Eva-Lisa Petersson

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.

Exercise or basic body awareness therapy as add-on treatment for major depression: A controlled study

BACKGROUND While physical exercise as adjunctive treatment for major depression has received considerable attention in recent years, the evidence is conflicting. This study evaluates the effects of two different add-on treatments: exercise and basic body awareness therapy. METHODS Randomized controlled trial with two intervention groups and one control, including 62 adults on antidepressant medication, who fulfilled criteria for current major depression as determined by the Mini International Neuropsychiatric Interview. Interventions (10 weeks) were aerobic exercise or basic body awareness therapy (BBAT), compared to a single consultation with advice on physical activity. Primary outcome was depression severity, rated by a blinded assessor using the Montgomery Asberg Rating Scale (MADRS). Secondary outcomes were global function, cardiovascular fitness, self-rated depression, anxiety and body awareness. RESULTS Improvements in MADRS score (mean change=-10.3, 95% CI (-13.5 to -7.1), p=0.038) and cardiovascular fitness (mean change=2.4ml oxygen/kg/min, 95% CI (1.5 to 3.3), p=0.017) were observed in the exercise group. Per-protocol analysis confirmed the effects of exercise, and indicated that BBAT has an effect on self-rated depression. LIMITATIONS The small sample size and the challenge of missing data. Participants׳ positive expectations regarding the exercise intervention need to be considered. CONCLUSIONS Exercise in a physical therapy setting seems to have effect on depression severity and fitness, in major depression. Our findings suggest that physical therapy can be a viable clinical strategy to inspire and guide persons with major depression to exercise. More research is needed to clarify the effects of basic body awareness therapy.

Capacity to work while depressed and anxious--a phenomenological study.

Abstract Purpose: The aim was to explore experiences of capacity to work in persons working while depressed and anxious in order to identify the essence of the phenomenon capacity to work. Method: Four focus groups were conducted with 17 participants employed within the regular job market. Illness experiences ranged from symptoms to clinical diagnoses. A phenomenological approach was employed. Results: The phenomenon of capacity to work was distinguished by nine constituents related to task, time, context and social interactions. The phenomenon encompassed a lost familiarity with one’s ordinary work performance, the use of a working facade and adoption of new time-consuming work practices. Feelings of exposure in interpersonal encounters, disruption of work place order, lost “refueling” and a trade-off of between work capacity and leisure-time activities was also identified. The reduced capacity was pointed out as invisible, this invisibility was considered troublesome. Conclusions: A complex and comprehensive concept emerged, not earlier described in work capacity studies. Rehabilitation processes would benefit from deeper knowledge of the individual’s capacity to work in order to make efficient adjustments at work. Results can have particular relevance both in clinical and occupational health practice, as well as in the workplaces, in supporting re-entering workers after sickness absence. Implications for Rehabilitation The reduced capacity to work due to depression and anxiety is not always understandable or observable for others, therefore, the rehabilitation process would benefit from increased knowledge and understanding of the difficulties afflicted individuals experience at work. Identifying tasks that contribute to “refueling” at work might enhance the success of the rehabilitation. Rehabilitation programs could be tailored to better address the inabilities that impact on the capacity to work when depressed and anxious.

To score or not to score: a qualitative study on GPs views on the use of instruments for depression

BACKGROUND To improve the detection, diagnosis and follow-up of depression in primary care patients, it has been proposed that GPs should employ assessment instruments as a complement to the consultation. However, most GPs do not use such instruments routinely. OBJECTIVE To explore perceptions of Swedish GPs on the use of instruments in the medical consultation. METHODS Twenty-seven GPs discussed in five focus groups that were digitally recorded, transcribed verbatim and analysed by systematic text condensation. RESULTS Six code groups emerged from the focus group discussions: (i) a perceived pressure from authorities and psychiatry to report depression scores; (ii) the scores were considered to be of limited value for the GP but could help the patient by facilitating sick leave compensation and hospitalization; (iii) instruments hampered the dialogue with the patient and non-verbal information was lost; (iv) the reliability of questionnaires was questioned; (v) instruments were seen as not fitting into primary care and GPs were uncertain how to use them and (vi) the main advantage of instruments was to promote communication with specific categories of patients. CONCLUSIONS Using instruments to obtain a quantitative score of depression was of no benefit to the GPs. Given the weak evidence for the clinical relevance of many instruments, there is little reason to introduce them into practice. However, the instruments can facilitate communication with external actors and specific groups of patients.

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.

Patients’ perspectives on the use of the Montgomery-Asberg depression rating scale self-assessment version in primary care

Abstract Objective: The aim of the current study was to better understand how patients with depression perceive the use of MADRS-S in primary care consultations with GPs. Design: Qualitative study. Focus group discussion and analysis through Systematic Text Condensation. Setting: Primary Health Care, Region Västra Götaland, Sweden. Subjects: Nine patients with mild/moderate depression who participated in a RCT evaluating the effects of regular use of the Montgomery-Åsberg Depression Self-assessment scale (MADRS-S) during the GP consultations. Main Outcome measure: Patients’ experiences and perceptions of the use of MADRS-S in primary care. Results: Three categories emerged from the analysis: (I) confirmation; MADRS-S shows that I have depression and how serious it is, (II) centeredness; the most important thing is for the GP to listen to and take me seriously and (III) clarification; MADRS-S helps me understand why I need treatment for depression. Conclusion: Use of MADRS-S was perceived as a confirmation for the patients that they had depression and how serious it was. MADRS-S showed the patients something black on white that describes and confirms the diagnosis. The informants emphasized the importance of patient-centeredness; of being listened to and to be taken seriously during the consultation. Use of self-assessment scales such as MADRS-S could find its place, but needs to adjust to the multifaceted environment that primary care provides. Key Points Patients with depression in primary care perceive that the use of a self-assessment scale in the consultation purposefully can contribute in several ways. The scale contributes to Confirmation: MADRS-S shows that I have depression and how serious it is. Centeredness: The most important thing is for the GP to listen to and take me seriously. Clarification: MADRS-S helps me understand why I need treatment for depression.

Creating a safety net for patients with depression in primary care; a qualitative study of care managers’ experiences

Abstract Objective: The aim of this study was to explore nurses’ experiences and perceptions of working as care managers at primary care centers. Design: Qualitative, focus group study. Systematic text condensation was used to analyze the data. Setting: Primary health care in the region of Västra Götaland and region of Dalarna in Sweden. Subjects: Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support. Main outcome measures: The nurses’ experiences and perceptions of working as care managers at primary care centers. Results: The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression. Conclusion: The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care. Key Points   The care managers described their role as an additional support to the already existing care at the primary care center.  •  They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression.  •  Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful.  •  Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.