| 1. |
- Alaie, Iman
(författare)
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Adulthood Outcomes of Child and Adolescent Depression : From Mental Health to Social Functioning
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Depression is a common mental disorder affecting people across the lifespan, with first onset frequently occurring in the teenage years. The disorder is costly to society and constitutes one of the leading causes of disability in youths and adults worldwide. Research demonstrates that depression in childhood or adolescence is linked to adverse adult consequences, including mental health problems, physical health issues, various social difficulties, and economic hardships. While the specific factors and mechanisms associated with these long-term adversities are not well understood, previous studies point to the relevance of considering the heterogeneity in early-life depression.The overarching aim of this doctoral thesis was to shed more light on long-term outcomes of childhood and adolescent depression across multiple life domains. This work made use of extensive follow-up data gathered in Sweden and USA, as part of two community-based longitudinal cohort studies of depressed and nondepressed youths prospectively followed into adulthood. In the Uppsala Longitudinal Adolescent Depression Study, participants were interviewed around age 16 (n=631) and age 31 (n=409). Using linkage to nationwide population-based registries, participants were followed up around age 40 (n=576). In the Great Smoky Mountains Study, participants were interviewed at repeated occasions in childhood and adolescence (n=1,420), and at further follow-ups in adulthood extending up to age 30 (n=1,336).Findings from this work suggest that childhood/adolescent depression can have long-lasting associations with a broad spectrum of adverse outcomes. First, the risk of adult depression is known to be elevated among those exposed to depression in early life; however, depressed youths experiencing major conflicts with parents may be at an additionally increased risk of subsequent depression recurrence. Second, early-life depression was found to be associated with higher levels of adult psychiatric disorders, and also with worse health, criminal, and social functioning, even when accounting for a multitude of potential confounders. Third, early-life depression was predictive of poor labor market outcomes, especially for those with persistent depression. This link was partially mediated by the course of depression. Fourth, the welfare burden associated with early depression amounted to considerable public expenditures in adulthood, particularly for those with persistent depression or comorbid psychiatric conditions such as anxiety and disruptive behavior disorders.The adverse long-term consequences in the wake of early-life depression underscore the importance of prevention and treatment approaches that are both efficacious and cost-effective. Such targeted efforts may have the potential to avert later ill-health, impairment, and possibly also economic disadvantage.
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| 2. |
- Cernvall, Martin, 1980-
(författare)
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Symptoms of Posttraumatic Stress in Parents of Children on Cancer Treatment : Factor Structure, Experiential Avoidance, and Internet-based Guided Self-help
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Having a child diagnosed with cancer is stressful and many parents of children on treatment for cancer report symptoms of posttraumatic stress (PTSS). The overall purpose was to, among parents of children on treatment for cancer, investigate the factor structure of PTSS; investigate the relationships between experiential avoidance (EA), rumination, PTSS and depression; and to develop, test, and evaluate a guided self-help intervention provided via the internet.In a longitudinal study with three assessments (n = 249-203) results indicated that a four-factor solution of PTSS including the factors re-experiencing, avoidance, dysphoria, and hyper-arousal provided best fit and that the pattern and size of factor loadings were equivalent across the three assessments (Study I). In a case study with pre-, post-, and follow-up assessments a guided self-intervention was well received with clinical significant and reliable improvements in PTSS, depression, and quality of life (Study II). Furthermore, in cross-sectional analyses (n = 79) EA and rumination were positively associated with PTSS and depression and provided incremental explanation in depression while controlling for demographic characteristics, anxiety, and PTSS. In longitudinal analyses (n = 20), EA but not rumination predicted PTSS and depression while controlling for initial levels (Study III). Finally, in a randomized controlled trial with parents fulfilling the modified symptom criteria on the PTSD-Checklist allocated to guided self-help via the internet (n = 31) or to a wait-list control condition (n = 27) there was a significant intervention effect with a large effect size for the primary outcome PTSS. Similar results were observed for the secondary outcomes depression and anxiety, but not for EA and rumination. Exploratory analyses suggested that the relationships between EA and PTSS and between EA and depression were weakened in the intervention group (Study IV).The studies included in the current thesis suggest that a four-factor solution should be used when assessing PTSS in parents of children on cancer treatment. Furthermore, rumination and EA in particular seem to be important constructs to consider when understanding PTSS and depression in this population. Finally, guided self-help via the internet shows promise in reducing PTSS and depression among parents of children on cancer treatment who report a high level of PTSS.
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| 3. |
- Coumoundouros, Chelsea
(författare)
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E-mental health interventions for informal caregivers : Development with a focus on implementation
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The four studies within this thesis contributed to the identification of key factors to be considered when designing and implementing e-mental health (e-MH) interventions for informal caregivers. Study I was a mixed-methods systematic review to examine factors related to the effectiveness and implementation of e-MH interventions for informal caregivers of adults with chronic diseases. A thematic synthesis with deductive coding using the Consolidated Framework for Implementation Research (CFIR) identified 152 implementation barriers and facilitators. Barriers and facilitators primarily related to intervention and user characteristics. Exploration of barriers and facilitators related to the implementation setting or wider context was limited.Study II was a cross-sectional survey to examine contextual factors related to informal caregivers (e.g. intervention preferences, caregiving situation) to inform the development of a cognitive behavioural therapy (CBT) self-help intervention to support the mental health of informal caregivers of people living with chronic kidney disease (CKD). The majority of participants were caring for a male spouse or partner living with CKD, and over half were experiencing at least mild depressive symptoms. Informal caregivers reported preferences for CBT self-help interventions to be delivered via the internet, a workbook, or individually in-person, with additional support provided in-person or via email by a trained professional at a non-profit organisation.Study III was a qualitative study to explore the perspectives of professionals (i.e. potential implementers) anticipated to play key roles in the future implementation of an e-MH intervention for informal caregivers of people living with CKD regarding the intervention’s design, delivery, and implementation. Manifest content analysis with primarily deductive coding using the CFIR led to identification of 29 generic categories representing implementation determinants. Potential implementers considered an e-MH intervention as fitting within some existing healthcare delivery models and work routines, however, capacity to be involved with intervention delivery was low. Equitable support access was important to ensure intervention acceptability.Study IV was a qualitative study to explore informal caregivers’ experiences of accessing and receiving support while caring for someone living with CKD. Reflexive thematic analysis generated three themes: (1) “Systems seem to get in the way” – challenges within support systems, describing challenges encountered when navigating complex systems; (2) Relying on yourself, describing how informal caregivers relied on their own skills and networks to find support; and (3) Support systems can “take the pressure off”, describing how support systems were perceived as supportive when empathetic and reliable.
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| 4. |
- Dahlberg, Anton
(författare)
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Capturing and addressing preschool children’s emotional and behavioural problems : Using parents’, teachers’ and children’s perspectives
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Emotional and behavioural problems (EBP) are among the most common mental health problems in preschool children. EBP are also associated with poor parent mental health. Untreated, EBP can persist or worsen over time. In order to capture and address preschool children’s EBP, we need scientifically valid instruments that can access the perspectives of informants from different contexts of the child. We also need cut-off values for questionnaires assessing EBP that are representative of the population. Parenting support is a recommended intervention for addressing EBP in preschool children. Most parenting support programmes have a solid evidence-base and show positive effects on child EBP and parent wellbeing. However, we need a better understanding of the children’s emotional and relational experiences, especially in relation to their parents. Further, although the implementation of evidence-based interventions is a complex matter with substantial impact on intervention success, few studies assess the implementation process of parenting programmes. The studies constituting this thesis focused on preschool children. The Strengths and Difficulties Questionnaire (SDQ) was assessed for capturing EBP. Study I assessed the construct validity of the SDQ and its five subscales, when rated by fathers and preschool teachers. Confirmatory factor analysis was applied to evaluate construct validity. Results indicated that the SDQ can be used as an instrument to measure EBP in preschool children, rated by parents and preschool teachers. In study II, we established Swedish norms for the SDQ for preschool children. Results suggested lower SDQ cut-offs for Swedish preschool children compared with other countries, and higher cut-offs for boys compared with girls. In study III, preschool children whose parents participated in a parenting programme were interviewed regarding their emotional and relational experiences at home. Data were analysed using qualitative content analysis. The children provided accounts of negative and positive interactions with their parents, elaborately describing a coercive cycle with escalating conflicts and lack of problem resolution. In study IV, the implementation of the parenting programme Triple P in a preschool setting was assessed using the RE-AIM framework. Results indicated a successful implementation that relied on customisation of the programme; assessment of the process from parent, staff, and organisation levels; interdisciplinary collaboration; and continuous work on securing maintenance over time. This thesis provides pieces to a complex puzzle of understanding and addressing child mental health problems, particularly EBP. Assessing EBP from different perspectives and promoting children’s voices are essential, as well as actively working with the implementation of evidence-based programmes.
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| 5. |
- Humphries, Sophia
(författare)
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Taking mind matters to heart : E-health methods to assess and treat psychological distress associated with myocardial infarction and Takotsubo syndrome
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis comprises five studies investigating psychological distress in patients with myocardial infarction (MI) and Takotsubo syndrome (TS), with a focus on using e-health methods for data collection and delivery of psychological interventions. The aim of study 1 was to explore the long-term (12 month) effect of an internet-delivered intervention for MI patients experiencing self-reported symptoms of anxiety or depression compared to a control group without access to the treatment intervention. Using data from several Swedish national registers we also investigated whether the intervention had any effect on risk for adverse cardiovascular (CV) events, including recurrent MI and CV-related mortality. Effect of treatment was not significant between groups on lowering symptoms of anxiety or depression nor for risk of CV events or CV-related mortality. Low treatment adherence is discussed as a probable reason for these findings. Study 2 aimed to build from the lessons learned in study 1, as well as the existing literature and continuous input and collaboration with patient research partners (PRPs) to develop an internet intervention designed for patients experiencing high levels of anxiety or stress following MI with non-obstructed coronary arteries (MINOCA) or TS. We present the processes involved during the development and creation of this novel internet intervention. Following on from this, in Study 3 we tested the feasibility of this intervention using pre-specified progression criteria that was aimed to assess whether the intervention and study protocol were feasible in a randomised controlled trial (RCT). We screened patients for eligibility and offered participation in the study to those who met the pre-defined inclusion criteria. We collected both psychometric and qualitative data and assessed progression criteria that covered: recruitment, time and resources, proportion of participants completing the intervention and, participant experiences of the intervention. Study 4 used data from the Swedish national registers to estimate the association of health-related quality of life (HRQoL) with high vs low dose of β-blocker, prescribed after MI. The aim was to investigate, in advance of an ongoing register-based RCT, whether there is any association of β-blocker dose on patient reported HRQoL. Since there are many reasons for a patient to receive a high or low dose respectively, controlling for possible confounding was crucial. We used the European Quality of Life Five Dimensions questionnaire (EQ-5D) to assess HRQoL using data from over 35000 unique, first-time MI patients in Sweden.Study 5 presents the trial design, rationale and baseline data from the first 100 patients recruited into a registry-based RCT sub-study focussed on investigating several psychological-related outcomes in patients randomised to receive β-blocker treatment or no treatment. The feasibility, strengths and challenges of using digitalised in-hospital data collection techniques are also evaluated.
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| 6. |
- Sveen, Josefin, 1976-
(författare)
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Posttraumatic Stress and Cognitive Processes in Patients with Burns
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A severe burn is one of the most traumatic injuries a person can experience. Posttraumatic stress disorder (PTSD) is relatively common after burns, and can be devastating for the individual’s possibilities for recovery. The principal aims were to gain knowledge regarding posttraumatic stress symptoms and cognitive processes after burn and to evaluate methods for assessing symptoms of PTSD up to one year after burn. The psychometric properties of a Swedish version of the Impact of Event Scale-Revised (IES-R) were examined. The results indicate that the IES-R is a valid screening instrument for measuring PTSD symptoms in patients with burns and it can be used during hospitalisation to identify resilient individuals. The pattern of PTSD symptoms over time was also investigated. Four distinct trajectories of PTSD symptoms were identified, i.e. four groups of patients with significantly different onsets and courses. The trajectories differed in the expected direction regarding several risk factors associated with PTSD symptoms. Several previously known risk factors for PTSD symptoms were also identified including burn severity, psychiatric history, previous life events, early psychological symptoms, neuroticism-related personality traits, avoidant coping and low social support. The risk factors correspond well with those reported in the international trauma literature, which strengthens the findings in this thesis. Finally, using the emotional Stroop task at one year post burn it was found that burn-specific attentional bias was common and associated with more previous life events, more perceived life threat, larger burns and higher levels of PTSD symptoms. In summary, there are individual differences in the development and course of PTSD symptoms after burn and attentional bias is a common cognitive phenomenon related to these symptoms. The findings also support the use of the IES-R as a screening instrument for PTSD symptoms in patients with burns.
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| 7. |
- Alfonsson, Sven
(författare)
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Treatment Adherence in Internet-Based CBT : The Effects of Presentation, Support and Motivation
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Homework assignments that patient work with between sessions is a key component in both face-to-face and Internet-based Cognitive Behavior Therapy (CBT). However, adherence to assignments is often low and it is largely unclear what factors predict or affect treatment adherence, and in the end, treatment outcomes. The overall aim of this thesis was to investigate if treatment presentation and therapist support can affect adherence and treatment outcome in internet-based CBT, whether adherence can be predicted by motivation variables and to compare differences in face-to-face and online conditions in this regard.A randomized controlled trial with a brief online relaxation program for people with stress and anxiety symptoms was conducted (n = 162). Participants in the enhanced support conditions completed a larger proportion of the online treatment but adherence was not affected by enhanced treatment presentation (Study I). Participants reported reduced symptoms of stress and anxiety after the relaxation program but there were no significant additional effects of enhanced presentation or support (Study II). Participants who adhered to the prescribed assignments reported lower symptom levels at study end, regardless of treatment conditions. Adherence to the online treatment was predicted by subject factors such as treatment credibility prior to the treatment and intrinsic motivation during the treatment (Study III). To further elucidate how motivation may affect adherence, an experiment with a one-session psychotherapy model was subsequently conducted (n = 100). Participants who were randomized to the face-to-face condition reported higher motivation for the assignment and completed significantly more of the homework compared to participants in the online condition (Study IV). Self-reported intrinsic motivation could predict adherence in both conditions while new motivational variables were identified specifically for the online condition.The results from these studies confirm that adherence to assignments in Internet-based CBT is difficult to affect with treatment features but can be predicted early in treatment by subject factors such as treatment credibility and motivation. How such motivational variables can be affected to improve treatments is still unclear.
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| 8. |
- Bodin, Maja, 1984-
(författare)
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To Plan or Not to Plan : Gender Perspectives on Pregnancy Planning, Fertility Awareness and Preconception Health and Care
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The level of pregnancy planning is of importance to the well-being of parents and children. Unintended and/or unwanted pregnancies are often associated with less health promoting behavior during pregnancy, poorer health of the new born, and relationship dissatisfaction. Preconception care is a health service with the purpose to encourage people to become mindful about their reproductive intentions and raise fertility awareness, in order to maintain or improve reproductive health.Reproductive health is a highly gendered area, both due to biological conditions and social expectations on gender. In most cases, the focus of reproductive health and health promotion is on cis-women and their bodies. This thesis mainly focuses on persons self-identifying as men. The aim is to scrutinize the area of preconception health, investigate what pregnancy planning means to men and explore the relationship between pregnancy planning and fertility awareness.In Study I, 136 couples who attended their first antenatal visit answered questions about pregnancy planning. Most pregnancies were planned and couples had similar perceptions of the level of their planning. Study II describes pregnancy planning behavior and fertility knowledge among 796 recent fathers. Also in this study, most pregnancies were planned and 17% of the men had made at least one preconception lifestyle adjustment to improve health and fertility. Fertility knowledge varied greatly, although men with higher education demonstrated higher knowledge. Study III explores if Reproductive Life Plan-based counselling during a sexual health visit could increase men’s fertility awareness. The counselling had a moderate effect on participants’ fertility knowledge but managed to raise new thoughts about their own fertility, and was well received. Study IV follows up on the results from the first three studies, through in-depth interviews and focus group discussions with 25 men aged 23-49. Most participants took their fertility for granted. To cis-men in heterosexual relationships, the meaning of pregnancy planning usually meant taking the decision to try to become pregnant, and not much more. Trans-men and gay men where more invested in practical planning issues. In conclusion, this thesis shows how pregnancy planning is gendered, and that it is a more complex phenomenon than previously acknowledged.
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| 9. |
- Fredriksson, Mio, 1976-
(författare)
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Between Equity and Local Autonomy : A Governance Dilemma in Swedish Healthcare
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Both national equity in healthcare and the county councils’ local autonomy are important values supported by Swedish law. Politically it is a balancing act; how much freedom should the county councils have and to what extent should healthcare be equal throughout the country? The general aim of this dissertation, concerning political governance in Swedish healthcare, is to investigate the tensional values of national equity and local autonomy in the light of current trends in healthcare governance in Sweden. How is this tension manifested? Four studies are included in the dissertation. These studies show that the Swedish state is becoming more active in governing and regulating healthcare, for example by the use of informative governance and legislation, which increasingly rely on monitoring and evaluation of results that are made public. The findings show that the tension between national equity and local autonomy is manifested in increasing emphasis on national equity – or rather national equivalence – which is interpreted in terms of Swedish healthcare being recentralized. Delivery and financing of healthcare are still the responsibilities of the county councils. Planning and arranging – the setting of the regulatory framework – is increasingly taken over by the central state. Although power seems to be transferred from local level to central level, the county councils’ autonomy is only partially restricted, which means Swedish healthcare is still decentralized. However, if the recentralization process proceeds further, the county councils´ autonomy may be seriously challenged. Another challenge is to maintain or strengthen the procedures for democratic legitimacy through citizen participation at the local level. When local autonomy looses ground, it becomes more difficult to tailor healthcare according to local needs and conditions in the county councils, and decisions are taken at greater distance from the citizens.
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| 10. |
- Gingnell, Malin, 1982-
(författare)
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Ovarian Steroid Hormones, Emotion Processing and Mood
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- It is known that some psychiatric disorders may deteriorate in relation to the menstrual cycle. However, in some conditions, such as premenstrual dysphoric disorder (PMDD), symptomatology is triggered mainly by the variations in ovarian steroid hormones. Although symptoms induced by fluctuations in ovarian steroids often are affective, little is known about how emotion processing in women is influenced by variations, or actual levels, of ovarian steroid hormones.The general aim of this thesis was to evaluate menstrual cycle effects on reactivity in emotion generating and controlling areas in the corticolimbic system to emotional stimulation and anticipation, in healthy controls and women with PMDD. A second aim was to evaluate corticolimbic reactivity during long-term administration of exogenous ovarian steroids.In study I, III and IV effects of the menstrual cycle on emotional reactivity in women with PMDD was studied. In study I, women with PMDD in displayed higher amygdala reactivity than healthy controls to emotional faces, not in the luteal phase as was hypothesised, but in the follicular phase. No difference between menstrual cycle phases was obtained in women with PMDD, while healthy controls had an increased reactivity in the luteal phase. The results of study I was further elaborated in study III, where women with PMDD were observed to have an increased anticipatory reactivity to negative emotional stimuli. However, no differences in amygdala reactivity to emotional stimuli were obtained across the menstrual cycle. Finally, in study IV the hypothesis that amygdala reactivity increase in the luteal phase in women with PMDD is linked to social stimuli rather than generally arousing stimuli was suggested, tested and supported.In study II, re-exposure to COC induced mood symptoms de novo in women with a previous history of COC-induced adverse mood. Women treated with COC reported increased levels of mood symptoms both as compared to before treatment, and as compared to the placebo group. There was a relatively strong correlation between depressive scores before and during treatment. The effects of repeated COC administration on subjective measures and brain function were however dissociated with increased aversive experiences accompanied by reduced reactivity in the insular cortex.
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