Viktor Kaldo

A randomized controlled trial of Internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus.

OBJECTIVE Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format. METHOD Ninety-nine participants (mean age = 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n = 32), ACT (n = 35), or a control condition (monitored Internet discussion forum; n = 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up. RESULTS Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [-17.03, -2.94], d = 0.70, and 95% CI [-16.29, -2.53], d = 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [-44.65, -20.45], d = 1.34), with no significant difference between treatments (95% CI [-14.87, 11.21], d = 0.16). CONCLUSIONS Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

Internet-based cognitive behaviour therapy for obsessive–compulsive disorder: a randomized controlled trial

Background Cognitive behaviour therapy (CBT) is an effective treatment for obsessive–compulsive disorder (OCD) but access to CBT is limited. Internet-based CBT (ICBT) with therapist support is potentially a more accessible treatment. There are no randomized controlled trials testing ICBT for OCD. The aim of this study was to investigate the efficacy of ICBT for OCD in a randomized controlled trial. Method Participants (n=101) diagnosed with OCD were randomized to either 10 weeks of ICBT or to an attention control condition, consisting of online supportive therapy. The primary outcome measure was the Yale–Brown Obsessive Compulsive Scale (YBOCS) administered by blinded assessors. Results Both treatments lead to significant improvements in OCD symptoms, but ICBT resulted in larger improvements than the control condition on the YBOCS, with a significant between-group effect size (Cohens d) of 1.12 (95% CI 0.69–1.53) at post-treatment. The proportion of participants showing clinically significant improvement was 60% (95% CI 46–72) in the ICBT group compared to 6% (95% CI 1–17) in the control condition. The results were sustained at follow-up. Conclusions ICBT is an efficacious treatment for OCD that could substantially increase access to CBT for OCD patients. Replication studies are warranted.

Internet versus group cognitive-behavioral treatment of distress associated with tinnitus: a randomized controlled trial.

Tinnitus distress can be reduced by means of cognitive-behavior therapy (CBT), and the treatment can be delivered in different ways. The most recent format is Internet-based self-help. The aim of this study was to compare this treatment (n= 26) with standard group-based CBT (n=25) in a randomized controlled trial. Outcomes on self-report inventories measuring tinnitus distress were evaluated immediately after and 1 year after treatment. Results showed that both groups had improved, and there were few differences between them. The effect size for the Internet treatment was d=0.73 (95% CI=0.16-1.30) and for the group treatment was d=0.64 (95% CI=0.07-1.21). The Internet treatment consumed less therapist time and was 1.7 times as cost-effective as the group treatment. At pretreatment patients rated the Internet treatment as less credible than the group treatment. In conclusion, Internet treatment for tinnitus distress merits further investigation, as the outcomes achieved are promising.

Effectiveness of Internet-based cognitive behaviour therapy for depression in routine psychiatric care

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.

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.

Effectiveness of Internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care

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.

Internet-based cognitive behavior therapy for obsessive compulsive disorder: A pilot study

BackgroundCognitive behavior therapy (CBT) is widely regarded as an effective treatment for obsessive compulsive disorder (OCD), but access to CBT therapists is limited. Internet-based CBT (ICBT) with therapist support is a way to increase access to CBT but has not been developed or tested for OCD. The aim of this study was to evaluate ICBT for OCD.MethodAn open trial where patients (N = 23) received a 15-week ICBT program with therapist support consisting of psychoeducation, cognitive restructuring and exposure with response prevention. The primary outcome was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which was assessed by a psychiatrist before and immediately after treatment. Secondary outcomes were self-rated measures of OCD symptoms, depressive symptoms, general functioning, anxiety and quality of life. All assessments were made at baseline and post-treatment.ResultsAll participants completed the primary outcome measure at all assessment points. There were reductions in OCD symptoms with a large within-group effect size (Cohens d = 1.56). At post-treatment, 61% of participants had a clinically significant improvement and 43% no longer fulfilled the diagnostic criteria of OCD. The treatment also resulted in statistically significant improvements in self-rated OCD symptoms, general functioning and depression.ConclusionsICBT with therapist support reduces OCD symptoms, depressive symptoms and improves general functioning. Randomized trials are needed to confirm the effectiveness of this new treatment format.Trial RegistrationClinicalTrials.gov: NCT01348529

Physical exercise and internet-based cognitive-behavioural therapy in the treatment of depression: randomised controlled trial

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.

D-Cycloserine vs Placebo as Adjunct to Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder and Interaction With Antidepressants: A Randomized Clinical Trial.

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: t62 = -3.00; P = .004; and t61 = -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. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01649895.

Treatment of tinnitus in the elderly : A controlled trial of cognitive behavior therapy

The aim of the study was to investigate the effects of cognitive behavioral therapy (CBT) in elderly people with tinnitus (<65 years). Thirty-seven patients were called in for a structured interview. Following exclusion, twenty-three participated in the trial. All participants underwent medical ear, nose, and throat (ENT) examination, audiometry, and tinnitus matchings. A randomized controlled design with a waiting list control group was used. A CBT treatment package was delivered in six weekly two hour group sessions. Outcome was measured using validated self-report inventories and daily diary ratings of annoyance, loudness and sleep quality for one week pre-treatment, post-treatment. A three month follow-up was included at which time all participants had received treatment, but in a shorter format for the control group. Results showed statistically significant reductions of tinnitus-related distress. Thus, CBT was better than no treatment, but the particular aspects of CBT that contributed to the effects can not be established. In conclusion, the findings give some support for the use of group CBT for elderly people with tinnitus. Sumario El objetivo de este estudio fue investigar los efectos de la terapia conductual cognitiva (CBT) en ancianos con acúfeno (<65 años) Se llamaron 37 pacientes para una entrevista estructurada y de ellos 23 participaron en la prueba después de un proceso de exclusión. Todos los participantes fueron objeto de un examen médico ORL, audiometría y acufenometría. Se uso un diseño controlado al azar con un grupo de control de una lista de espera. Se dio un paquete de tratamiento en sesiones grupales de 2 horas seis veces por semana. Los resultados se midieron usando cuestionarios de autoreporte y las anotaciones diarias del índice de molestia, intensidad subjetiva y calidad del sueño durante una semana previa y una posterior al tratamiento, pero en un formato corto para el grupo control. Los resultados muestran reducciones estadísticamente significativas del malestar relacionado con el acúfeno. Así, la CBT se considera mejor que la ausencia de tratamiento. Pero los aspectos particulares de la CBT que contribuyeron a obtener esos efectos no pueden ser establecidos. En conclusión, los hallazgos apoyan en alguna forma el uso de CBT grupal para ancianos con acúfeno.