| 1. |
- Jolstedt, Maral, et al.
(författare)
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Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders : a single-centre, single-blind, randomised controlled trial
- 2018
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Ingår i: Lancet child and adolescent health. - Stockholm : Karolinska Institutet, Dept of Clinical Neuroscience. - 2352-4642 .- 2352-4650. ; 2:11, s. 792-801
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Tidskriftsartikel (refereegranskat)abstract
- Background: Paediatric anxiety disorders are associated with substantial disability and long-term adverse consequences, but only a small proportion of affected children have access to evidence-based treatment. Internet-delivered cognitive behavioural therapy (ICBT) could help increase accessibility but needs further rigorous assessment. We aimed to assess the efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders. Methods: We did a single-blind randomised controlled trial in a clinical research unit within the Child and Adolescent Mental Health Services in Stockholm (Sweden). Eligible participants were children aged 8-12 years with a diagnosis of a principal anxiety disorder (seperation anxiety disorder, generalised anxiety disorder, specific phobia, social anxiety disorder, or panic disorder) of at least moderate severity. We randomly allocated participants (1:1) to ICBT or internet-delivered child-directed play, an active comparator aimed to improve parent child relationships and increase a child's self-esteem without directly targeting anxiety. Block sizes for the randomisation varied between four and six and were generated using a computer random-number generator, and the allocation was concealed from the researchers by opaque sealed envelopes. Both treatment programmes comprised 12 modules presented over 12 weeks with weekly asynchronous online therapist support, and consisted of texts, films, illustrations, and exercises. The primary outcome was severity rating of the principal anxiety disorder 12-weeks post-treatment, via the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders-IV (a rating of at least 4 corresponds to meeting the criteria for the principal diagnosis), assessed by clinicians masked to treatment allocation. All participants were included in the primary analysis (intention-to-treat). This trial is registered at ClinicalTrials.gov, number NCTO 2350257. Findings: Between March 11, 2015, and Oct 21, 2016, 131 participants were recruited and allocated to either ICBT (n=66) or internet-delivered child-directed play (n=65). The clinician-assessed severity rating of the principal anxiety disorder improved significantly after the 12-weeks treatment period for participants in both ICBT (within-group effect size 1.22, 95% CI 0 78-1.65) and the active control (0.72, 0.44-1.00) groups. However, greater improvement was seen with ICBT than with the active control (estimated mean difference 0.79, 95% CI 0.42-1.16, p=0.002; between-group effect size 0.77, 95% CI 0.40-1.15). 29 (48%) participants in the ICBT group no longer had their principal diagnosis, compared to nine (15%) in the active control group (odds ratio 5.41, 95% CI 2.26 to 12.90, p<0.0001); the number needed to treat for ICBT to gain one additional participant in remission was three (95% CI 2.85 to 3.15). ICBT resulted in an average societal-cost saving of 493 05 (95% CI 477.17 to 508.92) per participant. No severe adverse events were reported. Interpretation ICBT is an efficacious and cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care.
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| 2. |
- Jolstedt, Maral
(författare)
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Internet-delivered cognitive behaviour therapy for paediatric anxiety disorders in clinical settings : increasing access to evidence-based treatments
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Paediatric anxiety disorders are common, impairing and associated with a societal and economic burden. Even though there are efficacious treatments to treat these disorders, access to them are limited. Internet-delivered cognitive behaviour therapy (ICBT) has gained support for being an efficacious treatment for paediatric anxiety disorders and is suggested as one possible solution to increase access to evidence-based treatments. Aims and methods: The main aim of this thesis was to evaluate the BiP Anxiety programme, for children aged 8 to 12 years old with an anxiety disorder, in two clinical settings. First by conducting a randomised controlled trial within a specialised ICBT clinic part of the child and adolescent mental health services (CAMHS) in Stockholm. Secondly by conducting a pilot feasibility trial at a CAMHS outpatient clinic in rural Sweden. Specific aims were to evaluate (1) the effects and cost-effectiveness ofICBT compared to an active placebo control, (2) the long term effect of ICBT within a stepped-care model where non-remitters of treatment were offered additional treatment, (3) predictors of treatment outcome, and ( 4) the feasibility and potential effectiveness ofICBT when disseminated in an outpatient clinic in rural Sweden. Results: ICBT was effective in reducing anxiety symptoms in a cost-effective manner when compared to a placebo condition controlling for non-specific therapeutic factors such as attention and weekly homework assignments. Treatment gains were maintained up to 12 months after the end of the treatment. Participants with a principal diagnosis of separation anxiety disorder, and those more engaged in behaviour change were more likely to be in remission at the three-months follow-up. Participants with more severe anxiety were less likely of being in remission. Additional face-to-face treatment for non-remitters ofICBT was efficacious for those receiving it. The majority of non-remitters however declined this offer down, mostly due to already receiving treatment for other mental health disorders ( e.g., depression) at their local CAMHS. Also, ICBT seemed to be feasible and potentially also effective when disseminated to an outpatient clinic in rural Sweden. Conclusion: ICBT is an effective treatment, at least for children with moderate anxiety disorders. ICBT could be suitable as a first-line treatment, but a greater understanding about to whom it should be offered and when the treatment should be stepped up is needed. ICBT should be implemented as part of a specialised clinic to ensure the necessary education, support and supervision. However, other models of implementation might be required in rural areas where the resources needed for a specialised clinic cannot be motivated.
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| 3. |
- Jolstedt, Maral, et al.
(författare)
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Long-term outcomes of internet-delivered cognitive behaviour therapy for paediatric anxiety disorders : towards a stepped care model of health care delivery
- 2021
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Ingår i: European Child and Adolescent Psychiatry. - : Springer Nature. - 1018-8827 .- 1435-165X. ; 30, s. 1723-1732
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Tidskriftsartikel (refereegranskat)abstract
- Internet-delivered cognitive behaviour therapy (ICBT) is emerging as a powerful tool to fill the gap between demand and availability of evidence-based treatment for paediatric anxiety disorders. However, it is still unclear how to best implement it in routine clinical care. 123 children (8-12 years) with anxiety disorders underwent a 12-week ICBT programme with limited therapist support. Participants were assessed 3- and 12-month post-ICBT (3MFU and 12MFU, respectively). Non-remitters who still fulfilled diagnostic criteria for their principal anxiety disorder at 3MFU were offered additional manualised face-to-face (F2F) CBT. The aim of the study was to emulate a stepped-care model of health care delivery, where the long-term treatment gains of ICBT as well as the potential benefit of proving addition treatment to non-remitters of ICBT were evaluated. Remitters of ICBT (n = 73) continued to improve throughout the study period (pre-ICBT to 12MFU; Cohen'sd = 2.42). At 12MFU, 89% (n = 65) were free from their principal anxiety disorder. Of all the participants classed as non-remitters at 3MFU (n = 37), 48.6% (n = 18) accepted the offer to receive additional F2F CBT. These participants also improved with a large effect from pre-ICBT to 12MFU (Cohen'sd = 2.27), with the largest effect occurring during F2F CBT. At 12MFU, 83% (n = 15) were free from their principal anxiety disorders. The majority of non-remitters declining additional F2F CBT (63.2%;n = 12) did so due to already receiving treatment at their local CAMHS, prior to 3MFU. The effects of ICBT for anxiety disorders are durable at least up to 1 year after the end of treatment. Patients who fail to fully benefit from ICBT improved further with additional F2F sessions at our clinic, suggesting that it may be feasible to implement ICBT within a stepped-care model of health care delivery.
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| 4. |
- Lenhard, Fabian, et al.
(författare)
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The Internet Intervention Patient Adherence Scale for Guided Internet-Delivered Behavioral Interventions: Development and Psychometric Evaluation.
- 2019
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Ingår i: Journal of medical Internet research. - : JMIR Publications Inc.. - 1438-8871. ; 21:10
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Tidskriftsartikel (refereegranskat)abstract
- Patient adherence is defined as the extent to which a patient complies with medical or health advice. At present, there is a lack of reliable and valid measures specifically designed to measure adherence to internet-delivered behavioral interventions.The objective of this study was to develop and psychometrically evaluate a novel measure of adherence to guided internet-delivered behavioral interventions.In collaboration with experienced clinicians and researchers in the field, a 5-item, clinician-rated internet intervention Patient Adherence Scale (iiPAS) was developed. The initial scale was tested in a sample of children and adolescents (N=50) participating in internet-delivered cognitive behavioral therapy (ICBT) studies. A revised version of the iiPAS was then administered to a larger sample of children and adolescents (N=148) with various behavioral problems participating in ICBT trials. The scale was evaluated according to a classical test theory framework.The iiPAS demonstrated excellent internal consistency. Factor analyses revealed one underlying factor, explaining about 80% of the variance, suggesting that the scale captures a homogeneous adherence construct. The iiPAS was strongly associated with objective measures of patient activity in ICBT (number of logins, number of written characters, and completed modules). Furthermore, mid- and posttreatment ratings of the iiPAS were significantly correlated with treatment outcomes. By contrast, objective measures of patient activity in the Web-based platform did not correlate with treatment outcomes.The iiPAS could be a useful tool to measure adherence in a broad range of internet-delivered behavioral interventions.
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| 5. |
- Nordh, Martina, et al.
(författare)
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Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety Disorder : A Randomized Clinical Trial
- 2021
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Ingår i: JAMA psychiatry. - : American Medical Association (AMA). - 2168-6238 .- 2168-622X. ; 78:7, s. 705-713
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Tidskriftsartikel (refereegranskat)abstract
- Importance Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited.Objective To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT).Design, Setting, and Participants This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study.Interventions ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist.Main Outcomes and Measures The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor–rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs.Results Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group.Conclusions and Relevance In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD.Trial Registration ClinicalTrials.gov Identifier: NCT03247075
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| 6. |
- Rautio, Daniel, et al.
(författare)
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Therapist-guided, Internet-delivered cognitive behaviour therapy for adolescents with body dysmorphic disorder : A feasibility trial with long-term follow-up
- 2023
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Ingår i: Internet Interventions. - 2214-7829. ; 34
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Tidskriftsartikel (refereegranskat)abstract
- Body dysmorphic disorder (BDD) is a prevalent and impairing psychiatric condition that typically debuts in adolescence and is associated with risky behaviours. The disorder can be effectively treated with cognitive behaviour therapy (CBT). However, CBT for BDD is seldom available primarily due to a shortage of trained therapists. Internet-delivered CBT (ICBT) can be a way to increase treatment availability. The aim of this feasibility trial was to evaluate the feasibility, safety, and preliminary efficacy of a CBT protocol for adolescents with BDD, adapted to be delivered over the Internet with minimal therapist support. A total of 20 participants (12–17-year-olds) meeting criteria for BDD were recruited nationally to a specialist outpatient clinic in Stockholm, Sweden. One participant withdrew consent and their data could not be analysed. Nineteen participants were offered 12 modules of therapist-guided ICBT for BDD and were followed up to 12 months post-treatment. Preliminary efficacy was measured at the a priori primary endpoint (3-month follow-up) and at the 12-month follow-up with the clinician-rated Yale-Brown Obsessive Compulsive Scale Modified for BDD for Adolescents. The treatment was rated as both credible and satisfactory and was associated with a large and statistically significant reduction in BDD symptom severity (d = 2.94). The proportion of participants classified as responders at the primary endpoint was 73.7%, and the proportion of full or partial remitters was 63.2%. The average therapist support time was 8 min per participant per week. Treatment gains continued to accrue up to the 12-month follow-up. Two participants attempted suicide and another two reported non-suicidal self-injuries during the study period. ICBT with minimal therapist support is a feasible, potentially efficacious, and durable treatment for adolescents with BDD. Risky behaviours typical of this patient group should be carefully monitored during treatment.
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| 7. |
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| 8. |
- Vigerland, Sarah, et al.
(författare)
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Effectiveness of internet-delivered cognitive behavioural therapy for anxiety and obsessive-compulsive disorders within routine clinical care in rural Sweden
- 2024
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Ingår i: Internet Interventions. - 2214-7829. ; 36
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Tidskriftsartikel (refereegranskat)abstract
- Few studies have evaluated the implementation of ICBT in regular child and adolescent mental health services (CAMHS). This study aimed to explore the acceptability, feasibility, and effectiveness of ICBT for children and adolescents with anxiety disorders and obsessive-compulsive disorder (OCD) within a rural CAMHS. The study also explored outcome predictors and long-term outcomes. Eighty-three participants were consecutively recruited from a non-specialized CAMHS in Region Jämtland Härjedalen in northern Sweden. Therapist-guided ICBT was offered during 12 weeks to children aged 8–17 with an anxiety disorder or OCD. Acceptability and feasibility measures included treatment adherence, treatment satisfaction, and adverse events. The primary outcome measure was the Clinical Global Impression–Severity. Secondary measures of effectiveness included clinician-, self-, and parent-ratings of symptom severity and functional impairment. Assessments were completed at baseline, post-treatment, and three-month follow-up (primary endpoint). A two-year follow up was conducted using medical records. Potential predictors included both patient characteristics and treatment variables. Results indicated that ICBT was both acceptable and feasible according to study measures. Statistically significant improvements were found from baseline to the three-month follow-up on clinician rated severity (B [SE] = −0.92 [0.09]; p < .001), as well as on all secondary measures. Forty-three percent of participants no longer fulfilled criteria for their principal disorder at the three-month follow-up. No serious adverse events were reported. Clinical improvement was highest among children with higher functioning at baseline (B [SE] = −0.05 [0.02]; p < .05). Forty-six percent of participants had been in contact with CAMHS during the two-year follow-up period, mainly for reasons other than their initial diagnosis. Findings suggest that ICBT could be an acceptable and feasible treatment option for young people with anxiety disorders and OCD in rural non-specialized CAMHS settings. Further studies are needed to confirm treatment effectiveness in this setting. Trial registration: NCT02926365.
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| 9. |
- Wahlund, Tove, et al.
(författare)
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Intolerance of uncertainty-focused treatment for adolescents with excessive worry - A pilot feasibility study
- 2020
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Ingår i: Cognitive and Behavioral Practice. - : Elsevier BV. - 1077-7229. ; 27:2, s. 215-230
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Tidskriftsartikel (refereegranskat)abstract
- Bouts of excessive worry are common across the lifespan, increasing in frequency and complexity during adolescence and adulthood, and are found in several psychiatric disorders, particularly the anxiety disorders. There are evidence-based treatments for adolescents with anxiety disorders but psychological treatments designed specifically to target excessive worrying in adolescents are rare. Intolerance of uncertainty (IU), a cognitive predisposition described as a fear of the unknown, is highly associated with worry among adolescents. This study investigated the feasibility, acceptability, and preliminary efficacy of IU-focused cognitive behavioral therapy (IU-CBT) for adolescents with excessive worry. Twelve participants (aged 13–17 years) with excessive worry, irrespective of psychiatric diagnosis, were provided weekly face-to-face sessions, primarily including therapist and self-guided exposure to situations involving uncertainty. Sessions were supplemented with an internet-delivered educational program for parents, designed to teach parents about worry, IU and helpful parental behaviors. The main outcome measure was the Penn-State Worry Questionnaire for Children (PSWQ-C). The treatment was well tolerated with no dropouts and families reporting being satisfied with the treatment. Participants were able to grasp the notion of IU and its relationship to worry and avoidance. Significant reductions were observed for self-reported worry, anxiety, depression, IU, and parent-reported worry, as were significant increases in global functioning. Based on a clinician rating, 58.3% were categorized as much or very much improved at posttreatment, rising to 66% at 3-month follow-up. Participants with generalized anxiety disorder (GAD) benefitted more from treatment than those with social anxiety disorder. The findings suggest that this IU-focused psychological intervention is acceptable and feasible to adolescents with excessive worry but may be most effective for those with GAD.
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| 10. |
- Wahlund, Tove, et al.
(författare)
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Online cognitive behavior therapy for adolescents with excessive worry : a multiple baseline design feasibility study
- 2020
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Ingår i: mHealth. - : AME Publishing Company. - 2306-9740. ; 6
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Tidskriftsartikel (refereegranskat)abstract
- Background: One in twenty adolescents experience excessive worry and evidence-based psychological therapies are not sufficiently widespread to reach most of those affected. In this multiple baseline evaluation, we assess the feasibility and preliminary efficacy of a scalable, online cognitive-behavioral intervention for adolescents with excessive worry (BIP worry).Methods: Thirteen adolescents (age 13–17) with excessive worry underwent the 10-week online BIP worry intervention. The treatment also included an online intervention for parents. Completion rates, treatment satisfaction, and adverse events were measures of feasibility. Clinical outcomes included worry severity, symptoms of other anxiety and depression, and general functioning. To control for time and spontaneous fluctuations in symptoms, adolescents were randomized to a 2-, 6-, or 10-week baseline phase prior to treatment. A short measure of worry severity was administered weekly during the baseline and treatment phases. Outcomes were assessed before the baseline-phase, at pre-treatment, post-treatment, and at 1- and 3-month follow-ups.Results: Twelve of 13 included adolescents, together with their parents, participated in BIP worry, with a mean completion rate of 9.8 of the 10 treatment modules. Adolescents reported an average of 4.4 exposures per week as homework during treatment. High levels of treatment adherence, credibility, and satisfaction, and no serious adverse events were reported. Therapists averaged 21 min per week communicating with each family. Linear mixed effects models indicated significant improvements in worry, anxiety, and general functioning from pre- to post-treatment, with these gains maintained at 1- and 3-months follow-up. Reductions in worry severity during treatment were significantly larger than during the baseline phase. The results from the multiple baseline evaluation suggested an association between the introduction of the BIP worry intervention and subsequent symptom change for some but not all adolescents.Conclusions: BIP worry is a feasible and potentially effective treatment. As the treatment is scalable and involves limited therapist contact, it represents a low-cost method for treating adolescents with excessive worry and anxiety. Further investigation under randomized controlled trial (RCT) conditions is warranted.
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