Fredrik Holländare

A Comparison of Psychometric Properties Between Internet and Paper Versions of Two Depression Instruments (BDI-II and MADRS-S) Administered to Clinic Patients

Background Self-report measures can guide clinical decisions and are useful when evaluating treatment outcomes. However, many clinicians do not use self-report measures systematically in their clinical practice. Internet-based questionnaires could facilitate administration, but the psychometric properties of the online version of an instrument should be explored before implementation. The recommendation from the International Test Commission is to test the psychometric properties of each questionnaire separately. Objective Our objective was to compare the psychometric properties of paper-and-pencil versions and Internet versions of two questionnaires measuring depressive symptoms. Methods The 87 participating patients were recruited from primary care and psychiatric care within the public health care system in Sweden. Participants completed the Beck Depression Inventory (BDI-II) and the Montgomery-Åsberg Depression Rating Scale—Self-rated (MADRS-S), both on paper and on the Internet. The order was randomized to control for order effects. Symptom severity in the sample ranged from mild to severe depressive symptoms. Results Psychometric properties of the two administration formats were mostly equivalent. The internal consistency was similar for the Internet and paper versions, and significant correlations were found between the formats for both MADRS-S (r = .84) and the BDI-II (r = .89). Differences between paper and Internet total scores were not statistically significant for either questionnaire nor for the MADRS-S question dealing with suicidality (item 9) when analyzed separately. The score on the BDI-II question about suicidality (item 9) was significantly lower when administered via the Internet compared with the paper score, but the difference was small (effect size, Cohen’s [d] = 0.14). There were significant main effects for order of administration on both questionnaires and significant interaction effects between format and order. This should not, however, pose a problem in clinical use as long as the administration format is not changed when repeated measurements are made. Conclusions The MADRS-S can be transferred to online use without affecting the psychometric properties in a clinically meaningful way. The full BDI-II also seems to retain its properties when transferred; however, the item measuring suicidality in the Internet version needs further investigation since it was associated with a lower score in this study. The use of online questionnaires offers clinicians a more practical way of measuring depressive symptoms and has the potential to save resources.

Randomized trial of Internet-based relapse prevention for partially remitted depression

Holländare F, Johnsson S, Randestad M, Tillfors M, Carlbring P, Andersson G, Engström I. Randomized trial of Internet‐based relapse prevention for partially remitted depression.

Development of a New Approach to Guided Self-Help via the Internet: The Swedish Experience

ABSTRACT This article describes the development and empirical status of guided Internet-delivered self-help. The treatment approach combines the benefits of bibliotherapy with book-length text materials and the support given online via web pages and e-mail. Interactive features such as online registrations, tests, and online discussion forums are also included. Cognitive behavior therapy (CBT) guided the research and clinical implementations of this approach, as it lends itself more easily to the self-help format compared with other presently available psychotherapy approaches. We include an overview of the research, current issues and research in service delivery, lessons learned through a program of research, and directions for future investigations.

Two-year outcome of internet-based relapse prevention for partially remitted depression.

The objective of the study was to investigate the long-term effects of internet-based relapse prevention for sufferers of partially remitted depression. Eighty-four individuals with partially remitted unipolar depression were randomized to either internet-based CBT (iCBT) or to a control group. After the ten week intervention period the participants were followed for 24 months and diagnostic interviews conducted to detect relapse. The intervention and monthly self-ratings of depressive symptoms were administered via an internet-based platform that ensured secure communication with all participants. Significantly fewer participants in the iCBT group had experienced a relapse compared with those in the control group two years after the internet-based intervention. The relapse rate in the iCBT group was 13.7% (CI 95%=2.5-24.9) and in the control group it was 60.9% (CI 95%=44.8-77). Furthermore, a significantly larger proportion of the iCBT group experienced remission two years after the intervention compared with the control group. Internet-based CBT seems promising for preventing relapse in sufferers of partially remitted depression.

Group cognitive behavioural therapy for insomnia: Effects on sleep and depressive symptomatology in a sample with comorbidity.

AIM To investigate the effects of group CBT for insomnia (CBT-I) on insomnia and depressive symptomatology in a comorbid sample through a randomised controlled trial with a 6 month follow-up. METHODS 64 participants were recruited through advertisements and randomised to receive CBT-I or an active control (relaxation training: RT) during four group sessions. Insomnia Severity Index and BDI-II were the primary outcome measures, assessed pre-treatment, post-treatment and at 6 month follow-up. Insomnia and depressive diagnoses, and functional impairment were assessed before and after treatment, whereas sleep diary data was gathered continuously from one week before treatment until after treatment. RESULTS CBT-I was more efficient than RT in reducing insomnia severity and equally effective in reducing depressive symptoms, although CBT-I was associated with a higher proportion of remitted persons than RT, regarding both insomnia and depression diagnoses. Also, CBT-I was associated with less functional impairment, shorter sleep onset latency and wake after sleep onset but both treatments had equal improvements of sleep quality, early morning awakenings and total sleep time. CONCLUSION Group CBT-I is an efficient form of insomnia-treatment for people with insomnia comorbid with depressive symptomatology. The mixed results regarding depression outcomes warrants replication and further studies into treatment mechanisms.

Internet delivered cognitive behavior therapy for antenatal depression : A randomised controlled trial

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-Åsberg 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.

Therapist behaviours in internet-based cognitive behaviour therapy (ICBT) for depressive symptoms

Internet-based cognitive behaviour therapy (ICBT) is efficacious for treating depression, with therapist guidance identified as important for favourable outcomes. We have limited knowledge, however, about the fundamental components of therapist guidance in ICBT. The purpose of this study was to systematically examine therapist messages sent to patients during the course of ICBT for depressive symptoms in order to identify common “therapist behaviours” and the extent to which these behaviours correlate with completion of modules and improvements in symptoms at post-treatment, one- and two-year follow-up. A total of 664 e-mails from 5 therapists to 42 patients were analysed using qualitative content analysis. The most frequent behaviour was encouraging that accounted for 31.5% of the total number of coded behaviours. This was followed by affirming (25.1%), guiding (22.2%) and urging (9.8%). Less frequently the therapists clarified the internet treatment framework, informed about module content, emphasised the importance of patient responsibility, confronted the patient and made self-disclosures. Six of the nine identified therapist behaviours correlated with module completion. Three behaviours correlated with symptom improvement. Affirming correlated significantly (r = .42, p = .005) with improvement in depressive symptoms at post-treatment and after two years (r = .39, p = .014). Encouraging was associated with outcome directly after treatment (r = .52, p = .001). Self-disclosure was correlated with improvement in depressive symptoms at post-treatment (r = .44, p = .003). The study contributes to a better understanding of therapist behaviours in ICBT for depressive symptoms. Future directions for research are discussed.

Internet-Based Cognitive Behavioral Therapy for Residual Symptoms in Bipolar Disorder Type II: A Single-Subject Design Pilot Study

Background Bipolar disorder is a chronic condition with recurring episodes that often lead to suffering, decreased functioning, and sick leave. Pharmacotherapy in the form of mood stabilizers is widely available, but does not eliminate the risk of a new depressive or (hypo)manic episode. One way to reduce the risk of future episodes is to combine pharmacological treatment with individual or group psychological interventions. However, access to such interventions is often limited due to a shortage of trained therapists. In unipolar depression there is now robust evidence of the effectiveness of Internet-based psychological interventions, usually comprising psychoeducation and cognitive behavioral therapy (CBT). Internet-based interventions for persons suffering from bipolar disorder could increase access to psychological treatment. Objective The aim of this study was to investigate the feasibility of an Internet-based intervention, as well as its effect on residual depressive symptoms in persons diagnosed with bipolar disorder type II (BP-II). The most important outcomes were depressive symptoms, treatment adherence, and whether the patient perceived the intervention as helpful. Methods A total of 7 patients diagnosed with bipolar disorder type II at a Swedish psychiatric outpatient clinic were offered the opportunity to participate. Of the 7 patients, 3 (43%) dropped out before treatment began, and 4 (57%) were treated by means of an online, Internet-based intervention based on CBT (iCBT). The intervention was primarily aimed at psychoeducation, treatment of residual depressive symptoms, emotion regulation, and improved sleep. All patients had ongoing pharmacological treatment at recruitment and established contact with a psychiatrist. The duration of BP-II among the treated patients was between 6 and 31 years. A single-subject design was used and the results of the 4 participating patients were presented individually. Results Initiating treatment was perceived as too demanding under current life circumstances for 3 patients who consequently dropped out during baseline assessment. Self-ratings using the Montgomery-Åsberg Depression Rating Scale—Self-rated (MADRS-S) showed symptom reduction in 3 (75%) of the 4 treated cases during iCBT. In the evaluation of the treatment, 2 patients reported that they perceived that the treatment had reduced symptoms a little, 1 that it had reduced symptoms very much, and 1 not at all. Treatment adherence (ie, module completion) was fairly high in 3 cases. In general, the modules were perceived as fairly helpful or very helpful by the patients. In one case, there was a reliable change—according to the Reliable Change Index—in self-rated symptoms of depression and perseverative thinking. Conclusions The treatment seemed to have acceptable feasibility. The iCBT intervention could be an effective way to treat residual symptoms in some patients with bipolar disorder type II. This should be investigated in a larger study. Trial Registration ClinicalTrials.gov NCT01742351; https://clinicaltrials.gov/ct2/show/NCT01742351 (Archived by WebCite at http://www.webcitation.org/6XnVpv4C3).

Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome

Abstract Background and aims Validating and invalidating responses play an important role in communication with pain patients, for example regarding emotion regulation and adherence to treatment. However, it is unclear how patients’ perceptions of validation and invalidation relate to patient characteristics and treatment outcome. The aim of this study was to investigate the occurrence of subgroups based on pain patients’ perceptions of validation and invalidation from their physicians. The stability of these perceptions and differences between subgroups regarding pain, pain interference, negative affectivity and treatment outcome were also explored. Methods A total of 108 pain patients answered questionnaires regarding perceived validation and invalidation, pain severity, pain interference, and negative affectivity before and after pain rehabilitation treatment. Two cluster analyses using perceived validation and invalidation were performed, one on pre-scores and one on post-scores. The stability of patient perceptions from pre- to post-treatment was investigated, and clusters were compared on pain severity, pain interference, and negative affectivity. Finally, the connection between perceived validation and invalidation and treatment outcome was explored. Results Three clusters emerged both before and after treatment: (1) low validation and heightened invalidation, (2) moderate validation and invalidation, and (3) high validation and low invalidation. Perceptions of validation and invalidation were generally stable over time, although there were individuals whose perceptions changed. When compared to the other two clusters, the low validation/heightened invalidation cluster displayed significantly higher levels of pain interference and negative affectivity post-treatment but not pre-treatment. The whole sample significantly improved on pain interference and depression, but treatment outcome was independent of cluster. Unexpectedly, differences between clusters on pain interference and negative affectivity were only found post-treatment. This appeared to be due to the pre- and post-heightened invalidation clusters not containing the same individuals. Therefore, additional analyses were conducted to investigate the individuals who changed clusters. Results showed that patients scoring high on negative affectivity ended up in the heightened invalidation cluster post-treatment. Conclusions Taken together, most patients felt understood when communicating with their rehabilitation physician. However, a smaller group of patients experienced the opposite: low levels of validation and heightened levels of invalidation. This group stood out as more problematic, reporting greater pain interference and negative affectivity when compared to the other groups after treatment. Patient perceptions were typically stable over time, but some individuals changed cluster, and these movements seemed to be related to negative affectivity and pain interference. These results do not support a connection between perceived validation and invalidation from physicians (meeting the patients pre- and post-treatment) and treatment outcome. Overall, our results suggest that there is a connection between negative affectivity and pain interference in the patients, and perceived validation and invalidation from the physicians. Implications In clinical practice, it is important to pay attention to comorbid psychological problems and level of pain interference, since these factors may negatively influence effective communication. A focus on decreasing invalidating responses and/or increasing validating responses might be particularly important for patients with high levels of psychological problems and pain interference.

Internet delivered transdiagnostic treatment with telephone support for pain patients with emotional comorbidity: a replicated single case study

In pain patients, comorbid emotional problems have been linked to negative outcomes, including suboptimal treatment gains. Developing parsimonious and accessible treatment options is therefore important. The overarching aim of this study was to test an internet delivered therapist guided transdiagnostic treatment with telephone support. An adapted version of the Unified Protocol for Transdiagnostic Treatments of Emotional Disorders was used as an intervention for pain patients with residual pain problems and comorbid emotional problems after having received a multimodal pain rehabilitation. The study used a replicated AB single case experimental design (N = 5; 3 females). Outcome measures were depressive and general anxiety symptoms, pain intensity, pain coping problems, and diagnostic status. Feasibility measures (completion and compliance) and patient satisfaction were also assessed. Scores on Nonoverlap of All Pairs (NAP) indicate a decrease of anxiety for three participants and a decrease of depression for four participants. Decreases were small and did not always reach statistical significance. Also, Tau-U scores could only confirm a reliable trend for one participant. Two out of four patients who were diagnosed with psychiatric disorders before treatment did no longer fulfill diagnostic criteria posttreatment. No improvements could be seen on pain problems. The treatment was feasible and patient satisfaction was high. Hence, while an internet delivered transdiagnostic treatment with telephone support may be a feasible and accepted secondary intervention for pain patients with comorbid emotional problems, the effects are unclear. The gap between high patient satisfaction and small changes in symptomatology should be explored further.