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  • 1.
    Andersson, Erik
    et al.
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Enander, Jesper
    Karolinska Institutet.
    Djurfeldt, Diana Radu
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Cervenka, Simon
    Karolinska Institutet.
    Isung, Josef
    Karolinska Institutet.
    Svanborg, Cecilia
    Karolinska Institutet.
    Mataix-Cols, David
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Lindefors, Nils
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    d-Cycloserine vs Placebo as Adjunct to Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder and Interaction With Antidepressants A Randomized Clinical Trial2015In: JAMA psychiatry, ISSN 2168-6238, E-ISSN 2168-622X, Vol. 72, no 7, p. 659-667Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE It is unclear whether D-cycloserine (DCS), a partial N-methyl-D-aspartate agonist that enhances fear extinction, can augment the effects of exposure-based cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD). OBJECTIVES To examine whether DCS augments the effects of CBT for OCD and to explore (post hoc) whether concomitant antidepressant medication moderates the effects of DCS. DESIGN, SETTING, AND PARTICIPANTS A 12-week, double-blind randomized clinical trial with 3-month follow-up conducted at an academic medical center between September 4, 2012, and September 26, 2013. Participants included 128 adult outpatients with a primary diagnosis of OCD and a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 16 or higher. Concurrent antidepressant medication was permitted if the dose had been stable for at least 2 months prior to enrollment and remained unchanged during the trial. The main analysis was by intention-to-treat population. INTERVENTIONS All participants received a previously validated Internet-based CBT protocol over 12 weeks and were randomized to receive either 50 mg of DCS or placebo, administered 1 hour before each of 5 exposure and response prevention tasks. MAIN OUTCOMES AND MEASURES Clinician-administered Y-BOCS score at week 12 and at 3-month follow-up. Remission was defined as a score of 12 or lower on the Y-BOCS. RESULTS In the primary intention-to-treat analyses, DCS did not augment the effects of CBT compared with placebo (mean [SD] clinician-rated Y-BOCS score, DCS: 13.86 [6.50] at week 12 and 12.35 [7.75] at 3-month follow-up; placebo: 11.77 [5.95] at week 12 and 12.37 [6.68] at 3-month follow-up) but showed a significant interaction with antidepressants (clinician-rated Y-BOCS, B = -1.08; Z = -2.79; P = .005). Post hoc analyses revealed that antidepressants significantly impaired treatment response in the DCS group but not the placebo group, at both posttreatment and follow-up (clinician-rated Y-BOCS: t(62) = -3.00; P = .004; and t(61) = -3.49; P < .001, respectively). In the DCS group, a significantly greater proportion of antidepressant-free patients achieved remission status at follow-up (60% [95% CI, 45%-74%]) than antidepressant-medicated patients (24% [95% CI, 9%-48%]) (P = .008). Antidepressants had no effect in the placebo group (50% [95% CI, 36%-64%] remission rate in both groups). CONCLUSIONS AND RELEVANCE The findings suggest that antidepressants may interact with DCS to block its facilitating effect on fear extinction. Use of DCS may be a promising CBT augmentation strategy but only in antidepressant-free patients with OCD.

  • 2.
    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.

  • 3.
    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.

  • 4.
    Andersson, Erik
    et al.
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Hesser, Hugo
    Linköping University.
    Enander, Jesper
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Lindefors, Nils
    Karolinska Institutet.
    Ruck, Christian
    Karolinska Institutet.
    Testing the Mediating Effects of Obsessive Beliefs in Internet-Based Cognitive Behaviour Therapy for Obsessive-Compulsive Disorder: Results from a Randomized Controlled Trial2015In: Clinical Psychology and Psychotherapy, ISSN 1063-3995, E-ISSN 1099-0879, Vol. 22, no 6, p. 722-732Article in journal (Refereed)
    Abstract [en]

    Although cognitive interventions for obsessive-compulsive disorder (OCD) have been tested in randomized trials, there are few trials that have tested the specific mechanisms of cognitive interventions, i.e. how they achieve their effects. In this study, we aimed to investigate the mediating effects of a short cognitive intervention in the treatment of OCD and used data from a recently conducted randomized controlled trial where 101 participants were allocated to either Internet-based CBT (ICBT) or to a control condition. Obsessive beliefs were measured at pre-treatment, at the time they had received the cognitive intervention, and also at post-treatment. Weekly OCD symptoms were measured throughout the 10 weeks of treatment. We hypothesized that (1) the ICBT group would have greater reductions in obsessive beliefs (controlling for change in OCD symptoms) after completing the cognitive intervention, and that (2) this reduction would, in turn, predict greater OCD symptom reduction throughout the rest of the treatment period. Contrary to our expectations, the longitudinal mediation analysis indicated that (1) being randomized to ICBT actually increased the degree of obsessive beliefs after receiving the cognitive intervention at weeks 1-3, and (2) increase in obsessive beliefs predicted better outcome later in treatment. However, when repeating the analysis using cross-sectional data at post-treatment, the results were in line with the initial hypotheses. Results were replicated when the control condition received ICBT. We conclude that, although obsessive beliefs were significantly reduced at post-treatment for the ICBT group, early increase rather than decrease in obsessive beliefs predicted favourable outcome. Copyright (C) 2014 John Wiley & Sons, Ltd.

  • 5.
    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.

  • 6.
    Andersson, Erik
    et al.
    Karolinska Institutet.
    Steneby, S.
    Karolinska Institutet.
    Karlsson, K.
    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.
    Ruck, Christian
    Karolinska Institutet.
    Long-term efficacy of Internet-based cognitive behavior therapy for obsessive-compulsive disorder with or without booster: a randomized controlled trial2014In: Psychological Medicine, ISSN 0033-2917, E-ISSN 1469-8978, Vol. 44, no 13, p. 2877-2887Article in journal (Refereed)
    Abstract [en]

    Background. As relapse after completed cognitive behavior therapy (CBT) for obsessive-compulsive disorder (OCD) is common, many treatment protocols include booster programs to improve the long-term effects. However, the effects of booster programs are not well studied. In this study, we investigated the long-term efficacy of Internet-based CBT (ICBT) with therapist support for OCD with or without an Internet-based booster program. Method. A total of 101 participants were included in the long-term follow-up analysis of ICBT. Of these, 93 were randomized to a booster program or no booster program. Outcome assessments were collected at 4, 7, 12 and 24 months after receiving ICBT. Results. The entire sample had sustained long-term effects from pre-treatment to all follow-up assessments, with large within-group effect sizes (Cohen's d=1.58-2.09). The booster group had a significant mean reduction in OCD symptoms compared to the control condition from booster baseline (4 months) to 7 months, but not at 12 or 24 months. Participants in the booster group improved significantly in terms of general functioning at 7, 12 and 24 months, and had fewer relapses. Kaplan-Meier analysis also indicated a significantly slower relapse rate in the booster group. Conclusions. The results suggest that ICBT has sustained long-term effects and that adding an Internet-based booster program can further improve long-term outcome and prevent relapse for some OCD patients.

  • 7.
    Andersson, Evelyn
    et al.
    Karolinska Institutet, Sweden;Stockholm Countty Council, Sweden.
    Crowley, James J.
    Karolinska Institutet, Sweden;Univ N Carolina, USA;Univ N Carolina, USA.
    Lindefors, Nils
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Ljotsson, Brjann
    Karolinska Institutet, Sweden.
    Hedman-Lagerlöf, Erik
    Karolinska Institutet, Sweden.
    Boberg, Julia
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    El Alaoui, Samir
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Karlsson, Robert
    Karolinska Institutet, Sweden.
    Lu, Yi
    Karolinska Institutet, Sweden.
    Mattheisen, Manuel
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden;Aarhus Univ, Denmark.
    Kahler, Anna K.
    Karolinska Institutet, Sweden.
    Svanborg, Cecilia
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Mataix-Cols, David
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Mattsson, Simon
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Forsell, Erik
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Schalling, Martin
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Lavebratt, Catharina
    Karolinska Institutet, Sweden;Karolinska University Hosp, Sweden.
    Sullivan, Patrick F.
    Univ N Carolina, USA;Karolinska Institutet, Sweden.
    Ruck, Christian
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Genetics of response to cognitive behavior therapy in adults with major depression: a preliminary report2019In: Molecular Psychiatry, ISSN 1359-4184, E-ISSN 1476-5578, Vol. 24, no 4, p. 484-490Article in journal (Refereed)
    Abstract [en]

    Major depressive disorder is heritable and a leading cause of disability. Cognitive behavior therapy is an effective treatment for major depression. By quantifying genetic risk scores based on common genetic variants, the aim of this report was to explore the utility of psychiatric and cognitive trait genetic risk scores, for predicting the response of 894 adults with major depressive disorder to cognitive behavior therapy. The participants were recruited in a psychiatric setting, and the primary outcome score was measured using the Montgomery Asberg Depression Rating Scale-Self Rated. Single-nucleotide polymorphism genotyping arrays were used to calculate the genomic risk scores based on large genetic studies of six phenotypes: major depressive disorder, bipolar disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, intelligence, and educational attainment. Linear mixed-effect models were used to test the relationships between the six genetic risk scores and cognitive behavior therapy outcome. Our analyses yielded one significant interaction effect (B = 0.09, p < 0.001): the autism spectrum disorder genetic risk score correlated with Montgomery Asberg Depression Rating Scale-Self Rated changes during treatment, and the higher the autism spectrum disorder genetic load, the less the depressive symptoms decreased over time. The genetic risk scores for the other psychiatric and cognitive traits were not related to depressive symptom severity or change over time. Our preliminary results indicated, as expected, that the genomics of the response of patients with major depression to cognitive behavior therapy were complex and that future efforts should aim to maximize sample size and limit subject heterogeneity in order to gain a better understanding of the use of genetic risk factors to predict treatment outcome.

  • 8.
    Bendix, Marie
    et al.
    Umeå University.
    Uvnäs-Moberg, Kerstin
    Swedish University of Agricultural Sciences.
    Petersson, Maria
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Åsberg, Marie
    Karolinska Institutet.
    Jokinen, Jussi
    Umeå University;Karolinska Institutet.
    Insulin and glucagon in plasma and cerebrospinal fluid in suicide attempters and healthy controls2017In: Psychoneuroendocrinology, ISSN 0306-4530, E-ISSN 1873-3360, Vol. 81, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Mental disorders and related behaviors such as suicidality and violence have been associated to dysregulation of e g carbohydrate metabolism. We hypothesized that patients after suicide attempt, compared to healthy controls, would have higher insulin and lower glucagon levels in plasma and cerebrospinal fluid and that these changes would be associated to violent behavior. Twenty-eight medication-free patients (10 women, 18 men), hospitalized after suicide attempt, and 19 healthy controls (7 women, 12 men) were recruited with the aim to study risk factors for suicidal behavior. Psychological/psychiatric assessment was performed with SCID I and II or the SCID interview for healthy volunteers respectively, the Karolinska Interpersonal Violence Scale (KIVS) for assessment of lifetime violence expression behavior, the Montgomery-Asberg-Depression-Scale (MADRS) and the Comprehensive Psychological Rating Scale (CPRS) for symptomatic assessment of depression and appetite. Fasting levels of insulin and glucagon were measured in plasma (P) and cerebrospinal fluid (CSF). Suicide attempters had higher insulin- and lower glucagon-levels in plasma- and CSF compared to controls. Except for P-glucagon these associations remained significant after adjusting for age and/or BMI. Patients reported significantly more expressed interpersonal violence compared to healthy volunteers. Expressed violence was significantly positively correlated with P- and CSF-insulin and showed a significant negative correlation with P-glucagon in study participants. These findings confirm and extend prior reports that higher insulin and lower glucagon levels in plasma and cerebrospinal fluid are associated with suicidal behavior pointing towards a potential autonomic dysregulation in the control of insulin and glucagon secretion in suicidal patients. (C) 2017 Elsevier Ltd. All rights reserved.

  • 9.
    Beukes, Eldre W
    et al.
    Anglia Ruskin University, UK.
    Vlaescu, George
    Linköping University.
    Manchaiah, Vinaya
    Linköping University;Lamar University, USA;Audiology India, India.
    Baguley, David M
    Anglia Ruskin University, UK;Cambridge University Hospital NHS Foundation Trust, UK.
    Allen, Peter M
    Anglia Ruskin University, UK.
    Kaldo, Viktor
    Karolinska Institutet.
    Andersson, Gerhard
    Linköping University;Karolinska Institutet.
    Development and technical functionality of an Internet-based intervention for tinnitus in the UK2016In: Internet Interventions, ISSN 2214-7829, Vol. 6, p. 6-15Article in journal (Refereed)
    Abstract [en]

    Purpose

    Creative approaches to improve access to evidence-based tinnitus treatments are required. The purpose of this study was to develop an Internet-based cognitive behavioural therapy (iCBT) intervention, for those experiencing tinnitus in the United Kingdom (UK). Furthermore, it aimed, through technical functionality testing, to identify specific aspects of the iCBT that require improving.

    Method

    An innovative iCBT intervention for treating tinnitus in the UK has been developed using a cognitive-behavioural theoretical framework. This iCBT was evaluated by two user groups during this developmental phase. Initially, five expert reviews evaluated the intervention, prior to evaluation by a group of 29 adults experiencing significant levels of tinnitus distress. Both groups evaluated iCBT in an independent measures design, using a specifically designed satisfaction outcome measure.

    Results

    Overall, similar ratings were given by the expert reviewers and adults with tinnitus, showing a high level of satisfaction regarding the content, suitability, presentation, usability and exercises provided in the intervention. The iCBT intervention has been refined following technical functionality testing.

    Conclusions

    Rigorous testing of the developed iCBT intervention has been undertaken. These evaluations provide confidence that further clinical trials can commence in the UK, to assess the feasibility and effectiveness of this iCBT intervention for tinnitus.

  • 10.
    Blom, Kerstin
    et al.
    Karolinska Institutet.
    Jernelov, Susanna
    Karolinska Institutet.
    Ruck, Christian
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Three-Year Follow-Up Comparing Cognitive Behavioral Therapy for Depression to Cognitive Behavioral Therapy for Insomnia, for Patients With Both Diagnoses2017In: Sleep, ISSN 0161-8105, E-ISSN 1550-9109, Vol. 40, no 8, article id UNSP zsx108Article in journal (Refereed)
    Abstract [en]

    This 3-year follow-up compared insomnia treatment to depression treatment for patients with both diagnoses. Forty-three participants were randomized to either treatment, in the form of Internet-delivered therapist-guided cognitive behavior therapy (CBT), and 37 (86%) participants provided primary outcome data at the 3-year follow-up. After 3 years, reductions on depression severity were similar in both groups (between-group effect size, d = 0.33, p =.45), while the insomnia treatment had superior effects on insomnia severity (d = 0.66, p <.05). Overall, insomnia treatment was thus more beneficial than depression treatment. The implication for practitioners, supported by previous research, is that patients with co-occurring depression and insomnia should be offered CBT for insomnia, in addition to medication or psychological treatment for depression.

  • 11.
    Blom, Kerstin
    et al.
    Karolinska Institutet.
    Jernelov, Susanna
    Karolinska Institutet.
    Ruck, Christian
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Three-Year Follow-Up of Insomnia and Hypnotics after Controlled Internet Treatment for Insomnia2016In: Sleep, ISSN 0161-8105, E-ISSN 1550-9109, Vol. 39, no 6, p. 1267-1274, article id PII sp-00663-15Article in journal (Refereed)
    Abstract [en]

    Study Objectives: To investigate the long-term effects of therapist-guided Internet-based insomnia treatment on insomnia severity and sleep medication use, compared with active control. Methods: This study was an 8 week randomized controlled trial with follow-up posttreatment and at 6, 12, and 36 months, set at the Internet Psychiatry Clinic, Stockholm, Sweden. Participants were 148 media-recruited nondepressed adults with insomnia. Interventions were Guided Internet-based cognitive behavioral therapy for insomnia (ICBT-i) or active control treatment (ICBT-ctrl). Primary outcome was insomnia severity, measured with the Insomnia Severity Index. Secondary outcomes were sleep medication use and use of other treatments. Results: The large pretreatment to posttreatment improvements in insomnia severity of the ICBT-i group were maintained during follow-up. ICBT-ctrl exhibited significantly less improvement posttreatment (between-Cohen d = 0.85), but after 12 and 36 months, there was no longer a significant difference. The within-group effect sizes from pretreatment to the 36-months follow-up were 1.6 (ICBT-i) and 1.7 (ICBT-ctrl), and 74% of the interviewed participants no longer had insomnia diagnosis after 36 mo. ICBT-ctrl used significantly more sleep medication (P = 0.017) and underwent significantly more other insomnia treatments (P < 0.001) during the follow-up period. Conclusions: The large improvements in the ICBT-i group were maintained after 36 months, corroborating that CBT for insomnia has long-term effects. After 36 months, the groups did not differ in insomnia severity, but ICBT-ctrl had used more sleep medication and undergone more other additional insomnia treatments during the follow-up period.

  • 12.
    Blom, Kerstin
    et al.
    Karolinska Institutet.
    Jernelöv, Susanna
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Facilitating and hindering factors in Internet-delivered treatment for insomnia and depression2016In: Internet Interventions, ISSN 2214-7829, Vol. 4, p. 51-60Article in journal (Refereed)
    Abstract [en]

    Insomnia and depression is a common and debilitating comorbidity, and treatment is usually given mainly for depression. Guided Internet-based cognitive behavioral therapy for insomnia (ICBT-i) was, in a recent study on which this report is based, found superior to a treatment for depression (ICBT-d) for this patient group, but many patients did not reach remission.

  • 13.
    Blom, Kerstin
    et al.
    Karolinska Institutet.
    Jerneov, Susanna
    Karolinska Institutet.
    Kraepelien, Martin
    Karolinska Institutet.
    Bergdahl, Malin Olseni
    Karolinska Institutet.
    Jungmarker, Kristina
    Karolinska Institutet.
    Ankartjärn, Linda
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Internet Treatment Addressing either Insomnia or Depression, for Patients with both Diagnoses: A Randomized Trial2015In: Sleep, ISSN 0161-8105, E-ISSN 1550-9109, Vol. 38, no 2, p. 267-277Article in journal (Refereed)
    Abstract [en]

    Study Objectives: To compare treatment effects when patients with insomnia and depression receive treatment for either insomnia or depression. Design: A 9-w randomized controlled trial with 6- and 12-mo follow-up. Setting: Internet Psychiatry Clinic, Stockholm, Sweden. Participants: Forty-three adults in whom comorbid insomnia and depression were diagnosed, recruited via media and assessed by psychiatrists. Interventions: Guided Internet-delivered cognitive behavior therapy (ICBT) for either insomnia or depression. Measurements and Results: Primary outcome measures were symptom self-rating scales (Insomnia Severity Index [ISI] and the Montgomery Asberg Depression Rating Scale [MADRS-S]), assessed before and after treatment with follow-up after 6 and 12 mo. The participants' use of sleep medication and need for further treatment after completion of ICBT was also investigated. The insomnia treatment was more effective than the depression treatment in reducing insomnia severity during treatment (P = 0.05), and equally effective in reducing depression severity. Group differences in insomnia severity were maintained during the 12-mo follow-up period. Post treatment, participants receiving treatment for insomnia had significantly less self-rated need for further insomnia treatment (P < 0.001) and used less sleep medication (P < 0.05) than participants receiving treatment for depression. The need for depression treatment was similar in both groups. Conclusions: In this study, Internet-delivered treatment with cognitive behavior therapy (ICBT) for insomnia was more effective than ICBT for depression for patients with both diagnoses. This indicates, in line with previous research, that insomnia when comorbid with depression is not merely a symptom of depression, but needs specific treatment.

  • 14.
    Blom, Kerstin
    et al.
    Karolinska Institutet.
    Tillgren, Hanna Tarkian
    Linköping University.
    Wiklund, Tobias
    Dept PaLinköping University.
    Danlycke, Ewa
    Linköping University.
    Forssen, Mattias
    Linköping University.
    Söderström, Alexandra
    Linköping University.
    Johansson, Robert
    Linköping University.
    Hesser, Hugo
    Linköping University.
    Jernelov, Susanna
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Kaldo, Viktor
    Karolinska Institutet.
    Internet-vs. group-delivered cognitive behavior therapy for insomnia: A randomized controlled non-inferiority trial2015In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 70, p. 47-55Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to compare guided Internet-delivered to group-delivered cognitive behavioral therapy (CBT) for insomnia. We conducted an 8-week randomized controlled non-inferiority trial with 6-months follow-up. Participants were forty-eight adults with insomnia, recruited via media. Interventions were guided Internet-delivered CBT (ICBT) and group-delivered CBT (GCBT) for insomnia. Primary outcome measure was the Insomnia Severity Index (ISI), secondary outcome measures were sleep diary data, depressive symptoms, response- and remission rates. Both treatment groups showed significant improvements and large effect sizes for ISI (Within Cohen's d: ICBT post = 1.8, 6-months follow-up = 2.1; GCBT post = 2.1, 6-months follow-up = 2.2). Confidence interval of the difference between groups posttreatment and at FU6 indicated non-inferiority of ICBT compared to GCBT. At post-treatment, two thirds of patients in both groups were considered responders (ISI-reduction > 7p). Using diagnostic criteria, 63% (ICBT) and 75% (GCBT) were in remission. Sleep diary data showed moderate to large effect sizes. We conclude that both guided Internet-CBT and group-CBT in this study were efficacious with regard to insomnia severity, sleep parameters and depressive symptoms. The results are in line with previous research, and strengthen the evidence for guided Internet-CBT for insomnia. Trial registration: The study protocol was approved by, and registered with, the regional ethics review board in Linkoping, Sweden, registration number 2010/385-31. (C) 2015 The Authors. Published by Elsevier Ltd.

  • 15.
    Bothelius, Kristoffer
    et al.
    Uppsala University.
    Jernelov, Susanna
    Karolinska Institutet.
    Fredrikson, Mats
    Uppsala University.
    McCracken, Lance M.
    Kings Coll London, UK.
    Kaldo, Viktor
    Karolinska Institutet.
    Measuring Acceptance of Sleep Difficulties: The Development of the Sleep Problem Acceptance Questionnaire2015In: Sleep, ISSN 0161-8105, E-ISSN 1550-9109, Vol. 38, no 11, p. 1815-1822Article in journal (Refereed)
    Abstract [en]

    Study Objectives: Acceptance may be an important therapeutic process in sleep medicine, but valid psychometric instruments measuring acceptance related to sleep difficulties are lacking. The purpose of this study was to develop a measure of acceptance in insomnia, and to examine its factor structure as well as construct validity. Design: In a cross-sectional design, a principal component analysis for item reduction was conducted on a first sample (A) and a confirmatory factor analysis on a second sample (B). Construct validity was tested on a combined sample (C). Setting: Questionnaire items were derived from a measure of acceptance in chronic pain, and data were gathered through screening or available from pretreatment assessments in four insomnia treatment trials, administered online, via bibliotherapy and in primary care. Participants: Adults with insomnia: 372 in sample A and 215 in sample B. Sample C (n = 820) included sample A and B with another 233 participants added. Measures: Construct validity was assessed through relations with established acceptance and sleep scales. Results: The principal component analysis presented a two-factor solution with eight items, explaining 65.9% of the total variance. The confirmatory factor analysis supported the solution. Acceptance of sleep problems was more closely related to subjective symptoms and consequences of insomnia than to diary description of sleep, or to acceptance of general private events. Conclusions: The Sleep Problem Acceptance Questionnaire (SPAQ), containing the subscales "Activity Engagement" and "Willingness", is a valid tool to assess acceptance of insomnia.

  • 16.
    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.

  • 17.
    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.

  • 18.
    El Alaoui, Samir
    et al.
    Karolinska Institutet.
    Ljotsson, Brjann
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Svanborg, Cecilia
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Predicting Outcome in Internet-Based Cognitive Behaviour Therapy for Major Depression: A Large Cohort Study of Adult Patients in Routine Psychiatric Care2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 9, article id e0161191Article in journal (Refereed)
    Abstract [en]

    Background Although the effectiveness of therapist-guided internet-based cognitive behaviour therapy (ICBT) for treating depression has been well documented, knowledge of outcome predictors and risk factors associated with lower treatment response is limited, especially when the treatment has been conducted within a naturalistic clinical setting. Identification of such factors is important for clinicians when making treatment recommendations. Methods Data from a large cohort (N = 1738) of adult outpatients having been treated with ICBT for depression at an outpatient psychiatric clinic were analysed. A multilevel modelling approach was used to identify patient and treatment variables associated with the speed of recovery during treatment using weekly measurements of the Montgomery Asberg Depression Rating Scale Self-Rated (MADRS-S). Outcomes Adhering to the treatment, perceiving it as credible and working full-time emerged as predictors of a faster pace of recovery and were also associated with a lower level of depression at the end of treatment. Higher pre-treatment depression and sleep problems were associated with a greater improvement rate, but predicted higher depression after treatment. Having a history of psychotropic medication was associated with both slower improvement and higher post-treatment depression. Conclusion Perceived credibility of ICBT is a strong predictor of treatment response. Assessing patient beliefs and expectations may be a useful aid for clinicians when identifying those who are more or less likely to benefit from ICBT. Helping patients improve expectations prior to treatment may be an important goal for clinicians during the initial assessment phase.

  • 19.
    Forsell, Erik
    et al.
    Karolinska Institutet.
    Bendix, Marie
    Umeå University.
    Holländare, Fredrik
    Örebro University.
    von Schultz, Barbara Szymanska
    Karolinska University Hospital.
    Nasiell, Josefine
    Karolinska Institutet.
    Blomdahl-Wetterholm, Margareta
    Stockholms Läns Sjuvårdsområde SLSO.
    Eriksson, Caroline
    Uppsala University.
    Kvarned, Sara
    Uppsala University.
    van der Linden, Johanna Lindau
    Uppsala University.
    Söderberg, Elin
    Uppsala University.
    Jokinen, Jussi
    Karolinska Institutet;Umeå University.
    Wide, Katarina
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    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.

  • 20.
    Forsell, Erik
    et al.
    Karolinska Institutet, Sweden;Huddinge Hospital, Sweden.
    Jernelov, Susanna
    Karolinska Institutet, Sweden;Huddinge Hospital, Sweden.;Karolinska Inst, Dept Clin Neurosci, Div Psychol, Stockholm, Sweden.
    Blom, Kerstin
    Karolinska Institutet, Sweden;Huddinge Hospital, Sweden.
    Kraepelien, Martin
    Karolinska Institutet, Sweden;Huddinge Hospital, Sweden.
    Svanborg, Cecilia
    Karolinska Institutet, Sweden;Huddinge Hospital, Sweden.
    Andersson, Gerhard
    Karolinska Institutet, Sweden;Huddinge Hospital, Sweden;Linköping University, Sweden.
    Lindefors, Nils
    Karolinska Institutet, Sweden;Huddinge Hospital, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden;Huddinge Hospital, Sweden.
    Proof of Concept for an Adaptive Treatment Strategy to Prevent Failures in Internet-Delivered CBT: A Single-Blind Randomized Clinical Trial With Insomnia Patients2019In: American Journal of Psychiatry, ISSN 0002-953X, E-ISSN 1535-7228, Vol. 176, no 4, p. 315-323Article in journal (Refereed)
    Abstract [en]

    Objective: This study aimed to demonstrate proof of concept for an adaptive treatment strategy in Internet-delivered cognitive-behavioral therapy (ICBT), where risk of treatment failure is assessed early in treatment and treatment for at-risk patients is adapted to prevent treatment failure. Methods: A semiautomated algorithm assessed risk of treatment failure early in treatment in 251 patients undergoing ICBT for insomnia with therapist guidance. At-risk patients were randomly assigned to continue standard ICBT or to receive adapted ICBT. The primary outcome was self-rated insomnia symptoms using the Insomnia Severity Index in a linear mixed-effects model. The main secondary outcome was treatment failure (having neither responded nor remitted at the posttreatment assessment). Results: A total of 102 patients were classified as at risk and randomly assigned to receive adapted ICBT (N=51) or standard ICBT (N=51); 149 patients were classified as not at risk. Patients not at risk had significantly greater score reductions on the Insomnia Severity Index than at-risk patients given standard ICBT. Adapted ICBT for at-risk patients was significantly more successful in reducing symptoms compared with standard ICBT, and it decreased the risk of failing treatment (odds ratio= 0.33). At-risk patients receiving adapted ICBT were not more likely to experience treatment failure than those not at risk (odds ratio= 0.51), though they were less likely to experience remission. Adapted treatment required, on average, 14 more minutes of therapist-patient time per remaining week. Conclusions: An adaptive treatment strategy can increase treatment effects for at-risk patients and reduce the number of failed treatments. Future studies should improve accuracy in classification algorithms and identify key factors that boost the effect of adapted treatments.

  • 21.
    Forsell, Erik
    et al.
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Kraepelien, Martin
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Blom, Kerstin
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Isacsson, Nils
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Jernelov, Susanna
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Svanborg, Cecilia
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Rosen, Ann
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Development of a very brief scale for detecting and measuring panic disorder using two items from the Panic Disorder Severity Scale-Self Report2019In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 257, p. 615-622Article in journal (Refereed)
    Abstract [en]

    Objective: To minimize the burden in detecting and monitoring Panic Disorder and Agoraphobia by developing a very brief scale with selected items from the Panic Disorder Severity Scale-Self Report (PDSS-SR), and to investigate the proposed scale's psychometric properties in a comorbid sample. Methods: A sample of 5103 patients from the Internet Psychiatry Clinic in Sweden, diagnosed and treated with Internet-based cognitive behavioral therapy for panic disorder (n = 1390), social anxiety disorder (n = 1313) or depression (n = 2400), responded to the PDSS-SR. Six criteria related to factor structure, sensitivity to change and clinical representativeness were used to select items. Psychometric analyses for the selected very brief scale were performed. Results: Items 2 (distress during panic attacks) and 4 (agoraphobic avoidance), were selected to create the very brief PDSS-SR version. Correlations with the full scale were high at screening, pre and post, and for change (0.87-0.93). Categorical Omega was omega(c) = 0.74. With a cut-off of 3 points, the scale could detect panic disorder in a psychiatric sample with a sensitivity of 85% and a specificity of 66%. Limitations: Limitations include lack of healthy controls and lack of blinding on secondary outcome measures. Conclusion: The proposed 2-item PDSS-SR version is a good candidate for a very brief panic disorder questionnaire, both for detecting cases and for measuring change. This is especially useful in clinical settings when measuring more than one condition at a time.

  • 22.
    Görts Öberg, Katarina
    et al.
    Karolinska Institutet;Karolinska University Hospital.
    Hallberg, Jonas
    Karolinska Institutet;Karolinska University Hospital.
    Kaldo, Viktor
    Karolinska Institutet.
    Dhejne, Cecilia
    Karolinska University Hospital;Karolinska Institutet.
    Arver, Stefan
    Karolinska Institutet;Karolinska University Hospital.
    Hypersexual Disorder According to the Hypersexual Disorder Screening Inventory in Help-Seeking Swedish Men and Women With Self-Identified Hypersexual Behavior2017In: Sexual Medicine, E-ISSN 2050-1161, Vol. 5, no 4, p. E229-E236Article in journal (Refereed)
    Abstract [en]

    Introduction: The Hypersexual Disorder Screening Inventory (HDSI) was developed by the American Psychiatric Association for clinical screening of hypersexual disorder (HD). Aims: To examine the distribution of the proposed diagnostic entity HD according to the HDSI in a sample of men and women seeking help for problematic hypersexuality and evaluate some psychometric properties. Methods: Data on sociodemographics, the HDSI, the Sexual Compulsivity Scale (SCS), and the Cognitive and Behavioral Outcomes of Sexual Behavior were collected online from 16 women and 64 men who self-identified as hypersexual. Respondents were recruited by advertisements offering psychological treatment for hypersexual behavior. Main Outcome Measures: The HDSI, covering the proposed criteria for HD. Results: Of the entire sample, 50% fulfilled the criteria for HD. Compared with men, women scored higher on the HDSI, engaged more often in risky sexual behavior, and worried more about physical injuries and pain. Men primarily used pornography, whereas women had sexual encounters. The HD group reported a larger number of sexual specifiers, higher scores on the SCS, more negative effects of sexual behavior, and more concerns about consequences compared with the non-HD group. Sociodemographics had no influence on HD. The HDSI's core diagnostic criteria showed high internal reliability for men (a = 0.80) and women (a = 0.81). A moderate correlation between the HDSI and the SCS was found (0.51). The vast majority of the entire sample (76 of 80, 95%) fulfilled the criteria for sexual compulsivity according to the SCS. Conclusion: The HDSI could be used as a screening tool for HD, although further explorations of the empirical implications regarding criteria are needed, as are refinements of cutoff scores and specific sexual behaviors. Hypersexual problematic behavior causes distress and impairment and, although not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, HD should be endorsed as a diagnosis to develop evidence-based treatment and future studies on its etiology. Copyright (C) 2017, The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine. This is an open access article under the CC BY-NC-ND license.

  • 23.
    Hagström, David
    et al.
    Uppsala University.
    Kaldo, Viktor
    Karolinska Institutet.
    Escapism among players of MMORPGs: conceptual clarification, its relation to mental health factors, and development of a new measure2014In: CyberPsychology, Behavior and Social Networking, ISSN 2152-2715, E-ISSN 2152-2723, Vol. 17, no 1, p. 19-25Article in journal (Refereed)
    Abstract [en]

    Previous studies show that the concept of escapism needs to be clarified and that its relation to problematic online gaming and other factors needs further examination. This study uses well-established, basic learning theory to clarify the concept of escapism, and examines its relation to problematic gaming, psychological distress, and satisfaction with life among players of massively multiplayer online role-playing games (MMORPGs). MMORPG players (n=201) answered an online questionnaire where these factors were measured and correlated with a previously developed scale on motivation to play (MTPI), including extra items to cover positive and negative aspects of escapism. Factor analysis and construct validation show that positive aspects of escapism are theoretically and empirically unstable and that escapism is best clarified as purely "negative escapism," corresponding to playing being negatively reinforced as a way of avoiding everyday hassles and distress. Negative escapism had a stronger relationship to symptoms of Internet addiction, psychological distress, and life satisfaction than other variables and other more positive motivations to play. Future studies should use the revised subscale for escapism (in the MTPI-R) presented in the present study, for example when screening for Internet addiction.

  • 24.
    Hallberg, Jonas
    et al.
    Karolinska Institutet;Karolinska University Hospital.
    Kaldo, Viktor
    Karolinska Institutet.
    Arver, Stefan
    Karolinska Institutet;Karolinska University Hospital.
    Dhejne, Cecilia
    Karolinska University Hospital;Karolinska Institutet.
    Görts Öberg, Katarina
    Karolinska Institutet;Karolinska University Hospital.
    A Cognitive-Behavioral Therapy Group Intervention for Hypersexual Disorder: A Feasibility Study2017In: Journal of Sexual Medicine, ISSN 1743-6095, E-ISSN 1743-6109, Vol. 14, no 7, p. 950-958Article in journal (Refereed)
    Abstract [en]

    Background: The proposed criteria of the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition for hypersexual disorder (HD) included symptoms reported by patients seeking help for excessive and out-of-control non-paraphilic sexual behavior, including sexual behaviors in response to dysphoric mood states, impulsivity, and risk taking. Although no prior studies of cognitive-behavioral therapy (CBT) for the treatment of HD have been performed, CBT has been found effective for dysphoric mood states and impulsivity. Aim: To investigate the feasibility of a CBT manual developed for HD explored through symptom decrease, treatment attendance, and clients' treatment satisfaction. Methods: Ten men with a diagnosis of HD took part in the CBT group program. Measurements were taken before, during, and at the end of treatment and 3 and 6 months after treatment. Outcomes: The primary outcome was the Hypersexual Disorder: Current Assessment Scale (HD: CAS) score that measured the severity of problematic hypersexual symptoms and secondary outcomes were the Hypersexual Disorder Screening Inventory (HDSI) score, the proportion of attended sessions, and the Client Satisfaction Questionnaire (CSQ-8) score. Results: Main results were significant decreases of HD symptoms from before to after treatment on HD: CAS and HDSI scores and a decrease in the number of problematic sexual behaviors during the course of therapy. A high attendance rate of 93% and a high treatment satisfaction score on CSQ-8 also were found. Clinical Implications: The CBT program seemed to ameliorate the symptoms of HD and therefore might be a feasible treatment option. Strengths and Limitations: This study provides data from a CBT program for the treatment of the specific proposed criteria of HD. Because of the small sample and lack of a control group, the results can be considered only preliminary. Conclusion: Although participants reported decreased HD symptoms after attending the CBT program, future studies should evaluate the treatment program with a larger sample and a randomized controlled procedure to ensure treatment effectiveness. Copyright (C) 2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

  • 25.
    Hallberg, Jonas
    et al.
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Arver, Stefan
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Dhejne, Cecilia
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Jokinen, Jussi
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden;Umeå University, Sweden.
    Oberg, Katarina Gorts
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    A Randomized Controlled Study of Group-Administered Cognitive Behavioral Therapy for Hypersexual Disorder in Men2019In: Journal of Sexual Medicine, ISSN 1743-6095, E-ISSN 1743-6109, Vol. 16, no 5, p. 733-745Article in journal (Refereed)
    Abstract [en]

    Background: Hypersexual disorder (HD) is defined as a condition in which the individual loses control over engagement in sexual behaviors, leading to distress and negative effects on key life areas. Cognitive behavioral therapy (CBT) has been proven to reduce symptoms of hypersexual behavior; however, no randomized controlled study of CBT interventions for HD has been reported previously. Aim: To investigate the efficacy of group-administered CBT for HD. Methods: Male participants (n = 137) diagnosed with HD, were randomized between 7 weeks of group-administered CBT (n = 70) and a waitlist control receiving the intervention after 8 weeks (n = 67). Measurements were administered at pre-, mid-, and posttreatment, with follow-up after 3 and 6 months. Outcomes: The primary outcome was the Hypersexual Disorder: Current Assessment Scale (HD: CAS), and secondary outcomes were the Sexual Compulsivity Scale (SCS) and measures of depression (Montgomery-Asberg Depression Rating Scale (MADRS-S), psychological distress (Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), and treatment satisfaction (CSQ-8). Results: A significantly greater decrease in HD symptoms and sexual compulsivity, as well as significantly greater improvements in psychiatric well-being, were found for the treatment condition compared with the waitlist. These effects remained stable at 3 and 6 months after treatment. Clinical Implications: CBT can ameliorate HD symptoms and psychiatric distress, suggesting that the CBT program may serve as a first-line treatment in clinical settings. Strengths & Limitations: This is the first randomized controlled study evaluating the efficacy of a CBT programin a rather large sample of HD-specific diagnosed men. The long-termtreatment effects are vague due to the low response rate on follow-up measurements, and the efficacy of this program for hypersexual women remains unknown. Conclusion: This study supports the efficacy of a group-administered CBT program as a treatment option for HD; however, future studies should include women, comprise dismantling analysis of the constituting interventions, and evaluate other treatment formats, for example, administration via the Internet. Copyright (C) 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

  • 26.
    Hallgren, Mats
    et al.
    Karolinska Institutet.
    Helgadottir, Björg
    Karolinska Institutet.
    Herring, Matthew P.
    Univ Limerick, Ireland.
    Zeebari, Zangin
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Öjehagen, Agneta
    Lund University.
    Forsell, Yvonne
    Karolinska Institutet.
    Exercise and internet-based cognitive-behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up2016In: British Journal of Psychiatry, ISSN 0007-1250, E-ISSN 1472-1465, Vol. 209, no 5, p. 416-422Article in journal (Refereed)
    Abstract [en]

    Background Evidence-based treatment of depression continues to grow, but successful treatment and maintenance of treatment response remains limited. Aims To compare the effectiveness of exercise, internet-based cognitive behavioural therapy (ICBT) and usual care for depression. Method A multicentre, three-group parallel, randomised controlled trial was conducted with assessment at 3 months (post-treatment) and 12 months (primary end-point). Outcome assessors were masked to group allocation. Computer generated allocation was performed externally in blocks of 36 and the ratio of participants per group was 1:1:1. In total, 945 adults with mild to moderate depression aged 18-71 years were recruited from primary healthcare centres located throughout Sweden. Participants were randomly assigned to one of three 12-week interventions: supervised group exercise, clinician-supported ICBT or usual care by a physician. The primary outcome was depression severity assessed by the Montgomery-angstrom sberg Depression Rating Scale (MADRS). Results The response rate at 12-month follow-up was 84%. Depression severity reduced significantly in all three treatment groups in a quadratic trend over time. Mean differences in MADRS score at 12 months were 12.1 (ICBT), 11.4 (exercise) and 9.7 (usual care). At the primary end-point the group x time interaction was significant for both exercise and ICBT. Effect sizes for both interventions were small to moderate. Conclusions The long-term treatment effects reported here suggest that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults. (C) The Royal College of Psychiatrists 2016.

  • 27.
    Hallgren, Mats
    et al.
    Karolinska Institutet.
    Kraepelien, Martin
    Karolinska Institutet.
    Öjehagen, Agneta
    Lund University.
    Lindefors, Nils
    Karolinska Institutet.
    Zeebari, Zangin
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Forsell, Yvonne
    Karolinska Institutet.
    Physical exercise and internet-based cognitive-behavioural therapy in the treatment of depression: randomised controlled trial2015In: British Journal of Psychiatry, ISSN 0007-1250, E-ISSN 1472-1465, Vol. 207, no 3, p. 227-234Article in journal (Refereed)
    Abstract [en]

    Background Depression is common and tends to be recurrent. Alternative treatments are needed that are non-stigmatising, accessible and can be prescribed by general medical practitioners. Aims To compare the effectiveness of three interventions for depression: physical exercise, internet-based cognitive behavioural therapy (ICBT) and treatment as usual (TAU). A secondary aim was to assess changes in self-rated work capacity. Method A total of 946 patients diagnosed with mild to moderate depression were recruited through primary healthcare centres across Sweden and randomly assigned to one of three 12-week interventions (trail registry: KCTR study ID: KT20110063). Patients were reassessed at 3 months (response rate 78%). Results Patients in the exercise and ICBT groups reported larger improvements in depressive symptoms compared with TAU. Work capacity improved over time in all three groups (no significant differences). Conclusions Exercise and ICBT were more effective than TAU by a general medical practitioner, and both represent promising non-stigmatising treatment alternatives for patients with mild to moderate depression. Copyright and usage (C) The Royal College of Psychiatrists 2015.

  • 28.
    Hedman, E.
    et al.
    Karolinska Institutet.
    Ljótsson, B.
    Karolinska Institutet.
    Rück, C.
    Karolinska Institutet.
    Bergström, J.
    Stockholm University.
    Andersson, G.
    Karolinska Institutet;Linköping University.
    Kaldo, Viktor
    Karolinska Institutet.
    Jansson, L.
    Karolinska Institutet.
    Andersson, E.
    Karolinska Institutet.
    Andersson, E.
    Karolinska Institutet.
    Blom, K.
    Karolinska Institutet.
    El Alaoui, S.
    Karolinska Institutet.
    Falk, L.
    Karolinska Institutet.
    Ivarsson, J.
    Karolinska Institutet.
    Nasri, B.
    Karolinska Institutet.
    Rydh, S.
    Karolinska Institutet.
    Lindefors, N.
    Karolinska Institutet.
    Effectiveness of Internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care2013In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 128, no 6, p. 457-467Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    Guided Internet-based cognitive behaviour therapy (ICBT) for panic disorder has been shown to be efficacious in several randomized controlled trials. However, the effectiveness of the treatment when delivered within routine psychiatric care has not been studied. The aim of this study was to investigate the effectiveness of ICBT for panic disorder within the context of routine psychiatric care.

    METHOD:

    We conducted a cohort study investigating all patients (n = 570) who had received guided ICBT for panic disorder between 2007 and 2012 in a routine care setting at an out-patient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Panic Disorder Severity Scale-Self-report (PDSS-SR).

    RESULTS:

    Participants made large improvements from screening and pretreatment assessments to posttreatment (Cohen's d range on the PDSS-SR = 1.07-1.55). Improvements were sustained at 6-month follow-up.

    CONCLUSION:

    This study suggests that ICBT for panic disorder is as effective when delivered in a routine care context as in the previously published randomized controlled trials.

  • 29.
    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.

  • 30.
    Hedman, Erik
    et al.
    Karolinska Institutet.
    Ljótsson, Brjánn
    Karolinska Institutet.
    Blom, Kerstin
    Karolinska Institutet.
    El Alaoui, Samir
    Karolinska Institutet.
    Kraepelien, Martin
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Svanborg, Cecilia
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Telephone vs. Internet-administration of self-report measures of social anxiety, depressive symptoms, and insomnia: psychometric validation of a method to reduce the impact of missing data2013In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 15, no 10, p. 1-8, article id e229Article in journal (Refereed)
    Abstract [en]

    Background: Internet-administered self-report measures of social anxiety, depressive symptoms, and sleep difficulties are widely used in clinical trials and in clinical routine care, but data loss is a common problem that could render skewed estimates of symptom levels and treatment effects. One way of reducing the negative impact of missing data could be to use telephone administration of self-report measures as a means to complete the data missing from the online data collection.

    Objective: The aim of the study was to compare the convergence of telephone and Internet administration of self-report measures of social anxiety, depressive symptoms, and sleep difficulties.

    Methods: The Liebowitz Social Anxiety Scale-Self-Report (LSAS-SR), Montgomery-Åsberg Depression Rating Scale-Self-Rated (MADRS-S), and the Insomnia Severity Index (ISI) were administered over the telephone and via the Internet to a clinical sample (N=82) of psychiatric patients at a clinic specializing in Internet-delivered treatment. Shortened versions of the LSAS-SR and the ISI were used when administered via telephone.

    Results: As predicted, the results showed that the estimates produced by the two administration formats were highly correlated (r=.82-.91; P<.001) and internal consistencies were high in both administration formats (telephone: Cronbach alpha=.76-.86 and Internet: Cronbach alpha=.79-.93). The correlation coefficients were similar across questionnaires and the shorter versions of the questionnaires used in the telephone administration of the LSAS-SR and ISI performed in general equally well compared to when the full scale was used, as was the case with the MADRS-S.

    Conclusions: Telephone administration of self-report questionnaires is a valid method that can be used to reduce data loss in routine psychiatric practice as well as in clinical trials, thereby contributing to more accurate symptom estimates.

  • 31.
    Hedman, Erik
    et al.
    Karolinska Institutet.
    Ljótsson, Brjánn
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Hesser, Hugo
    Linköping University.
    El Alaoui, Samir
    Karolinska Institutet.
    Kraepelien, Martin
    Karolinska Institutet.
    Andersson, Evelyn
    Karolinska Institutet.
    Rück, Christian
    Karolinska Institutet.
    Svanborg, Cecilia
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Lindefors, Nils
    Karolinska Institutet.
    Effectiveness of Internet-based cognitive behaviour therapy for depression in routine psychiatric care2014In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 155, p. 49-58Article in journal (Refereed)
    Abstract [en]

    Background

    Efficacy of guided Internet-based cognitive behaviour therapy (ICBT) for depression has been demonstrated in several randomised controlled trials. Knowledge on the effectiveness of the treatment, i.e. how it works when delivered within routine care, is however scarce. The aim of this study was to investigate the effectiveness of ICBT for depression.

    Methods

    We conducted a cohort study investigating all patients (N=1203) who had received guided ICBT for depression between 2007 and 2013 in a routine care setting at an outpatient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Montgomery Åsberg Depression Rating Scale-Self rated (MADRS-S).

    Results

    Patients made large improvements from pre-treatment assessments to post-treatment on the primary outcome (effect size d on the MADRS-S=1.27, 99% CI, 1.14–1.39). Participants were significantly improved in terms of suicidal ideation and sleep difficulties. Improvements were sustained at 6-month follow-up.

    Limitations

    Attrition was rather large at 6-month follow-up. However, additional data was collected through telephone interviews with dropouts and advanced statistical models indicated that missing data did not bias the findings.

    Conclusions

    ICBT for depression can be highly effective when delivered within the context of routine psychiatric care. This study suggests that the effect sizes are at least as high when the treatment is delivered in routine psychiatric care by qualified staff as when delivered in a controlled trial setting.

  • 32.
    Heinonen, Essi
    et al.
    Karolinska Institutet;Karolinska University Hospital.
    Szymanska-von Schultz, Barbara
    Karolinska Institutet;Karolinska University Hospital.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet;Stockholm Hlth Care Reg.
    Nasiell, Josefine
    Karolinska Institutet;Karolinska University Hospital.
    Andersson, Ewa
    Karolinska Institutet.
    Bergmark, Mikaela
    Stockholm Hlth Care Reg.
    Blomdahl-Wetterholm, Margareta
    Stockholm Hlth Care Reg.
    Forsberg, Lisa
    Forsell, Erik
    Karolinska Institutet;Stockholm Hlth Care Reg.
    Forsgren, Anna
    Karolinska Institutet.
    Froojd, Sandra
    Stockholm Hlth Care Reg.
    Goldman, Amy
    Stockholm Hlth Care Reg.
    Nordenadler, Eva-Mari
    Stockholm Hlth Care Reg.
    Sklivanioti, Myrto
    Stockholm Hlth Care Reg.
    Blennow, Mats
    Karolinska Institutet;Karolinska University Hospital.
    Wide, Katarina
    Karolinska Institutet;Karolinska University Hospital.
    Gustafsson, Lars L.
    Karolinska Institutet;Karolinska University Hospital.
    MAGDALENA: study protocol of a randomised, placebo-controlled trial on cognitive development at 2 years of age in children exposed to SSRI in utero2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 8, article id e023281Article in journal (Refereed)
    Abstract [en]

    Introduction Ten per cent of all pregnant women are depressed. Standard therapy of pregnant women with moderate depression is selective serotonin reuptakeinhibitors (SSRI). Observational studies on neurodevelopment after fetal SSRI exposure show conflicting results. Our primary objective is to compare the cognitive development in children exposed to sertraline and maternal depression with those exposed to maternal depression and placebo in utero. We hypothesise that there is a significant neurodevelopmental difference between the groups. As a secondary objective, we study the add-on effect of sertraline to internet-based cognitive behavioural therapy (ICBT) to treat moderate depression during pregnancy. Methods and analysis MAGDALENA is a randomised, placebo-controlled, double-blinded trial in Stockholm Healthcare Region with 2.3 million inhabitants. The women are recruited in weeks 9-21 of pregnancy either through Antenatal Health Clinics or through social media. They are to be diagnosed with moderate depression without ongoing antidepressive therapy or any serious comorbidity. The women in the intervention arm receive sertraline combined with a 12-week period of ICBT; the control arm is treated with placebo and ICBT. We assess the cognitive development in the offspring at the age of 2 years using Bayley Scales of Infant and Toddler Development, third edition (BSID-III). We aim at recruiting 200 women, 100 women in each treatment arm, to ensure statistical power to detect a clinically relevant difference between the groups. Ethics and dissemination This randomised trial will provide long-sought evidence about the effects of SSRI and maternal depression during pregnancy on the neurodevelopment in the offspring. The study is approved by the Regional Ethical Review Board at Karolinska Institutet in Stockholm and the Swedish Medical Products Agency. It is registered with the European Clinical Trials Database (EudraCT), Number: 2013-004444-31. Results will be disseminated at scientific conferences, published in peer-reviewed journals and made available to the public.

  • 33.
    Jernelov, S.
    et al.
    Karolinska Institutet.
    Lekander, M.
    Karolinska Institutet;Stockholm University.
    Blom, K.
    Karolinska Institutet.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet.
    One and ten-year follow-up of insomnia severity after a randomized trial of behavioral self-help treatment for insomnia with or without therapist guidance2018In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, Vol. 27Article in journal (Other academic)
  • 34.
    Jernelöv, Susanna
    et al.
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Larsson, Ylva
    Karolinska Institutet, Sweden.
    Llenas, Milagros
    Karolinska Institutet, Sweden.
    Nasri, Berkeh
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Effects and clinical feasibility of a behavioral treatment for sleep problems in adult attention deficit hyperactivity disorder (ADHD): a pragmatic within-group pilot evaluation2019In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 19, p. 1-12, article id 226Article in journal (Refereed)
    Abstract [en]

    BackgroundSleep disturbances, including insomnia, are common in adult Attention Deficit Hyperactivity Disorder (ADHD). Treatment of choice for insomnia is cognitive behavioral therapy (CBT-i), but evidence is lacking for CBT-i in patients with ADHD.The purpose of this study was to investigate if patients with insomnia and other sleep problems, at a specialist clinic for ADHD, benefit from a group delivered behavioral treatment based on CBT-i; whether insomnia severity improves following this treatment.MethodsThis pragmatic within-group pilot study with a pre to post and three-month follow-up design was set at a specialist psychiatric out-patient clinic for adult ADHD.As an adjunct to care-as-usual at the clinic, a CBT-i-based group treatment targeting several sleep problems prevalent in the ADHD-population, was offered as 10 weekly 90-min group sessions and scheduled telephone support.All outcome measures were subjectively reported by participants. Data analyzed with dependent t-tests according to intent-to-treat.ResultsNineteen patients (37 [SD 13.7] years; 68% female) with ADHD and subjectively reported sleep problems provided informed consent and pre-treatment measures. Patients had suffered from sleep problems for 15.3 [SD 13.4] years, 42% used sleep medications, 79% used stimulant medication(s).At post-treatment, insomnia severity (Insomnia Severity Index; score range 0-28) had improved with 4.5 points (95% CI, 2.06-6.99, p=.002), at 3months with 6.8 points (95% CI, 4.71-8.91, p<.0001) from pre-treatment.ConclusionsCBT-i adjusted for ADHD is promising for improving insomnia severity in adult patients at specialist psychiatric out-patient clinics, who suffer from ADHD and sleep disturbances.Trial registrationStudy registered with the Regional ethical review board in Stockholm, January 13th 2016, Study id: 2015/2078-31/1. Study registered retrospectively with Clinicaltrials.org, February 21st 2019, ID: NCT03852966.

  • 35.
    Kaldo, Viktor
    et al.
    Uppsala University Hospital.
    Haak, Thomas
    Uppsala University Hospital.
    Buhrman, Monica
    Uppsala University.
    Alfonsson, Sven
    Uppsala University.
    Larsen, Hans-Christian
    Uppsala University Hospital.
    Andersson, Gerhard
    Linköping University.
    Internet-based cognitive behaviour therapy for tinnitus patients delivered in a regular clinical setting: outcome and analysis of treatment dropout2013In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 42, no 2, p. 146-158Article in journal (Refereed)
    Abstract [en]

    Cognitive behaviour therapy (CBT) can reduce tinnitus distress but is not available for most patients. Therapist guided, internet-based CBT (ICBT) increase availability and has been shown to be effective. However, the initial positive results need to be replicated in larger samples, and treatment dropout has not been thoroughly studied. Moreover, it has not been evaluated if a low-intensity version of ICBT without therapist contact could be an alternative for patients who do not need or are able to manage the full ICBT-program. This study evaluated two parallel interventions delivered in regular care: ICBT for tinnitus distress (n = 293) and a low-intensity version of ICBT (n = 81) for patients with lower levels of tinnitus distress. We also explored predictors of dropout from ICBT and if dropout influences outcome. Tinnitus Reaction Questionnaire (Wilson, Henry, Bowen, & Haralambous, 1991) was used as the primary outcome. Secondary outcomes were measures of depression, anxiety, sleep, and sound sensitivity. Significant reductions following ICBT were found on all measures after treatment and also at a three-month follow-up. Patients receiving low-intensity ICBT showed a significant reduction in distress, even when they had low levels of distress initially. Treatment dropout was preceded by an increase in days spent at each treatment step but not by an increased distress. Early dropout was related to worse outcome. ICBT can be used in a regular clinical setting to reduce tinnitus distress. Early dropouts may need additional management. For help-seeking patients with lower distress, a low-intensity version of ICBT can be used.

  • 36.
    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.

  • 37.
    Kaldo, Viktor
    et al.
    Karolinska Institutet;Huddinge Hospital.
    Lundin, Andreas
    Karolinska Institutet.
    Hallgren, Mats
    Karolinska Institutet.
    Kraepelien, Martin
    Karolinska Institutet;Huddinge Hospital.
    Strid, Catharina
    Lund University.
    Ekblom, Örjan
    Swedish Sch Sport & Hlth Sci, GIH.
    Lavebratt, Catharina
    Karolinska Institutet;Karolinska University Hospital.
    Lindefors, Nils
    Karolinska Institutet;Huddinge Hospital.
    Öjehagen, Agneta
    Lund University.
    Forsell, Yvonne
    Karolinska Institutet.
    Effects of internet-based cognitive behavioural therapy and physical exercise on sick leave and employment in primary care patients with depression: two subgroup analyses2018In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 75, no 1, p. 52-58Article in journal (Refereed)
    Abstract [en]

    Objectives Depression can negatively impact work capacity, but treatment effects on sick leave and employment are unclear. This study evaluates if internet-based cognitive behavioural therapy (ICBT) or physical exercise (PE), with already reported positive effects on clinical outcome and short-term work ability, has better effects on employment, sick leave and long-term work ability compared with treatment as usual (TAU) for depressed primary care patients (German clinical trials: DRKS00008745). Methods After randomisation and exclusion of patients not relevant for work-related analysis, patients were divided into two subgroups: initially unemployed (total n=118) evaluated on employment, and employed (total n=703) evaluated on long-term sick leave. Secondary outcomes were self-rated work ability and average number of sick days per month evaluated for both subgroups. Assessments (self-reports) were made at baseline and follow-up at 3 and 12 months. Results For the initially unemployed subgroup, 52.6% were employed after 1 year (response rate 82%). Both PE (risk ratio (RR)=0.44; 95% CI 0.23 to 0.87) and ICBT (RR=0.37; 95% CI 0.16 to 0.84) showed lower rates compared with TAU after 3 months, but no difference was found after 1 year (PE: RR=0.97; 95% CI 0.69 to 1.57; ICBT: RR=1.23; 95% CI 0.72 to 2,13), For those with initial employment, long-term sick leave (response rate 75%) decreased from 7.8% to 6.5%, but neither PE (RR=1.4; 95% CI 0.52 to 3.74) nor ICBT (RR=0.99; 95% CI 0.39 to 2,46) decreased more than TAU, although a temporary positive effect for PE was found. All groups increased self-rated work ability with no differences found. Conclusions No long-term effects were found for the initially unemployed on employment status or for the initially employed on sick leave. New types of interventions need to be explored.

  • 38.
    Kaldo, Viktor
    et al.
    Karolinska Institutet.
    Ramnerö, Jonas
    Stockholm University.
    Jernelöv, Susanna
    Karolinska Institutet.
    Involving clients in treatment methods: A neglected interaction in the therapeutic relationship2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 6, p. 1136-1141, article id 2015-30577-001Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    The authors investigate a model on how clients' differential involvement in therapeutic methods mediates the effect of therapist support in psychological treatment-in this case, a cognitive behaviorally based bibliotherapy for insomnia, administered with or without supportive telephone calls.

    METHOD:

    Eighty-nine participants, who fulfilled diagnostic criteria for insomnia, had a mean age of 49.1 years (range, 18-73 years) and were predominantly female (77%), fairly well educated, and mainly Caucasian. Participants were randomized between a bibliotherapeutic self-help treatment and the same treatment with the addition of therapist support. Primary outcome measure was the Insomnia Severity Index. Data on involvement in different methods and aspects of the treatment were estimated by clients at posttreatment and validated against therapist ratings of client involvement during treatment. Structural equation modeling was used to test if the effect of therapeutic support on outcome was mediated by involvement in treatment.

    RESULTS:

    Carrying out the treatment with therapist support significantly boosted the therapeutic effects. A mediational analysis with involvement in the three key treatment methods (sleep restriction, sleep compression, and stimulus control) as the mediator fully mediated the differential effect between the two conditions (Sobel test; r = .31; z = 2.173; p < .05) and explained 68.4% of the total effect.

    CONCLUSIONS:

    Therapeutic support improved outcome via higher patient involvement rather than having a direct effect on outcome. Thus, relationship and methods could be regarded as interactional, and patient involvement should be considered. These factors could be further studied in treatments where specific ingredients within the therapeutic contact can be experimentally manipulated.

  • 39.
    Karyotaki, Eirini
    et al.
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Ebert, David Daniel
    Friedrich Alexander Univ Erlangen Nurnberg, Germany.
    Donkin, Liesje
    Univ Sydney, Australia.
    Riper, Heleen
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Twisk, Jos
    Vrije Univ Amsterdam, Netherlands.
    Burger, Simone
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Rozental, Alexander
    UCL, UK;Karolinska Institutet.
    Lange, Alfred
    Univ Amsterdam, Netherlands.
    Williams, Alishia D.
    Univ Utrecht, Netherlands.
    Zarski, Anna Carlotta
    Friedrich Alexander Univ Erlangen Nurnberg, Germany.
    Geraedts, Anna
    HumanTotalCare, Netherlands.
    van Straten, Annemieke
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Kleiboer, Annet
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Meyer, Bjoern
    Gaia AG, Res Dept, Germany;City Univ London, UK.
    Ince, Burgin B. Unlu
    Middle East Tech Univ, Turkey.
    Buntrock, Claudia
    Friedrich Alexander Univ Erlangen Nurnberg, Germany.
    Lehr, Dirk
    Leuphana Univ Luneburg, Germany.
    Snoek, Frank J.
    Vrije Univ Amsterdam Med Ctr, Netherlands.
    Andrews, Gavin
    Univ New South Wales, Australia.
    Andersson, Gerhard
    Linköping University;Karolinska Institutet.
    Choi, Isabella
    Univ Sydney, Australia.
    Ruwaard, Jeroen
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Klein, Jan Philipp
    Luebeck Univ, Germany.
    Newby, Jill M.
    Univ New South Wales, Australia;MRC Cognit & Brain Sci Unit, UK.
    Schroder, Johanna
    Univ Med Ctr Hamburg Eppendorf, Germany;Inst Sex Res & Forens Psychiat, Germany.
    Laferton, Johannes A. C.
    Friedrich Alexander Univ Erlangen Nurnberg, Germany.
    Van Bastelaar, Kim
    Vrije Univ Amsterdam Med Ctr, Netherlands.
    Imamura, Kotaro
    Univ Tokyo, Japan.
    Vernmark, Kristofer
    Linköping University.
    Boss, Leif
    Leuphana Univ Luneburg, Germany.
    Sheeber, Lisa B.
    Oregon Res Inst, USA.
    Kivi, Marie
    University of Gothenburg.
    Berking, Matthias
    Friedrich Alexander Univ Erlangen Nurnberg, Germany.
    Tito, Nickolai
    Macquarie Univ, Australia.
    Carlbring, Per
    Stockholm University;Univ Southern Denmark, Denmark.
    Johansson, Robert
    Linköping University;Karolinska Institutet.
    Kenter, Robin
    Univ Bergen, Norway.
    Perini, Sarah
    St Vincents Hosp, Australia.
    Moritz, Steffen
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Nobis, Stephanie
    Leuphana Univ Luneburg, Germany.
    Berger, Thomas
    Univ Bern, Switzerland.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet.
    Forsell, Yvonne
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kraepelien, Martin
    Karolinska Institutet.
    Bjorkelund, Cecilia
    University of Gothenburg.
    Kawakami, Norito
    Univ Tokyo, Japan.
    Cuijpers, Pim
    VU, Amsterdam Publ Hlth Res Inst, Netherlands.
    Do guided internet-based interventions result in clinically relevant changes for patients with depression?: An individual participant data meta-analysis2018In: Clinical Psychology Review, ISSN 0272-7358, E-ISSN 1873-7811, Vol. 63, p. 80-92Article, review/survey (Refereed)
    Abstract [en]

    Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients' groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR = 2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR = 2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR = 1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR = 1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving intemet-based treatment (OR = 1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.

  • 40.
    Kraepelien, Martin
    et al.
    Karolinska Institutet, Sweden.
    Blom, Kerstin
    Karolinska Institutet, Sweden;Haukeland Hosp, Norway.
    Lindefors, Nils
    Karolinska Institutet, Sweden.
    Johansson, Robert
    Stockholm University, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden.
    The effects of component-specific treatment compliance in individually tailored internet-based treatment2019In: Clinical Psychology and Psychotherapy, ISSN 1063-3995, E-ISSN 1099-0879, Vol. 26, no 3, p. 298-308Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to explore the effects of treatment compliance in a guided individually tailored internet-based treatment (TAIL) in relation to depression and co-morbid symptoms. Compliance with the homework in the different treatment components in TAIL, each aimed at a specific condition, was rated for 207 participants by independent assessors. Six subgroups (n = 34-131) were constructed consisting of participants with co-occurring symptoms of worry, panic, social anxiety, stress, insomnia, or pain. For each group, hierarchical regression was used to investigate whether the total sum of compliance points, Overall Compliance, predicted reductions in depression and in condition-specific symptoms. Also, in each subgroup, it was tested whether working with specific treatment components, Specific Compliance, predicted reduction of the targeted symptoms. Overall Compliance predicted 15% of the reduction in depression symptoms. For participants with worry, panic, social anxiety, stress, or insomnia, Overall Compliance also predicted symptom reductions in that specific condition. Specific Compliance predicted reduction in the targeted symptoms for participants with social anxiety, stress, and insomnia. Specific Compliance with stress and insomnia components also predicted reductions in depression. Our results strengthen the importance of compliance in internet-based treatments. Because compliance with stress and insomnia components was particularly important for broad symptom reductions, these conditions should not be ignored when treating patients with co-morbid symptoms.

  • 41.
    Kraepelien, Martin
    et al.
    Karolinska Institutet.
    Forsell, Erik
    Karolinska Institutet.
    Karin, Eyal
    Macquarie Univ, Australia.
    Johansson, Robert
    Karolinska Institutet;Stockholm University.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet.
    Comparing individually tailored to disorder-specific internet-based cognitive-behavioural therapy: benchmarking study2018In: BJPsych Open, E-ISSN 2056-4724, Vol. 4, no 4, p. 282-284Article in journal (Refereed)
    Abstract [en]

    Disorder-specific internet-based cognitive-behavioural therapy (ICBT) is effective for depression, panic disorder and social anxiety. In this benchmarking study, a new, individually tailored, ICBT programme (TAIL) showed effects on depression (n = 284, d = 1.33) that were non-inferior to disorder-specific ICBT for depression in routine care (n = 2358, d = 1.35). However, the hypotheses that TAIL for individuals with social anxiety or panic disorder is inferior to disorder-specific ICBT could not be rejected (social anxiety: TAIL d = 0.74 versus disorder-specific d = 0.81; panic: TAIL d = 1.11 versus disorder-specific d = 1.47). Our findings strengthen the empirical base for TAIL as an alternative to disorder-specific ICBT for depression. (c) The Royal College of Psychiatrists 2018.

  • 42.
    Kraepelien, Martin
    et al.
    Karolinska Institutet.
    Mattsson, Simon
    Karolinska Institutet.
    Hedman-Lagerlöf, Erik
    Karolinska Institutet.
    Petersson, Ingemar F.
    Lund University.
    Forsell, Yvonne
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet.
    Cost-effectiveness of internet-based cognitive-behavioural therapy and physical exercise for depression2018In: BJPsych Open, E-ISSN 2056-4724, Vol. 4, no 4, p. 265-273Article in journal (Refereed)
    Abstract [en]

    Background Both internet-based cognitive-behavioural therapy (ICBT) and physical exercise are alternatives to treatment as usual (TAU) in managing mild to moderate depression in primary care. Aims To determine the cost-effectiveness of ICBT and physical exercise compared with TAU in primary care. Method Economic evaluation of a randomised controlled trial (N=945) in Sweden. Costs were estimated by a service use questionnaire and used together with the effects on quality-adjusted life-years (QALYs). The primary 3-month healthcare provider perspective in primary care was complemented by a 1-year societal perspective. Results The primary analysis showed that incremental cost per QALY gain was (sic)8817 for ICBT and (sic)14 571 for physical exercise compared with TAU. At the established willingness-to-pay threshold of (sic) 21 536 ( pound 20 000) per QALY, the probability of ICBT being cost-effective is 90%, and for physical exercise is 76%, compared with TAU. Conclusions From a primary care perspective, both ICBT and physical exercise for depression are likely to be cost-effective compared with TAU. (c) The Royal College of Psychiatrists 2018.

  • 43.
    Kraepelien, Martin
    et al.
    Karolinska Institutet.
    Svenningsson, Per
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Internet-based cognitive behavioral therapy for depression and anxiety in Parkinson's disease: A pilot study2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 1, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Background

    Parkinson's disease (PD) is often associated with depression and anxiety. The availability of evidence-based psychological interventions is low.

    Objective

    This pilot study investigates the feasibility and preliminary effect of internet-based cognitive behavioral therapy (ICBT) for depression and anxiety in PD.

    Methods

    9 patients with PD with comorbid symptoms on the relevant subscale of Hospital Anxiety and Depression Scale (HADS), of either depression (HADS-D > 7) or anxiety (HADS-A > 7) received 12 weeks of ICBT, specially adapted for depression and anxiety in PD. Primary outcome was change in depression and anxiety symptoms, measured with HADS total score. Effects on non-motor symptoms, PD specific health and quality of life and insomnia were explored, plus the participant's involvement, satisfaction, and subjective evaluation of the treatment.

    Results

    Participants reported lower symptoms on HADS after ICBT (Cohen's d = 0.79, p < 0.05). However, levels of inactivity were rather high and questionnaires and comments from participants suggested that the treatment can be improved, for example by adding more therapist support.

    Conclusions

    The results suggest that ICBT could be a feasible way to alleviate depression and anxiety in PD. However, a somewhat simplified treatment and different ways to provide support to enhance adherence and outcome are warranted.

  • 44.
    Lancee, Jaap
    et al.
    Univ Amsterdam, Netherlands.
    van Straten, Annemieke
    Vrije Univ Amsterdam, Netherlands.
    Morina, Nexhmedin
    Univ Amsterdam, Netherlands.
    Kaldo, Viktor
    Karolinska Institutet.
    Kamphuis, Jan H.
    Univ Amsterdam, Netherlands.
    Guided Online or Face-to-Face Cognitive Behavioral Treatment for Insomnia: A Randomized Wait-List Controlled Trial2016In: Sleep, ISSN 0161-8105, E-ISSN 1550-9109, Vol. 39, no 1, p. 183-191Article in journal (Refereed)
    Abstract [en]

    Study Objectives: To compare the efficacy of guided online and individual face-to-face cognitive behavioral treatment for insomnia (CBT-I) to a wait-list condition. Methods: A randomized controlled trial comparing three conditions: guided online; face-to-face; wait-list. Posttest measurements were administered to all conditions, along with 3-and 6-mo follow-up assessments to the online and face-to-face conditions. Ninety media-recruited participants meeting the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for insomnia were randomly allocated to either guided online CBT-I (n = 30), individual face-to-face CBT-I (n = 30), or wait-list (n = 30). Results: At post-assessment, the online (Cohen d = 1.2) and face-to-face (Cohen d = 2.3) intervention groups showed significantly larger treatment effects than the wait-list group on insomnia severity (insomnia severity index). Large treatment effects were also found for the sleep diary estimates (except for total sleep time), and anxiety and depression measures (for depression only in the face-to-face condition). Face-to-face treatment yielded a statistically larger treatment effect (Cohen d = 0.9) on insomnia severity than the online condition at all time points. In addition, a moderate differential effect size favoring face-to-face treatment emerged at the 3-and 6-mo follow-up on all sleep diary estimates. Face-to-face treatment further outperformed online treatment on depression and anxiety outcomes. Conclusions: These data show superior performance of face-to-face treatment relative to online treatment. Yet, our results also suggest that online treatment may offer a potentially cost-effective alternative to and complement face-to-face treatment.

  • 45.
    Larsson, Billy P. M.
    et al.
    University of Gothenburg.
    Broberg, Anders G.
    University of Gothenburg.
    Kaldo, Viktor
    Karolinska Institutet.
    Do psychotherapists with different theoretical orientations stereotype or prejudge each other?2013In: Journal of Contemporary Psychotherapy, ISSN 0022-0116, E-ISSN 1573-3564, Vol. 43, no 3, p. 169-178Article in journal (Refereed)
    Abstract [en]

    This study investigates a possible threat to the progress of psychotherapy. It aims to detect and compare stereotyped or even prejudiced views among psychotherapists of different theoretical orientations, building on social psychological theory of in-groups and out-groups. Swedish psychotherapists (n = 416) of four different orientations (psychodynamic, cognitive, behavioural, or integrative/eclectic) used the valuable elements in psychotherapy questionnaire to rate the importance of various elements in psychotherapy. They also estimated how therapists of other orientations would rate these elements. These estimates were then compared with therapists’ actual self-ratings in order to detect patterns of stereotyping or prejudiced views. Psychotherapists exaggerate the differences between their own and other orientations in a stereotyped way, but correctly predict what members of their own orientation (in-group) find important. However, they overestimate how important ‘orientation-typical features’ are to those of other orientations (out-group), indicating a clear tendency to stereotype. Overall, integrative/eclectic therapists’ estimates were less stereotyped than the estimates of therapists of other orientations. A somewhat unexpected finding was that cognitive and behavioural therapists seem more inclined towards stereotyping. The stereotyped views of other theoretical orientations among psychotherapists can be argued to have negative connotations and may thus be seen as prejudices. These prejudices could create irrational and unnecessary obstacles to the development of both the science and the practice of psychotherapy and signal the need for psychotherapists of all orientations to develop a more balanced picture of each other.

  • 46.
    Löf, J
    et al.
    Stockholm County Council, Sweden.
    Clinton, D
    Karolinska Institutet, Sweden;Institute for Eating Disorders, Oslo, Norway.
    Kaldo, Viktor
    Stockholm County Council, Sweden;Karolinska Institutet, Sweden.
    Rydén, G
    Child and Adolescent Psychiatry Clinic, Stockholm, Sweden.
    Symptom, alexithymia and self-image outcomes of Mentalisation-based treatment for borderline personality disorder: a naturalistic study2018In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 18, no 1, p. 1-9, article id 185Article in journal (Refereed)
    Abstract [en]

    Background: Mentalisation-based treatment (MBT) in borderline personality disorder (BPD) has a growing evidence base, but there is a lack of effectiveness and moderator studies. The present study examined the effectiveness of MBT in a naturalistic setting and explored psychiatric and psychological moderators of outcome. 

    Method: Borderline and general psychiatric symptoms, suicidality, self-harm, alexithymia and self-image were measured in a group of BPD patients (n = 75) receiving MBT; assessments were made at baseline, and subsequently after 6, 12 and 18 months (when treatment ended). Borderline symptoms were the primary outcome variable. 

    Results: Borderline symptoms improved significantly (d = 0.79, p <.001), as did general psychiatric symptoms, suicidality, self-harm, self-rated alexithymiaand self-image. BPD severity or psychological moderators had no effect on outcome. Younger patients improved more on self-harm, although this could be explained by the fact that older patients had considerably lower baseline self-harm. 

    Conclusions: MBT seems to be an effective treatment in a naturalistic setting for BPD patients. This study is one of the first studies of MBT showing that outcomes related to mentalisation, self-image and self-rated alexithymia improved. Initial symptom severity did not influence results indicating that MBT treatment is well adapted to patients with severe BPD symptoms. 

    Trial registration: The study was retrospectively registered 25 September 2017 in the ClinicalTrials.gov PRS registry, no. NCT03295838.

  • 47.
    Moëll, Birger
    et al.
    Karolinska Institutet;Stockholm University.
    Kollberg, Linnea
    Karolinska Institutet.
    Nasri, Berkeh
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Living SMART - A randomized controlled trial of a guided online course teaching adults with ADHD or sub-clinical ADHD to use smartphones to structure their everyday life2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 1, p. 24-31Article in journal (Refereed)
    Abstract [en]

    Abstract

    Objective

    To evaluate an online intervention for adults with ADHD that aimed to improve organizational skills and attention with the help of smartphone applications.

    Method

    Participants (n = 57) were recruited and assessed through questionnaires and telephone interviews. Diagnoses of ADHD were confirmed for 83% of the participants, 5% most probably had the diagnoses, and 12% did not fulfill all diagnostic criteria despite high levels of symptoms. Participants were randomized between the intervention (n = 29) and a wait-list control group (n = 28). The 6-week intervention involved support from a coach in finding a routine for organizing everyday life with the help of smartphone applications. The primary outcome measure was ASRS Inattention. Secondary outcomes were ASRS sub-scale Hyperactivity and measures of depression, anxiety, stress, quality of life and general level of functioning. Blind evaluators also assessed improvement in organization and inattention at post treatment.

    Result

    The participants receiving the Living Smart course reduced their average scores on ASRS-Inattention from 28.1 (SD = 4.5) to 22.9 (SD = 4.3) which was a significantly larger reduction than found in the control group. 33% of participants were considered clinically significantly improved according to the blind evaluator, compared to 0% in the control group. The same results were found when only participants with a confirmed diagnose were included in the analyses.

    Conclusion

    Adults with ADHD seem to be able to use smartphone applications to organize their everyday life and can be taught how to do this via online interventions.

  • 48.
    Nasri, Berkeh
    et al.
    Karolinska Institutet;Huddinge hospital.
    Castenfors, Malin
    PRIMA Child and Adult Psychiatry, Stockholm.
    Fredlund, Peggy
    Huddinge hospital.
    Ginsberg, Ylva
    Karolinska Institutet;Huddinge hospital.
    Lindefors, Nils
    Karolinska Institutet;Huddinge hospital.
    Kaldo, Viktor
    Karolinska Institutet;Huddinge hospital.
    Group Treatment for Adults With ADHD Based on a Novel Combination of Cognitive and Dialectical Behavior Interventions: A Feasibility Study2017In: Journal of Attention Disorders, ISSN 1087-0547, E-ISSN 1557-1246Article in journal (Refereed)
    Abstract [en]

    Objectives: To evaluate feasibility and preliminary effects of a new group treatment manual for adults with ADHD and to explore adherence to treatment and its relation to outcome. Method:Eighteen adults with ADHD recruited from neuropsychiatric units in Stockholm underwent a 14-week program including combined cognitive and dialectical behavior therapy. Assessments were made at baseline, posttreatment, and follow-up, at one and six months after treatment end. Primary outcome measure was the Adult ADHD Self Report Scale version 1.1. Results/Conclusion: ADHD symptoms significantly decreased (d = 1.29) and remained stable for 6 months. Measures of depression, perceived stress, and anxiety were also significantly reduced. Attendance and patient satisfaction was high. Use, comprehension, and perceived benefit of treatment components varied from medium to high. Total use of treatment components was, in general, positively correlated with favorable outcome. The current combination of treatment components may be a valuable addition to available treatments in psychiatric care.

  • 49.
    Rahman, M. S.
    et al.
    Karolinska Institutet, Sweden.
    Zhao, X.
    Karolinska Institutet, Sweden.
    Liu, J. J.
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Torres, E. Q.
    Karolinska Institutet, Sweden.
    Tibert, B.
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Kumar, P.
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden.
    Lindefors, N.
    Karolinska Institutet, Sweden.
    Forsell, Y.
    Karolinska Institutet, Sweden.
    Lavebratt, C.
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Exercise Reduces Salivary Morning Cortisol Levels in Patients with Depression2019In: Molecular Neuropsychiatry, ISSN 2296-9209, Vol. 4, no 4, p. 196-203Article in journal (Refereed)
    Abstract [en]

    Purpose of the Study: Cortisol hypersecretion plays a role in depression pathophysiology. Internet-based cognitive behavioural therapy (ICBT) and physical exercise (PE) are new treatment alternatives for depression, and their long-lasting effect on cortisol is unknown. We investigated cortisol level changes after 12 weeks of ICBT, PE or treatment as usual (TAU).

    Procedures: The present pre-post repeated measure study analysed data derived from a randomised controlled trial evaluating the effects of 12 weeks’ interventions of ICBT, PE and TAU in depressed primary care patients (Sweden 2011–2013) and aimed at prospectively evaluating the within-group effects of ICBT, PE and TAU on diurnal salivary cortisol levels in a small representative subsample (n = 56, 38 and 27, respectively).

    Results: We found a marked flattening of the diurnal cortisol slope (p = 0.004) and a reduced cortisol level at awakening (p = 0.017) after 12 weeks of PE treatment. No apparent effects of ICBT or TAU interventions were seen on diurnal cortisol levels.

    Conclusions and Message: PE reduced the rate of cortisol level decline across the day in depressed adults. ICBT and TAU treatments had no detectable effects on diurnal cortisol levels. Larger samples are required for the detection and comparison of smaller effects of PE, ICBT and TAU on diurnal cortisol levels.

  • 50.
    Rosen, A.
    et al.
    Karolinska Institutet.
    Jernelov, S.
    Karolinska Institutet.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet.
    Forsell, E.
    Karolinska Institutet.
    Akerstedt, T.
    Karolinska Institutet.
    D'onofrio, P.
    Stockholm University.
    Cognitive behavior therapy for insomnia - is sleep compression an equally effective and less difficult alternative compared to sleep restriction?2018In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, Vol. 27Article in journal (Other academic)
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