| 1. |
- Bergman Nordgren, Lise, 1983-
(författare)
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Individually tailored internet-based cognitive behavioural therapy for anxiety disorders
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Fear is an innate emotion and an adaptive response to provide protection from potential harm. When fear is excessive and out of proportion in relation to the confronted situation, it can lead to the development of an anxiety disorder. Many individuals feel anxious at some point, but not all experience clinical anxiety or meet the diagnostic criteria of an anxiety disorder. Still, anxiety disorders are the most prevalent form of psychiatric disorder in the general population. More often than not people suffering from one anxiety disorder also present other psychiatric conditions. As of today, cognitive and behavioural treatments have been tested and found to positively affect anxiety disorders, making them the treatment of choice. Nevertheless, many patients do not seek or receive adequate treatment.One common critique of the research trials from which the recommendations for treatments stem is the use of a single protocol targeting only one diagnosis. This is because many people suffer from comorbidities. Another problem connected to the recommendation that cognitive behavioural therapy (CBT) should be the treatment of choice for anxiety disorders is the lack of therapists with adequate training. One possible way of dealing both with the shortcoming of therapists and making CBT more accessible is the use of the Internet. Internet-based CBT (ICBT) has been tested in numerous trials during the last 15 years, showing positive outcomes for a large variety of disorders. Many ICBT trials also make use of a single protocol. Another way of dealing with comorbidities might be to tailor the treatment to let characteristics and preferences of the patient guide the design of the protocol. Little is known about possible effects of tailoring the ICBT, the effects of therapeutic relationships in ICBT, and the effectiveness and cost-effectiveness of these treatments. This thesis is based on three studies on two separate randomized controlled trials (RCTs) using the same set of modules accessible for the tailored protocol.Study I was an RCT investigating treatment effects up to two-year after completion, showing favourable outcomes of the treatment in a self-recruited sample at all measure points. Study II was a secondary analysis exploring possible relations between working alliance and treatment outcome for participants in the treatment group recruited for Study I indicating that working alliance predict outcome in this tailored treatment. The second RCT was an effectiveness trial (Study III) analysing treatment effects and cost-effectiveness of the treatment up to one year post treatment in a primary-care population. This study showed positive treatment effects both regarding symptom reduction and cost-effectiveness, and that effects were sustained at one year post treatment. Conclusions drawn from these studies are that individually tailored ICBT seems to be a feasible approach for patients with anxiety disorders regardless of comorbidities, and a responsible choice in terms of societal costs.
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| 2. |
- Carlbring, Per, 1972-
(författare)
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Panic! Its Prevalence, Diagnosis and Treatment via the Internet
- 2004
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- As evidenced by several trials, cognitive behavior therapy (CBT) is a highly effective treatment for Panic disorder with or without agoraphobia (PD). However, therapists are short in supply, and patients with agoraphobia may not seek therapy due to fear of leaving their homes or traveling certain distances. A major challenge therefore is to increase the accessibility and affordability of evidence-based psychological treatments.This thesis is based on five studies; three treatment studies set up as randomized controlled trails (RCT), one prevalence study, and one study testing the equivalence of an Internet-administered diagnostic assessment tool with a clinician-administered interview.Study I showed that the Swedish 12-month PD prevalence is consistent with findings in most other parts of the Western world (2.2%; CI 95% 1.0%-3.4%). There was a significant sex difference, with a greater prevalence for women (3.6%) compared to men (0.7%).Study II showed that the validity of the computerized diagnostic interview (CIDI-SF) was generally low. However, the agoraphobia and obsessive-compulsive disorder modules had good specificity and sensitivity, respectively.The three RCTs showed, directly or indirectly, that Internet-based self-help is superior to a waiting-list. When 10 individual weekly sessions of CBT for PD was compared with a 10-module self-help program on the Internet, the results suggest that Internet-administered self-help, plus minimal therapist contact via e-mail, is as effective as traditional individual CBT (80% vs. 67% no longer met criteria for panic disorder; composite within-group effect size was Cohen’s d= 0.78 vs. 0.99). One-year follow-up confirmed the results (92% vs. 88% no longer met criteria for panic disorder; d= 0.80 vs. 0.93). The results generally provide evidence to support the continued use and development of Internet-distributed self-help programs.
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| 3. |
- Dahlin, Mats, 1975-
(författare)
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Development and evaluation of an internet-based treatment for generalized anxiety disorder : An acceptance-based approach
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Generalized anxiety disorder (GAD) is a chronic condition characterized by an excessive and uncontrollable worry. GAD has a highly negative impact on all aspects of life, and the costs for society are considerable. Cognitive behaviour therapy (CBT), delivered face-to- face or online, has been shown to be effective in treating GAD. However, there are still room for improvement, with treatment content and format of delivery being two areas to further investigate. Internet-based treatments are often based on a generic CBT model of GAD and include treatment strategies such as cognitive restructuring and relaxation. Furthermore, the impact of therapist support has shown inconclusive results.Overall, this thesis aimed to evaluate the effects of a new internet-based treatment for GAD, based on acceptance, mindfulness, and valued action, delivered with different types of support. Study I was a small pilot trial with a within-group design. The study included 16 participants diagnosed with GAD who received the newly developed treatment program with weekly therapist support. Statistically significant and large effect sizes were observed on self-rated worry at post-treatment, and the effects were maintained at a three-months follow-up. Study II included 103 participants diagnosed with GAD who were randomized to nine weeks of treatment with the treatment program and weekly support, or a waiting-list control group. Statistically significant moderate to large effects were observed on primary and secondary outcomes in favour of the treatment. The exception was a measure of quality of life, with no significant difference between the two groups. The treatment effects were maintained at a six-months follow-up. Study III was a pilot trial including 33 participants diagnosed with GAD. A within-group design was used to investigate the effects of the treatment program delivered with automated messages and support on demand. Significant and large within-group effects were observed on all outcome measures at post-treatment with the exception of quality of life, for which there was a small effect. Study IV was a pilot factorial design trial that compared the acceptance-based treatment program against a self-tailored treatment, as well as two types of support: scheduled support and support on demand. The study included 85 participants with GAD randomized to four different treatment groups. Significant moderate to large effects were observed in all treatment groups, with no statistically significant differences between the groups on self-rated outcome measures. Receiving scheduled support was rated as more positive than support on demand, and self-tailored treatment was rated as more positive than the acceptance-based treatment. Treatment satisfaction was high in all studies.In conclusion, the studies indicate that an internet-based treatment based on acceptance, mindfulness, and valued action is a viable option in the treatment of GAD.
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| 4. |
- Forsström, David, 1981-
(författare)
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The use and experience of responsible gambling tools : An explorative analysis of user behavior regarding a responsible gambling tool and the consequences of use
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Responsible gambling tools are an intervention that is designed to decrease gambling among individuals with an at-risk gambling behavior. Studies have indicated that responsible gambling tools can decrease gambling behavior, but little is known about how this intervention is used by gamblers. The aim of the present thesis was to explore different facets of the use, experience and functions of these tools. Study I used descriptive statistics and latent class analysis (LCA) combined with multinomial regression to explore the use of the responsible gambling tool Playscan among 9528 gamblers (regular and at-risk gamblers). The participants had volunteered to use the tool. The functions of the tool had a high rate of initial use but a low rate of repeated use. The LCA identified five user classes. Two of the classes (self-testers and multifunctional users) were defined as high users of the tool and had a higher risk of developing gambling problems according to multinomial regression. The multifunctional users were characterized by an extensive use of all the functions while the other high usage class had an extensive use of the self-test. The three other classes were as follows: those who did not use the tool, those who visited the tool but did not engage in any of the functions, and those who only used the tool’s advice on how to decrease their gambling. Participants’ reasons for use and non-use of the tool were attributed to their degree of need of the tool and its functions. The tool’s most widely used function was the self-test that investigated the level of negative consequences faced by a user due to his or her gambling. Study II was a qualitative study investigating participants’ views, experiences and their reasons for using the tool. The study was conducted by interviewing 20 volunteer users of the tool. These semi-structured interviews were analyzed by thematic analysis. The results showed that the users had a positive attitude towards the tool and understood its purpose. The self-test was the most widely used function in this sample as well. However, the participants’ positive attitude toward the tool did not effectively encourage them to use it; they displayed low use of the tool’s functions. This paradox was explained by lack of feedback and the fact that some participants did not understand that they had registered to use the tool. Providing more feedback and tailoring the feedback to individual users were seen as ways of bridging the paradox. Study II also found that participants used the gambling website (which Playscan was linked to) in an analogue way, preparing their bets before placing them online. This limited the time they spent on the site and inhibited their use of Playscan. Study III was motivated by the extensive use of the self-test among users in Study I and Study II. The aim of Study III was to investigate the psychometric properties of the self-test (known as GamTest) to better understand how it could be used with Playscan in the most efficient way. Two thousand two hundred and thirty four respondents answered the questionnaire, along with instruments measuring depression, anxiety and another instrument measuring problems due to gambling. Factor analysis, parallel analysis, Cronbach’s alpha, and correlations were used to establish the tool’s psychometric properties. The results yielded a three-factor model, excellent reliability, and high correlation with the Problem Gambling Severity Index (PGSI), endorsing the validity of the self-test. The results also indicated that the questionnaire could be effectively shortened. Overall, the studies show that the tool has an initial high use, low repeated use and that the self-test is the most used feature. In addition, the self-test had good psychometric properties.
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| 5. |
- Ivanova, Ekaterina, 1987-
(författare)
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Responsible provision of online gambling : Effects, usability and gamblers’ experiences of protective measures implemented in online gambling environments
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Problem gambling is considered a public health problem in many countries and is associated with serious financial and health-related harms for both problem gamblers and significant others. It is possible to create gambling environments that would promote sustainable gambling behaviors and prevent excessive gambling. However, research on the effectiveness of tools for responsible provision of gambling is scarce and the quality of the research is low. Also, there exists a conflict of interest between making a profit when providing gambling and protecting vulnerable customers. The general aim of the project was to study the effects, usability and gamblers’ experiences of tools for responsible provision of online gambling. Study I evaluated the effects of a prompt to set voluntary deposit-limit of optional size among 4,328 customers of an online gambling platform. During the data collection period, all customers from Finland registering an account on the gambling platform were randomized into being prompted to set a deposit-limit either 1) at-registration, 2) before their first deposit, 3) after their first deposit or 4) to an unprompted control group. Gambling intensity, measured with aggregated net loss, was tracked during 90 days after registration. No differences in gambling intensity between the intervention and control groups were found neither on the whole-group level (B (95% CI) =-0.080 (-0.229-0.069), p=.291), nor in the subgroup of the most involved gamblers (B (95% CI) =0.042(-0.359-0.442), p=.838). Study II aimed at predicting gaming freeze (as a proxy parameter for problem gambling) in online gamblers. For the sample of N=2,618 (N=1,309 freezers), a total of 105 predictors were created based on the data tracked by the gambling platform. The analysis was carried out using the machine learning method Random Forest. The predictive accuracy of the model applied to the dataset was 0.615, with a specificity of 0.686 and a sensitivity of 0.543. Study III aimed at investigating non-problem gamblers’ experiences of protective measures. A total of N=10,200 active customers of an online gambling platform were asked to rate their previous experiences of protective tools, their inclination to abandon a gambling service due to perceived overexposure to protective measures and answer questions on their symptoms of problem gambling. N=1,223 responded to the questionnaire, with the majority of the sample being moderate-risk gamblers (38.5%), followed by low-risk gamblers (26.8%), non-problem gamblers (18.9%) and problem gamblers (15.8%). In general, non-problem gamblers were not more disturbed by protective measures than other categories of gamblers. More problem gamblers have previously abandoned a gambling service due to perceived overexposure to protective measures compared to non-problem gamblers (OR(95% CI)= 7.17(3.61-14.23), p<.001). In conclusion, a prompt to set a voluntary deposit-limit of optional size did not appear to be effective in decreasing gambling intensity in online gamblers, indicating the need of evaluating alternative designs. Predicting gaming freezes in the current project resulted in a low accuracy, indicating that gaming freeze is not suitable as a proxy measurement for problem gambling and suggesting the need for collecting subjective data on symptoms of problem gambling. The results of Study III suggest that protective measures can be tested and implemented without the risk of disturbing recreational gamblers.
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| 6. |
- Johansson, Robert
(författare)
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Treating depression and its comorbidity : From individualized Internet-delivered cognitive behavior therapy to affect-focused psychodynamic psychotherapy
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overarching goal of this thesis has been to enhance Internet-delivered psychological treatments for depression and its comorbidity. To this end, three randomized controlled trials (Study II, III and IV) with a total of 313 participants were conducted. A prevalence study (Study I) was also conducted to provide an up-to-date estimate of the prevalence of depression, anxiety disorders, and their comorbidity in the Swedish general population.Study I showed that more than every sixth individual in Sweden suffers from symptoms of depression and/or anxiety. Comorbidity between depression and anxiety was substantial and associated with higher symptom burden and lower health-related quality of life. Study II showed that a tailored Internet-based CBT protocol (ICBT) was effective in reducing symptoms of depression when compared to a control group. Among individuals with more severe depression and comorbidities, the tailored ICBT treatment worked better than standardized ICBT. Study III showed that a psychodynamic Internet-based psychotherapy was highly effective in the treatment of depression, when compared to a group who received psychoeducation and online support. In Study IV, an Internet-delivered affect-focused psychodynamic psychotherapy proved to have a large effect on depression and a moderately large effect on anxiety disorders.In conclusion, this thesis shows that in the context of treating depression and its comorbidity, Internet-delivered psychological treatments can be potentially enhanced by psychodynamic psychotherapy and by individualization.
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| 7. |
- Jonsson, Jakob, 1968-
(författare)
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Preventing problem gambling: Focus on overconsumption
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A proportion of gamblers experience problems. The role of overconsumption in developing gambling problems is sparsely described in the literature and there is little scientific knowledge about the prevention of gambling problems. There are some promising results regarding personalized feedback on gambling habits, and there is a need for more research. The overall aim of this thesis was to explore the role of overconsumption in problem gambling and target it in a preventive intervention. The preventive intervention was to give gambling consumption feedback to high consumers in order to make them reflect upon their gambling habits and enhance their motivation for change. Study I aimed to explore the dimensionality of GamTest, an online test of gambling behaviour, and validate it against PGSI and the gambler’s own perceived problems. Data came from four Nordic gambling sites, n = 10,402. In an ESEM analyses, GamTest had a high degree of correspondence with the players’ own perceived problems and with the PGSI. In an EFA, GamTest captured five dimensions of problematic gambling (i.e. overconsumption of money and time, and negative financial, social and emotional consequences). A bifactor approach showed a general factor and four specific residual factors, negative emotional consequences contribute to the dominant part of the general factor. Study II aimed to examine both the psychometric properties of the Jonsson-Abbot Scale (JAS) and its predictive validity with respect to increased gambling risk and problem gambling onset. The results are based on repeated interviews with 3,818 participants within the Swedish longitudinal gambling study. The results indicate an acceptable fit of a three-factor solution in a CFA, with ‘Overconsumption (OC),’ ‘Gambling fallacies (GF),’ and ‘Reinforcers (RI)’ as factors. When controlled for risk potential measured at baseline, GF and RI were significant predictors of gambling risk potential, and GF and OC were significant predictors of problem gambling onset at 12-month follow up. Study III’s primary objective was to investigate the effects of providing personalized feedback on gambling intensity among high consumers in Norway. An RCT design was used to evaluate how behavioural feedback by telephone or letters affects subsequent gambling expenditure. A sample of 1,003 statistical matched triplets, from the top 0.5 % of customers, were randomly assigned to telephone, letter, or a no-contact control condition. Over 12 weeks, theoretical loss decreased 29 % for the telephone, and 15 % for the letter, conditions, compared with 3 % for the control group. Study IV was a 12-month follow-up of Study III, aimed to investigate the relative effects over twelve months. The telephone group showed a 30 % reduction in theoretical loss, the letter group 13 %, both outperforming the control group with a 7 % reduction. Less than 1% in all groups stopped playing at Norsk Tipping. These four studies indicate that overconsumption of gambling plays different roles in problem gambling. The role of overconsumption in preventing gambling problems is discussed. Contacting high consumers about their gambling expenditure appears to be an effective method for gambling companies to meet their duty of care for customers. Technical evolution has made it possible for gambling companies to fulfil their duty of care, but this has to be regulated and mandatory if it is to be effective.
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| 8. |
- Lindqvist, Karin, 1987-
(författare)
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Making Connections : Outcomes and the Role of the Therapeutic Relationship in Internet-Delivered Psychodynamic Treatment for Adolescent Depression
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Major depressive disorder (MDD) is ranked one of the most burdensome disorders for adolescents worldwide. There is an urgent need for accessible interventions, as many adolescents suffering from MDD do not receive treatment. Internet-delivered interventions remove barriers to seeking and receiving treatment, and internet-delivered cognitive behavioural therapy (ICBT) has been found to be effective for adolescent MDD. However, not all are helped by ICBT and treatment alternatives are needed. Internet-delivered psychodynamic therapy (IPDT) has previously been tested with promising effects in adults, but no studies have assessed its efficacy for adolescents. Furthermore, little is known about mechanisms of change in internet interventions targeting adolescent MDD and how adolescents experience the therapeutic relationship in IPDT. This thesis aims to evaluate efficacy as well as processes and experiences of IPDT, from different perspectives.Study I investigated effects of IPDT for adolescents aged 15–18 (n = 76) suffering from MDD, compared to control condition. IPDT was found to be significantly more effective than a supportive control condition on reducing depression (d = 0.82). Furthermore, moderate to large significant effects in favour of IPDT were found for comorbid anxiety, emotion regulation and self-compassion.Study II explored participants’ (n = 18) experiences of the psychotherapeutic relationship in IPDT. Semi-structured interviews were analysed using thematic analysis. Four themes were created: “a meaningful and significant relationship with someone who cared”, “a helping relationship with someone who guided and motivated me through therapy”; “a relationship made safer and more open by the fact that we didn’t have to meet”; and “a nonsignificant relationship with someone I didn’t really know and who didn’t know me”.Study III examined the relationship between therapeutic alliance, emotion regulation and outcome week-by-week in IPDT and ICBT for adolescent depression (n = 272). Results showed that therapeutic alliance, as rated by both therapist and participant, predicted outcome in depressive symptoms week-by-week in both treatments. Furthermore, this relationship was mediated by emotion regulation, again in both treatments.In conclusion, results from this thesis indicate that IPDT may be a viable treatment option for adolescent depression. Furthermore, it is possible to form a close and safe relationship between therapist and participant, experienced as important for the psychotherapeutic process by many participants. Lastly, therapeutic alliance plays an important role in both IPDT and ICBT for adolescent depression, partly through its effect on emotion regulation.
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| 9. |
- Lundgren, Tobias
(författare)
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ACT Treatment of Epilepsy : Time for a behavioral model?
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The present dissertation contributes to the understanding of behavioral treatment of epilepsy and supports the integration of medical and behavioral science to develop a treatment model to help those who suffer from drug refractory epilepsy. There is a lack of well-designed randomized controlled trials evaluating behavioral therapy for epilepsy. Medical science has contributed significantly to the development of antiepileptic drugs for seizure control, yet despite these efforts approximately 1/3 of patients suffer from recurrent seizures. The comorbidity between epilepsy and psychiatric problems is significant and quality of life is lower for those who suffer from epilepsy compared to those who suffer from other chronic illnesses. The purpose of the present dissertation is to develop and evaluate a behavioral treatment model for those who suffer from recurrent epileptic seizures and associated problems. Acceptance and commitment therapy (ACT) is compared to supportive treatment and yoga. Outcome variables are seizure frequency, seizure index (frequency * duration) and quality of life. The dissertation consists of three studies; two studies with randomized controlled group designs to evaluate treatment effects and one mediational analysis study evaluating the effect of specific therapeutic processes. The mediational analysis examines specific ACT processes such as value attainment, epilepsy related psychological flexibility and persistency in overcoming barriers. The results of the two randomized controlled trials show a significant decrease in seizure frequency and seizure index in favor of the ACT group compared to the control groups and significant changes in life quality. The results of the mediational study indicate that the evaluated processes, alone or in combination, had a mediational role in three of the four outcome variables. In conclusion, the present dissertation supports the integration of behavior and medical science to help those who suffer from epilepsy and associated problems.
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| 10. |
- Ly, Kien Hoa
(författare)
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Use of a Smartphone Application in the Treatment of Depression : The New Wave of Digital Tools in Psychological Treatment
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Internet-delivered programs based on cognitive behavior therapy (CBT) have during the past decade shown to work in an effective way for the treatment of depression. Due to its accessibility and independence of time and location, smartphone-based CBT might represent the next generation of digital interventions. Depression is an affective disorder that affects as many as 350 million people worldwide. However, with CBT, depression can be treated, but access to this treatment is scarce due to limited health care resources and trained therapists. As a result of this, health care could highly benefit from the use of smartphones for delivering cost-effective treatment that can be made available to a large part of the population who suffer from depression. One treatment that should be especially suitable for the smartphone format is behavioral activation (BA), since it has strong empirical support as well as the benefits of being flexible and rather simple.The overall aim of the thesis was to test and further develop a BA smartphone application, as well as to build a method for how this smartphone application could be used in a comprehensive and effective way in depression treatment. To fulfill this aim, four studies were conducted. The results showed that smartphones have the ability to be used in an effective way in the treatment of depression, including as an add-on to traditional face-to-face sessions. The results also showed that the smartphone format was experienced as a portable and flexible way of accessing the treatment – and thus could be more present in everyday life.In conclusion, there is reason to believe that smartphones will be integrated even further in society and therefore may serve an important role in future mental health care. Since the first indications reveal that depression can be treated by means of a supported smartphone application, it is highly possible that applications for other mental health problems will follow. Furthermore, in this thesis, the same smartphone application has been tested in three different ways and there is potential to apply smartphones in a range of other formats, such as in relapse prevention and as a way to intensify treatment during periods when needed. From a psychiatric research point of view, as my research group has been doing trials on guided internet treatment for more than 15 years, it is now time to move to the next generation of information technology – smartphones.
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