Dominique Hange

Internet-Based Therapy for Mild to Moderate Depression in Swedish Primary Care: Short Term Results from the PRIM-NET Randomized Controlled Trial

Depression presents a serious condition for the individual and a major challenge to health care and society. Internet-based cognitive behavior therapy (ICBT) is a treatment option supported in several trials, but there is as yet a lack of effective studies of ICBT in “real world” primary care settings. We examined whether ICBT differed from treatment-as-usual (TAU) in reducing depressive symptoms after 3 months. TAU comprised of visits to general practitioner, registered nurse, antidepressant drugs, waiting list for, or psychotherapy, or combinations of these alternatives. Patients, aged ≥ 18 years, who tentatively met criteria for mild to moderate depression at 16 primary care centers in the south-western region of Sweden were recruited and then assessed in a diagnostic interview. A total of 90 patients were randomized to either TAU or ICBT. The ICBT treatment included interactive elements online, a workbook, a CD with mindfulness and acceptance exercises, and minimal therapist contact. The treatment period lasted for 12 weeks after which both groups were assessed. The main outcome measure was Beck Depression Inventory-II (BDI-II). Additional measures were Montgomery Åsberg Depression Rating Scale – self rating version (MADRS-S) and Beck Anxiety Inventory (BAI). The analyses revealed no significant difference between the two groups at post treatment, neither on BDI-II, MADRS-S, nor BAI. Twenty patients (56%) in the ICBT treatment completed all seven modules. Our findings suggest that ICBT may be successfully delivered in primary care and that the effectiveness, after 3 months, is at par with TAU.

Prevalence of perceived stress and associations to symptoms of exhaustion, depression and anxiety in a working age population seeking primary care - an observational study

BackgroundProlonged stress may lead to mental illness, but the prevalence of stress in a working age population seeking primary health care for whatever reason, is unknown. This paper seeks to examine to what extent this group perceives stress, as well as symptoms of burnout/exhaustion, depression and anxiety.MethodsIn 2009, 587 primary health care patients aged 18–65 years (377 women, 210 men), with an appointment with a primary health care physician, participated in the study.A screening questionnaire with questions about age, gender, marital status, employment, reason for medical consultation, and the QPS Nordic screening question about stress was distributed:” Stress is defined as a condition where you feel tense, restless, anxious or worried or cannot sleep at night because you think of problems all the time. Do you feel that kind of stress these days? There were five possible answers; “not at all” and ”only a little” (level 1),“to some extent” (level 2),“rather much” and “very much” (level 3). In a second step, symptoms of burnout/exhaustion (Shirom-Melamed Burnout Questionnaire and the Self-rated Exhaustion Disorder instrument) and anxiety/depression (Hospital Depression and Anxiety scale) were assessed among those with higher levels of perceived stress.Results345 (59%) of the study patients indicated stress levels 2 or 3 (237 women and 108 men). Women more often indicated increased levels of stress than men. Two thirds of the participants expressing stress levels 2–3 indicated a high degree of burnout, and approximately half of them indicated Exhaustion Disorder (ED). Among highly stressed patients (level 3), 33% reported symptoms indicating possible depression and 64% possible anxiety.ConclusionMore than half of this working age population perceived more than a little stress, as defined, women to a greater extent than men. Symptoms of burnout and exhaustion were common. A high level of perceived stress was often accompanied by symptoms of depression and/or anxiety.

Perceived mental stress in women associated with psychosomatic symptoms, but not mortality: observations from the Population Study of Women in Gothenburg, Sweden.

Purpose To investigate possible association between mental stress and psychosomatic symptoms, socioeconomic status, lifestyle, as well as incident mortality in a middle-aged female population followed over 37 years. Methods A prospective observational study initiated in 1968–1969, including 1462 women aged 60, 54, 50, 46, and 38 years, with follow-ups in 1974–1975, 1980–1981, and 2000–2001, was performed. Measures included self-reported mental stress as well as psychosomatic symptoms and smoking, physical activity, total cholesterol, S-triglycerides, body mass index, waist–hip ratio, blood pressure, socioeconomic status and mortality. Results Smoking, not being single, and not working outside home were strongly associated with reported mental stress at baseline. Women who reported high mental stress in 1968–1969 were more likely to report presence of abdominal symptoms (odds ratio [OR] = 1.85, 95% confidence interval [CI]: 1.39–2.46), headache/migraine (OR = 2.04, 95% CI: 1.53–2.72), frequent infections (OR = 1.75, 95% CI: 1.14–2.70), and musculoskeletal symptoms (OR = 1.70, 95% CI: 1.30–2.23) than women who did not report mental stress. Women without these symptoms at baseline 1968–1969, but with perceived mental stress were more likely to subsequently report incident abdominal symptoms (OR = 2.15, 95% CI: 1.39–3.34), headache/migraine (OR = 2.27, 95% CI: 1.48–3.48) and frequent infections (OR = 2.21, 95% CI: 1.12–4.36) in 1974–1975 than women without mental stress in 1968–1969. There was no association between perceived mental stress at baseline and mortality over 37 years of follow-up. Conclusion Women reporting mental stress had a higher frequency of psychosomatic symptoms than women who did not report these symptoms. Not working outside home and smoking rather than low socioeconomic status per se was associated with higher stress levels. Perception of high mental stress was not associated with increased mortality.

Comparison Between the Montgomery-Asberg Depression Rating Scale-Self and the Beck Depression Inventory II in Primary Care.

OBJECTIVE The Montgomery-Asberg Depression Rating Scale-Self (MADRS-S) and the Beck Depression Inventory II (BDI-II) are commonly used self-assessment instruments for screening and diagnosis of depression. The BDI-II has 21 items and the MADRS-S has 9 items. These instruments have been tested with psychiatric inpatients but not in outpatient primary care, where most patients with symptoms of depression initially seek treatment. The purpose of this study was to compare these 2 instruments in the primary care setting. METHOD Data were collected from 2 primary care randomized controlled trials that were performed from 2010 to 2013 in Sweden: the Primary Care Self-Assessment MADRS-S Study and Primary Care Internet-Based Cognitive Behavioral Therapy Study. There were 146 patients (73 patients each from both trials) who had newly diagnosed mild or moderate depression (per DSM-IV recommendations) and who had assessment with both the MADRS-S and BDI-II at primary care centers. Comparability and reliability of the instruments were estimated by Pearson product moment correlation and Cronbach α. RESULTS A good correlation was observed between the 2 instruments: 0.66 and 0.62 in the 2 study cohorts. The reliability within the 2 study cohorts was good for both MADRS-S (Cronbach α: 0.76 for both cohorts) and BDI-II items (Cronbach α: 0.88 and 0.85). CONCLUSIONS The 2 instruments showed good comparability and reliability for low, middle, and high total depression scores. The MADRS-S may be used as a rapid, easily administered, and inexpensive tool in primary care and has results comparable to the BDI-II in all domains.

Long-term effects of Internet-delivered cognitive behavioral therapy for depression in primary care – the PRIM-NET controlled trial

Abstract Objective: Internet-delivered cognitive behavioral therapy (ICBT) is recommended as an efficient treatment alternative for depression in primary care. However, only few previous studies have been conducted at primary care centers (PCCs). We evaluated long-term effects of ICBT treatment for depression compared to treatment as usual (TAU) in primary care settings. Design: Randomized controlled trial. Setting: Patients were enrolled at16 PCCs in south-west Sweden. Participants: Patients attending PCCs and diagnosed with depression (n = 90). Interventions: Patients were assessed by a primary care psychologist/psychotherapist and randomized to ICBT or TAU. The ICBT included an ICBT program consisting of seven modules and weekly therapist e-mail or telephone support during the 3-month treatment period. Main outcome measures: Questionnaires on depressive symptoms (BDI-II), quality of life (EQ-5D) and psychological distress (GHQ-12) were administered at baseline, with follow-ups at 3, 6 and 12 months. Antidepressants and sedatives use, sick leave and PCC contacts were registered. Results: Intra-individual change in depressive symptoms did not differ between the ICBT group and the TAU group during the treatment period or across the follow-up periods. At 3-month follow-up, significantly fewer patients in ICBT were on antidepressants. However, the difference leveled out at later follow-ups. There were no differences between the groups concerning psychological distress, sick leave or quality of life, except for a larger improvement in quality of life in the TAU group during the 0- to 6-month period. Conclusions: ICBT with weekly minimal therapist support in primary care can be equally effective as TAU among depressed patients also over a 12-month period. Clinical trial registration: The trial was registered in the Swedish Registry, researchweb.org, ID number 30511.

Patients’ experiences of a computerised self-help program for treating depression – a qualitative study of Internet mediated cognitive behavioural therapy in primary care

Abstract Objective: The objective of this study was to explore primary care patients’ experiences of Internet mediated cognitive behavioural therapy (iCBT) depression treatment. Design: Qualitative study. Data were collected from focus group discussions and individual interviews. Setting: Primary care. Method: Data were analysed by systematic text condensation by Malterud. Subjects: Thirteen patients having received iCBT for depression within the PRIM-NET study. Main outcome measures: Analysis presented different aspects of patients’ experiences of iCBT. Results: The informants described a need for face-to-face meetings with a therapist. A therapist who performed check-ups and supported the iCBT process seemed important. iCBT implies that a responsibility for the treatment is taken by the patient, and some patients felt left alone, while others felt well and secure. This was a way to work in privacy and freedom with a smoothly working technology although there was a lack of confidence and a feeling of risk regarding iCBT. Conclusion: iCBT is an attractive alternative to some patients with depression in primary care, but not to all. An individual treatment design seems to be preferred, and elements of iCBT could be included as a complement when treating depression in primary care. Such a procedure could relieve the overall treatment burden of depression. Key points Internet mediated cognitive behavioural therapy (iCBT) can be effective in treating depression in primary care, but patients’ experiences of iCBT are rarely studied • Most patients express a need for human contact, real-time interaction, dialogue and guidance when treated for depression. • The patient’s opportunity to influence the practical circumstances about iCBT is a success factor, though this freedom brings a large responsibility upon the receiver. • An individual treatment design seems to be crucial, and elements of iCBT could be included as a complement to face-to-face meetings.

experiences of staff members participating in primary care research activities: a qualitative study

Background The aim of this paper was to study primary care staff members’ experiences and perceptions of participating in a randomized controlled trial concerning Internet therapy. Methods Data were collected via five focus groups, each containing four to eight nurses or general practitioners. The systematic text condensation method described by Malterud was used for thematic analysis of meaning and content of data across cases. Results The informants believed it was important to conduct research within the primary care setting, but it was difficult to combine clinical work and research. They stressed also that there was a need for continuous information and communication between primary care centers and researchers as well as internally at each primary care center. Conclusion Staff members’ experiences of participating in a research study were positive, although associated with various difficulties. It is important to include staff members when designing clinical studies; information should be given continuously during the study and communication facilitated between different occupational groups working at the primary care center.

A 32-year longitudinal study of alcohol consumption in Swedish women: Reduced risk of myocardial infarction but increased risk of cancer

Objective. To assess associations between the intake of different types of alcoholic beverages and the 32-year incidence of myocardial infarction, stroke, diabetes, and cancer, as well as mortality, in a middle-aged female population. Design. Prospective study. Setting. Gothenburg, Sweden, population about 430 000. Subjects. Representative sample of a general population of women (1462 in total) aged 38 to 60 years in 1968–1969, followed up to the ages of 70 to 92 years in 2000–2001. Main outcome measures. Associations between alcohol intake and later risk of mortality and morbidity from myocardial infarction, stroke, diabetes, and cancer, studied longitudinally. Results. During the follow-up period, 185 women developed myocardial infarction, 162 developed stroke, 160 women became diabetic, and 345 developed cancer. Women who drank beer had a 30% lower risk (hazards ratio (HR) 0.70, 95% confidence interval (CI) 0.50–0.95) of developing myocardial infarcion and almost half the risk (HR 0.51 CI 0.33–0.80). A significant association between increased risk of death from cancer and high spirits consumption was also shown (hazards ratio [HR] 1.47, CI 1.06–2.05). Conclusions. Women with moderate consumption of beer had a reduced risk of developing myocardial infarction. High spirits consumption was associated with increased risk of cancer mortality.

The natural history of psychosomatic symptoms and their association with psychological symptoms: Observations from the Population Study of Women in Gothenburg

Objective: To study the prevalence of subjective unspecified psychological symptoms (UPS) in a cohort of middle-aged women and the development of psychosomatic symptoms over 24 years. Methods: In 1968–1969, 1462 randomly selected women, aged 38, 46, 50, 54 and 60, were recruited. A 24-year follow-up was performed in 1992–1993 (n=836). The same structured interview concerning psychological and psychosomatic symptoms was used on both occasions. Results: The prevalence of UPS was 28% in 1968–1969 and 20% in 1992–1993. Women with UPS in 1968–1969 were significantly more likely to have asthma/obstructive symptoms (34% vs 26%), headache (38% vs 22%) and abdominal symptoms (40% vs 21%), but not hypertension/high blood pressure (28% vs 28%), than women who did not report UPS. In 1992–1993, women with UPS in 1968–1969 were significantly still more likely to have asthmatic (25% vs 18%) and abdominal symptoms (44% vs 33%). Sixty-one per cent of women with UPS in 1968–1969 did not report such symptoms in 1992–1993, compared to 86% of women without UPS in 1968–1969 (p<0.001). Conclusion: Women reporting UPS seemed to have a higher frequency of simultaneous psychosomatic symptoms than women not reporting UPS. However, having UPS was apparently unassociated with the development of psychosomatic symptoms over time. Psychosomatic symptoms in women seem to be self-limiting and decrease with time.

Reducing menopausal symptoms for women during the menopause transition using group education in a primary health care setting—a randomized controlled trial

OBJECTIVES Womens physical and mental ill-health shows a marked increase during menopause, which usually occurs between 45 and 55 years of age. Mental illness and somatic symptoms are common causes of long-term sick leave. Women suffer from a lack of knowledge about the menopause transition and its associated symptoms. The aim of the study was to investigate whether group education for women in primary health care (PHC) about the menopause transition can improve their physical and mental ill-health. STUDY DESIGN This randomized controlled study was conducted in PHC and aimed to evaluate a group education programme for women aged 45-55 years, around the menopause transition. A total of 131 women were randomized to group education or no intervention. The group intervention included two education sessions with topics related to menopause. They answered two questionnaires at baseline and at four-month follow-up: the Menopause Rating Scale (MRS) and the Montgomery-Asberg Depression Rating Scale (MADRS). MAIN OUTCOME MEASURE Change in MRS and MADRS scores over the four months. RESULTS The intervention group experienced a slight reduction in symptoms while the control group mostly experienced the opposite. CONCLUSION This study showed that it was feasible to implement group education on menopause for women aged 45-55 years. THE CLINICAL TRIAL REGISTRATION NUMBER NTC02852811.