Filip K Arnberg

Internet-Delivered Psychological Treatments for Mood and Anxiety Disorders: A Systematic Review of Their Efficacy, Safety, and Cost-Effectiveness

Background Greater access to evidence-based psychological treatments is needed. This review aimed to evaluate whether internet-delivered psychological treatments for mood and anxiety disorders are efficacious, noninferior to established treatments, safe, and cost-effective for children, adolescents and adults. Methods We searched the literature for studies published until March 2013. Randomized controlled trials (RCTs) were considered for the assessment of short-term efficacy and safety and were pooled in meta-analyses. Other designs were also considered for long-term effect and cost-effectiveness. Comparisons against established treatments were evaluated for noninferiority. Two reviewers independently assessed the relevant studies for risk of bias. The quality of the evidence was graded using an international grading system. Results A total of 52 relevant RCTs were identified whereof 12 were excluded due to high risk of bias. Five cost-effectiveness studies were identified and three were excluded due to high risk of bias. The included trials mainly evaluated internet-delivered cognitive behavioral therapy (I-CBT) against a waiting list in adult volunteers and 88% were conducted in Sweden or Australia. One trial involved children. For adults, the quality of evidence was graded as moderate for the short-term efficacy of I-CBT vs. waiting list for mild/moderate depression (d = 0.83; 95% CI 0.59, 1.07) and social phobia (d = 0.85; 95% CI 0.66, 1.05), and moderate for no efficacy of internet-delivered attention bias modification vs. sham treatment for social phobia (d = −0.04; 95% CI −0.24, 0.35). The quality of evidence was graded as low/very low for other disorders, interventions, children/adolescents, noninferiority, adverse events, and cost-effectiveness. Conclusions I-CBT is a viable treatment option for adults with depression and some anxiety disorders who request this treatment modality. Important questions remain before broad implementation can be supported. Future research would benefit from prioritizing adapting treatments to children/adolescents and using noninferiority designs with established forms of treatment.

Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioral disorders: A review of current practice

BACKGROUND Data suggest that certain psychological interventions can induce harm in a significant number of patients. While the need for adequate reporting of harms in clinical trials has repeatedly been emphasized, it is uncertain whether such information is routinely collected and reported in trials within this research field. METHOD We used the two major databases in clinical psychology and medicine (PsycINFO and PubMed) to identify original publications from 2010 reporting randomized controlled trials of psychological interventions for patients with mental and behavioral disorders. Two reviewers searched the full-text reports for information about monitoring of adverse events, side effects, and deterioration. RESULTS A total of 132 eligible trials were identified. Only 28 trials (21%) included information that indicated any monitoring of harms on patient level. Four (3%) of these trials provided a description of adverse events as well as the methods used for collecting these data. Five of the trials (4%) reported adverse events but did not give complete information about the method. An additional four reports (3%) briefly stated that no adverse events occurred, whereas 15 trials (11%) only provided information on deterioration or indicated monitoring of deterioration. The probability of including harm-related information was related to the journal impact factor. CONCLUSION Important information about harms is not reported systematically within this research field, suggesting that the risk of reporting bias is nontrivial in conclusions about the risk-benefit ratio of psychological treatments. Guidelines on how to define, detect, and report harms related to psychological interventions could facilitate better reporting.

Social Support Moderates Posttraumatic Stress and General Distress After Disaster

Social support buffers the negative impact of stressful events. Less, however, is known about the characteristics of this association in the context of disaster and findings have been discrepant regarding direct and buffering effects. This study tested whether the protective effects of social support differed across levels of exposure severity (i.e., buffered distress) and assessed whether the buffering effect differed between event-specific and general distress. Participants were 4,600 adult Swedish tourists (44% of invited; 55% women) repatriated within 3 weeks after the 2004 Indian Ocean tsunami. A survey 14 months after the disaster included the Crisis Support Scale, the Impact of Event Scale-Revised (IES-R), and the General Health Questionnaire (GHQ-12). Social support buffered the negative impact of exposure on both outcomes. The support and distress association ranged from very small in participants with low exposure to moderate in those with high exposure (η(p)(2) = .004 to .053). The buffering effect was not found to differ between the IES-R and GHQ-12, F(2, 4589) = 0.87, p = .42. The findings suggest that social support moderates the stressor-distress relationship after disasters. This study might help explain discrepant findings and point to refinements of postdisaster interventions.

Impact of Exposure to Trauma on Posttraumatic Stress Disorder Symptomatology in Swedish Tourist Tsunami Survivors

The aim was to examine long-term mental health and posttraumatic stress symptomatology in a Swedish tourist population after exposure to the 2004 Southeast Asian tsunami. Data from 4822 returned questionnaires 14 months after the disaster were analyzed. Respondents were categorized into 3 subgroups: (1) danger-to-life exposure group (having been caught or chased by the waves), (2) nondanger-to-life exposure group (exposed to other disaster-related stressors), and (3) low exposure group. Main outcome measures were General Health Questionnaire-12 and Impact of Event Scale-22-Revised. Danger-to-life exposure was an important factor in causing more severe posttraumatic stress symptoms and in affecting mental health. Female gender, single status, and former trauma experiences were associated with greater distress. Other factors related to more severe symptoms were loss of relatives, physical injuries, viewing many dead bodies, experiencing life threat, and showing signs of cognitive confusion. Disaster exposure has a substantial impact on survivors, which stresses the need for long-lasting support.

The Effect of Traumatic Bereavement on Tsunami-Exposed Survivors

Fourteen months after the 2004 tsunami, mental health outcome was assessed in 187 bereaved relatives, 308 bereaved friends, and in 3,020 nonbereaved Swedish survivors. Of the bereaved relatives, 41% reported posttraumatic stress reactions and 62% reported impaired general mental health. Having been caught or chased by the tsunami in combination with bereavement was associated with increased posttraumatic stress reactions. Complicated grief reactions among relatives were almost as frequent as posttraumatic stress reactions. The highest levels of psychological distress were found among those who had lost children. Traumatic bereavement, in combination with exposure to life danger, is probably a risk factor for mental health sequelae after a natural disaster.

Traumatic bereavement, acute dissociation, and posttraumatic stress : 14 years after the MS Estonia disaster

This prospective longitudinal study aimed to examine posttraumatic stress in survivors 14 years after a ferry disaster, and estimate short- and long-term changes in stress associated with traumatic bereavement and acute dissociation. There were 852 people who perished in the disaster, 137 survived. The 51 Swedish survivors were surveyed with the Impact of Event Scale-Revised (IES-R) at 3 months, 1, 3, and 14 years (response rates 82%, 65%, 51%, and 69%). Symptoms decreased from 3 months to 1 year; no change was found thereafter. After 14 years, 27% reported significant symptoms. Traumatic bereavement, but not acute dissociation, was associated with long-term symptom elevation. Chronic posttraumatic stress can persist in a minority of survivors, and traumatic bereavement appears to hinder recovery.

Six years after the wave. Trajectories of posttraumatic stress following a natural disaster

BACKGROUND The characteristics of long-term trajectories of distress after disasters are unclear, since few studies include a comparison group. This study examines trajectories of recovery among survivors in comparison to individuals with indirect exposure. METHODS Postal surveys were sent to Swedish tourists, repatriated from the 2004 Indian Ocean tsunami (n=2268), at 1, 3, and 6 years after the tsunami to assess posttraumatic stress (PTS) and poor mental health. Items were used to ascertain high and moderate disaster exposure groups and an indirect exposure comparison group. RESULTS Long-term PTS trajectories were best characterized by a resilient (72.3%), a severe chronic (4.6%), a moderate chronic (11.2%) and a recovering (11.9%) trajectory. Trajectories reported higher levels of PTS than the comparison group. Exposure severity and bereavement were highly influential risk factors. CONCLUSIONS These findings have implications regarding anticipation of long-term psychological adjustment after natural disasters and need for interventions after a single traumatic event with few secondary stressors.

Prevalence and duration of PTSD in survivors 6 years after a natural disaster

The present study aimed to examine the prevalence of posttraumatic stress disorder (PTSD) in survivors with low levels of risk factors for PTSD. The sample included 142 adults (58% women, 54% university education, 93% employed/students/retired) on vacation in Southeast Asia during the 2004 Indian Ocean disaster. Semi-structured clinical interviews (SCID-I) were performed after 6 years including PTSD, depression, specific phobia, and alcohol abuse. The 6-year prevalence of PTSD was 11.3% and the current prevalence was 4.2%, with onset mainly within 1 month and remission within 3 years post-disaster. Suicidal ideation and comorbidity were common in PTSD cases. Lifetime prevalence of depression was 19%, specific phobia 7%, and alcohol abuse 4%. The findings suggest elevated levels of PTSD but not other disorders as compared with general population samples, but still lower levels than other disaster samples. Despite benign circumstances, however, the course and burden of PTSD were comparable to similar studies.

Post-disaster psychosocial services across Europe: The TENTS project

At present post-disaster activities and plans seem to vary widely. An adequate estimation of the availability of post-disaster psychosocial services across Europe is needed in order to compare them with recently developed evidence-informed psychosocial care guidelines. Here we report on the results of a cross-sectional web-based survey completed in 2008 by two hundred and eighty-six representatives of organizations involved in psychosocial responses to trauma and disaster from thirty-three different countries across Europe. The survey addressed planning and delivery of psychosocial care after disaster, methods of screening and diagnosis, types of interventions used, and other aspects of psychosocial care after trauma. The findings showed that planning and delivery of psychosocial care was inconsistent across Europe. Countries in East Europe seemed to have less central coordination of the post-disaster psychosocial response and fewer post-disaster guidelines that were integrated into specific disaster or contingency plans. Several forms of psychological debriefing, for which there is no evidence of efficacy to date, were still used in several areas particularly in North Europe. East European countries delivered evidence-based interventions for PTSD less frequently, whilst in South- and South-Eastern European countries anxiety suppressing medication such as benzodiazepines were prescribed more frequently to disaster victims than in other areas. Countries across Europe are currently providing sub-optimal psychosocial care for disaster victims. This short report shows that there is an urgent need for some countries to abandon non-effective interventions and others to develop more evidence based and effective services to facilitate the care of those involved in future disasters.

Psychiatric disorders and suicide attempts in Swedish survivors of the 2004 southeast Asia tsunami: a 5 year matched cohort study

BACKGROUND Survivors of natural disasters are thought to be at an increased risk of psychiatric disorders, however the extent of this risk, and whether it is linked to pre-existing psychopathology, is not known. We aimed to establish whether Swedish survivors of tsunamis from the 2004 Sumatra-Andaman earthquake had increased risks of psychiatric disorders and suicide attempts 5 years after repatriation. METHODS We identified Swedish survivors repatriated from southeast Asia (8762 adults and 3742 children) and 864 088 unexposed adults and 320 828 unexposed children matched for sex, age, and socioeconomic status. We retrieved psychiatric diagnoses and suicide attempts from the Swedish patient register for the 5 years after the tsunami (from Dec 26, 2004, to Jan 31, 2010) and estimated hazard ratios (HRs), then adjusted for pre-tsunami psychiatric disorders, and, for children, for parental pre-tsunami disorders. FINDINGS Exposed adults were more likely than unexposed adults to receive any psychiatric diagnosis (547 [6·2%] vs 47 734 [5·5%]; adjusted HR 1·21, 95% CI 1·11-1·32), particularly stress-related disorders (187 [2·1%] vs 8831 [1·0%]; 2·27, 1·96-2·62) and suicide attempts (38 [0·43%] vs 2752 [0·32%]; 1·54, 1·11-2·13), but not mood or anxiety disorders. Risk of psychiatric diagnoses did not differ between exposed and unexposed children and adolescents (248 [6·6] vs 22 081 [6·9%]; 0·98, 0·86-1·11), although exposed children and adolescents had a higher risk for suicide attempts with uncertain intent (1·43; 1·01-2·02) and stress-related disorders (1·79; 1·30-2·46), mainly during the first 3 months after the tsunami. INTERPRETATION The 2004 tsunami was, independently of previous psychiatric morbidity, associated with an increased risk of severe psychopathology, mainly stress-related disorders and suicide attempts, in children and adults. Survivors of natural disasters should be targeted with early interventions and active long-term follow-up to prevent, detect, and alleviate psychiatric disorders that might follow. FUNDING The Swedish Council for Working Life and Social Research, Swedish Board of Health and Welfare, Polish Ministry of Science and Higher Education, Swedish Society for Medical Research.