjunct to ICBT, we also investigated moderators of ICBT with or without booster. Results showed that more severe baseline OCD symptoms predicted worse end state outcome but also higher degree of change. Furthermore, high degree of working alliance predicted better outcome but patients with primary disgust emotions had worse treatment effects. The moderator analysis also indicated that scoring high on the obsessing subscale on the Obsessive-Compulsive Inventory-Revised predicted worse treatment outcome in the booster group. In conclusion, there are some possible predictors and moderators of ICBT for OCD but more research is needed with larger and clinically representative samples. (C) 2014 Elsevier Inc. All rights reserved.

  • 3.
    Andersson, Erik
    et al.
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Mattson, Simon
    Karolinska Institutet.
    Enander, Jesper
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Kaldo, Viktor
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    Cost-effectiveness of an internet-based booster program for patients with obsessive-compulsive disorder: Results from a randomized controlled trial2015In: Journal of Obsessive-Compulsive and Related Disorders, ISSN 2211-3649, E-ISSN 2211-3657, Vol. 4, p. 14-19Article in journal (Refereed)
    Abstract [en]

    Cognitive behavior therapy (CBT) is an effective treatment for OCD when delivered face-to-face, in group-format and also via the internet. However, despite overall large effect sizes, a considerable amount of the patients relapse. One intervention that has the potential to reduce these relapse rates is booster programs, but if booster program is a cost-effective method of preventing relapse is still unknown. We used health economical data from a recent randomized controlled trial, where patients who had undergone an internet-based CBT were randomly allocated to receive an additional booster program. Assessment points were 4-, 7-, 12- and 24-month. Health economical data were primarily analyzed using a societal perspective. Results showed that the booster program was effective in preventing relapse, and the cost of one avoided relapse was estimated to $1066-1489. Cost-effectiveness acceptability curves showed that the booster program had a 90% probability of being cost-effective given a willingness to pay of $1000-1050 the first year, but this figure grew considerably after two years ($2500-5500). We conclude that internet-based booster programs are probably a cost-effective alternative within one-year time frame and that more treatment may be needed to maintain adequate cost-effectiveness up to two years. (C) 2014 Elsevier Inc. All rights reserved.

  • 4.
    El Alaoui, Samir
    et al.
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Hesser, Hugo
    Linköping University.
    Kraepelien, Martin
    Karolinska Institutet.
    Andersson, Evelyn
    Karolinska Institutet.
    Ruck, Christian
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Ljotsson, Brjann
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Effectiveness of Internet-Based Cognitive-Behavior Therapy for Social Anxiety Disorder in Clinical Psychiatry2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 5, p. 902-914Article in journal (Refereed)
    Abstract [en]

    Objective: Internet-based cognitive-behavioral therapy (ICBT) has received increased attention as an innovative approach to improve access to evidence-based psychological treatments. Although the efficacy of ICBT for social anxiety disorder has been established in several studies, there is limited knowledge of its effectiveness and application in clinical psychiatric care. The purpose of this study was to evaluate the effectiveness of ICBT in the treatment of social anxiety disorder and to determine the significance of patient adherence and the clinic's years of experience in delivering ICBT. Method: A longitudinal cohort study was conducted using latent growth curve modeling of patients (N = 654) treated with ICBT at an outpatient psychiatric clinic between 2009 and 2013. The primary outcome measure was the Liebowitz Social Anxiety Scale-Self-Rated. Results: Significant reductions in symptoms of social anxiety were observed after treatment (effect size d = 0.86, 99% CI [0.74, 0.98]). Improvements were sustained at 6-month follow-up (d = 1.15, 99% CI [0.99, 1.32]). Patient adherence had a positive effect on the rate of improvement. A positive association between the clinic's years of experience with ICBT and treatment outcome was also observed. Conclusions: This study suggests that ICBT for social anxiety disorder is effective when delivered within the context of a unit specialized in Internet-based psychiatric care and may be considered as a treatment alternative for implementation within the mental health care system.

  • 5.
    El Alaoui, Samir
    et al.
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Andersson, Evelyn
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Lindefors, Nils
    Karolinska Institutet.
    Predictors of Symptomatic Change and Adherence in Internet-Based Cognitive Behaviour Therapy for Social Anxiety Disorder in Routine Psychiatric Care2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 4, article id e0124258Article in journal (Refereed)
    Abstract [en]

    Objective A 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. Method The 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. Results Higher 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. Conclusions Results 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.

  • 6.
    Hedman, Erik
    et al.
    Karolinska Institutet.
    El Alaoui, Samir
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Andersson, Erik
    Karolinska Institutet.
    Ruck, Christian
    Karolinska Institutet.
    Ghaderi, Ata
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Lekander, Mats
    Karolinska Institutet;Stockholm University.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Ljotsson, Brjann
    Karolinska Institutet.
    Clinical effectiveness and cost-effectiveness of Internet- vs. group-based cognitive behavior therapy for social anxiety disorder: 4-Year follow-up of a randomized trial2014In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 59, p. 20-29Article in journal (Refereed)
    Abstract [en]

    Social anxiety disorder (SAD) is common, debilitating and associated with high societal costs. The disorder can be effectively treated with Internet-based cognitive behavior therapy (ICBT), but no previous study has investigated the long-term clinical or health economic effects of ICBT for SAD in comparison to an evidence-based control treatment. The aim of the study was to investigate the clinical effectiveness and cost-effectiveness of ICBT compared to cognitive behavioral group therapy (CBGT) four years post-treatment. We conducted a 4-year follow-up study of participants who had received ICBT or CBGT for SAD within the context of a randomized controlled non-inferiority trial. The cost-effectiveness analyses were conducted taking a societal perspective. Participants in both treatment groups made large improvements from baseline to 4-year follow-up on the primary outcome measure (d = 1.34-1.48) and the 95% CI of the mean difference on the primary outcome was well within the non-inferiority margin. ICBT and CBGT were similarly cost-effective and both groups reduced their indirect costs. We conclude that ICBT for SAD yields large sustainable effects and is at least as long-term effective as CBGT. Intervention costs of both treatments are offset by net societal cost reductions in a short time. (C) 2014 Elsevier Ltd. All rights reserved.

  • 7.
    Kaldo, Viktor
    et al.
    Karolinska Institutet.
    Jernelöv, Susanna
    Karolinska Institutet.
    Blom, Kerstin
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Brodin, Maria
    Karolinska Institutet.
    Jörgensen, Mia
    Karolinska Institutet.
    Kraepelien, Martin
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Guided internet cognitive behavioral therapy for insomnia compared to a control treatment - A randomized trial2015In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 71, p. 90-100Article in journal (Refereed)
    Abstract [en]

    Aim: To evaluate if internet-delivered Cognitive Behavioral Therapy for insomnia (ICBT-i) with brief therapist support outperforms an active control treatment. Method: Adults diagnosed with insomnia were recruited via media (n = 148) and randomized to either eight weeks of ICBT-i or an active internet-based control treatment. Primary outcome was the insomnia severity index (ISI) assessed before and after treatment, with follow-ups after 6 and 12 months. Secondary outcomes were use of sleep medication, sleep parameters (sleep diary), perceived stress, and a screening of negative treatment effects. Hierarchical Linear Mixed Models were used for intent-to-treat analyses and handling of missing data. Results: ICBT-i was significantly more effective than the control treatment in reducing ISI (Cohen's d = 0.85), sleep medication, sleep efficiency, sleep latency, and sleep quality at post-treatment. The positive effects were sustained. However, after 12 months the difference was no longer significant due to a continuous decrease in ISI among controls, possibly due to their significantly higher utilization of insomnia relevant care after treatment Forty-six negative effects were reported but did not differ between interventions. Conclusions: Supported ICBT-i is more effective than an active control treatment in reducing insomnia severity and treatment gains remain stable one year after treatment (C) 2015 The Authors. Published by Elsevier Ltd.

  • 8.
    Schibbye, Peter
    et al.
    Karolinska Institutet;Sundsvall Härnösand Cty Hosp.
    Ghaderi, Ata
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Ruck, Christian
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Using Early Change to Predict Outcome in Cognitive Behaviour Therapy: Exploring Timeframe, Calculation Method, and Differences of Disorder-Specific versus General Measures2014In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 6, article id e100614Article in journal (Refereed)
    Abstract [en]

    Early change can predict outcome of psychological treatment, especially in cognitive behavior therapy. However, the optimal operationalization of "early change'' for maximizing its predictive ability, and differences in predictive ability of disorder-specific versus general mental health measures has yet to be clarified. This study aimed to investigate how well early change predicted outcome depending on the week it was measured, the calculation method (regression slope or simple subtraction), the type of measures used, and the target disorder. During 10-15 weeks of internet-based cognitive behavior therapy for depression, social anxiety disorder, or panic disorder, weekly ratings were collected through both disorder-specific measures and general measures (Outcome Questionnaire-45 (OQ-45) and Clinical Outcomes in Routine Evaluation-10 (CORE-10)). With outcome defined as the disorder-specific measure, change at week four was the optimal predictor. Slope and subtraction methods performed equally well. The OQ-45 explained 18% of outcome for depression, 14% for social anxiety disorder, and 0% for panic disorder. Corresponding values for CORE-10 were 23%, 29%, and 25%. Specific measures explained 41%, 43%, and 34% respectively: this exceeded the ability of general measures also when they predicted themselves. We conclude that a simple calculation method with a disorder-specific measure at week four seems to provide a good choice for predicting outcome in time-limited cognitive behavior therapy.

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