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1.	Eriksson-Liebon, Magda, et al. (author) Experience of internet-delivered cognitive behavioural therapy among patients with non-cardiac chest pain 2023 In: Journal of Clinical Nursing. - : Wiley. - 0962-1067 .- 1365-2702. ; 32:13-14, s. 4060-4069 Journal article (peer-reviewed)abstract Aims and Objective To explore the experiences of patients with non-cardiac chest pain and cardiac anxiety regarding participation in an internet-delivered cognitive behavioural therapy program. Background Non-cardiac chest pain is common and leads to cardiac anxiety. Internet-delivered cognitive behavioural therapy may be a possible option to decrease cardiac anxiety in these patients. We have recently evaluated the effect of an internet-delivered cognitive behavioural therapy program on cardiac anxiety. Design An inductive qualitative study using content analysis and the COREQ checklist. Methods Semi-structured interviews with 16 Swedish patients, who had participated in the internet-delivered cognitive behavioural therapy program. Results Three categories were found. The first, Driving factors for participation in the internet-delivered cognitive behavioural therapy program described the impact of pain on their lives and struggle that led them to participating in the program. The second, The program as a catalyst described that the program was helpful, trustworthy and useful and the last category, Learning to live with chest pain described the program as a tool for gaining the strength and skills to live a normal life despite chest pain. Conclusions The program was experienced as an opportunity to return to a normal life. The program was perceived as helpful, trustworthy and useful, which helped the participants challenge their fear of chest pain and death, and gain strength and new insights into their ability to live a normal life. Relevance to Clinical Practice A tailored internet-delivered cognitive behavioural therapy program delivered by a nurse therapist with clinical experience of the patient group is important to improve cardiac anxiety. Patient or Public Contribution Patients or the general public were not involved in the design, analysis or interpretation of the data of this study, but two patients with experience of non-cardiac chest pain were involved in the development of the pilot study. Trial Registration NCT03336112; .
2.	Eriksson-Liebon, Magda, et al. (author) Living with non-cardiac chest pain - An inductive qualitative interview study of spouses' perspectives 2024 In: Nursing Open. - : WILEY. - 2054-1058. ; 11:5 Journal article (peer-reviewed)abstract Aim: To explore spouses' experiences of living with a partner suffering from non-cardiac chest pain (NCPP). Design: An inductive qualitative study. Methods: Individual interviews (n = 10) were performed with spouses of partners having NCCP and cardiac anxiety. The analysis was performed according to Patton's guide for content analysis of qualitative data. Results: Three categories and seven subcategories were identified. First, 'a feeling of being neglected', where spouses felt ignored by healthcare professionals and excluded by their partners. Secondly, 'a tension between hope and despair' encompassed feelings of faith, support, unpreparedness for chest pain and situational frustration. Lastly, in 'a threat to ordinary life', spouses noted chest pain-induced changes impacting daily life, finances, leisure and relationships. To conclude, NCCP in partners significantly affects their spouses emotionally and practically. Spouses felt neglected and isolated, oscillating between hope and despair and experiencing faith, powerlessness and frustration. They also faced challenges in daily life and relationships.
3.	Eriksson-Liebon, Magda, et al. (author) Long-term effects and predictors of change of internet-delivered cognitive behavioural therapy on cardiac anxiety in patients with non-cardiac chest pain: a randomized controlled trial 2024 In: BMC Psychiatry. - : BMC. - 1471-244X. ; 24:1 Journal article (peer-reviewed)abstract BackgroundApproximately half of patients who seek care at Emergency Departments due to chest pain are diagnosed with Non-Cardiac Chest Pain (NCCP). Concerns for heart disease and misinterpretation of the symptoms increase cardiac anxiety and have a negative impact on patients' lives. Psychological interventions such as internet-delivered cognitive behavioral therapy (iCBT) are effective in treating psychological conditions such as anxiety, by helping patients to learn how to manage chest pain.AimsTo evaluate the effects of a nurse-led iCBT program on cardiac anxiety and secondary outcomes, as bodily sensations, depressive symptoms, health-related quality of life and chest pain frequency in patients with NCCP at 6- and 12-month follow-up, and to explore predictors that can have impact on the effects of the iCBT program on psychological distress.MethodsA longitudinal study of a Randomized Controlled Trial (RCT) evaluating the long-term effects of an iCBT program (n = 54) in patients with NCCP, compared to psychoeducation (n = 55). The primary outcome, cardiac anxiety was measured using the Cardiac Anxiety Questionnaire (CAQ), and the secondary outcomes were measured with The Body Sensations Questionnaire (BSQ), Patient Health Questionnaire-9 (PHQ-9), The EuroQol Visual Analog Scale (EQ-VAS) and a self-developed question to measure chest pain frequency. All measurements were performed before and after the intervention, and 3, 6 and 12 months after the intervention. Linear mixed model was used to test between-group differences in primary and secondary outcomes and multiple regression analysis was used to explore factors that may have an impact on the treatment effect of iCBT on cardiac anxiety.ResultsA total of 85% (n = 93/109) participants completed the 12-month follow-up. Mixed model analysis showed no statistically significant interaction effect of time and group between the iCBT and psychoeducation groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p = .009) regarding chest pain frequency favouring the iCBT group. In addition, we found a group effect in health-related quality of life (p = .03) favouring the iCBT group. The regression analysis showed that higher avoidance scores at baseline were associated with improvement in cardiac anxiety at 12-month follow-up.ConclusionsCardiac anxiety was reduced in patients with NCCP, but iCBT was not more effective than psychoeducation. Patients with a high tendency to avoid activities or situations that they believe could trigger cardiac symptoms may benefit more from psychological interventions targeting cardiac anxiety.Trial RegistrationThe trial was registered at ClinicalTrials.gov NCT03336112 on 08/11/2017.
4.	Eriksson-Liebon, Magda, 1986- (author) The effects and experiences of internet-delivered cognitive behavioural therapy : The perspectives of patients with non-cardiac chest pain and healthcare professionals in the emergency and cardiac care 2024 Doctoral thesis (other academic/artistic)abstract BackgroundNon-cardiac chest pain (NCCP) is a common issue, accounting for roughly half of all emergency department visits related to chest pain. Patients afflicted with NCCP often endure cardiac anxiety, misinterpreting the pain as heart-related and fearing it, despite the absence of any life-threatening cardiac issues. This anxiety often leads to the avoidance of physical activities, negatively impacting their quality of life. Cognitive behavioural therapy (CBT) has been shown to be effective in managing psychological distress such as anxiety and depression. CBT is a structured process that helps patients identify and restructure their negative thoughts, get a corrected and more realistic perception of their symptoms, and learn to manage their thoughts about chest pain. Despite its effectiveness, CBT is resource-intensive, and therefore internet-delivered cognitive behavioural therapy (iCBT) may be an alternative as it increases accessibility and is more cost-effective compared to traditional therapy methods. However, there is a lack of re-search on the effectiveness of this treatment approach for patients with NCCP and cardiac anxiety. Moreover, digital care technologies are still relatively unfamiliar in clinical practice, particularly in emergency departments, and the successful implementation of iCBT relies on healthcare professionals' acceptance and integration of digital care into clinical practice. Aim The overall aim of this dissertation was to evaluate the short- and long-term effects of a nurse-led iCBT program on psychological distress in patients with NCCP, and to explore their experiences participating in the iCBT program. In addition, the study aimed to describe healthcare professionals' perceptions of digital care in the emergency and cardiac care for patients with NCCP. Methods This dissertation comprises two quantitative and two qualitative studies. A randomised clinical trial (RCT) (studies I, II, and III) was conducted to evaluate cardiac anxiety, measured with the Cardiac Anxiety Questionnaire (CAQ); and secondary outcomes such as fear of body sensations, measured with The Body Sensations Questionnaire (BSQ); depressive symptoms, assessed with the Patient Health Questionnaire-9 (PHQ-9); health-related quality of life (HRQoL), measured using the EuroQol Visual Analog Scale (EQ-VAS); and chest pain frequency with a self-developed question. The RCT cohort consisted of 109 patients who had at least two healthcare consultations for NCCP in the past 6 months, experienced cardiac anxiety (CAQ score ≥24), and were randomised into a 5-week iCBT program (n=54) or psychoeducation (n=55). An intention-to-treat analysis was conducted, and linear mixed model analysis was used to assess between-group differences in primary and secondary outcomes. The iCBT program included psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments and feedback, while the control (psychoeducation) group received readable psychoeducation program aimed to increase knowledge about their mental health, symptoms, and the strategies that can be used to manage chest pain and improve their well-being. Study I was a short-term follow-up with a three-month duration. Study III was a longitudinal study with a 12-month follow-up. Additionally, factors impacting the treatment effect of iCBT on cardiac anxiety were also explored. Study II was a semi-structured qualitative study utilising an inductive approach with content analysis following Patton (2015). Face-to-face interviews were conducted with 16 participants from the iCBT group. Study IV was a qualitative descriptive study involving individual, digital/face-to-face semi-structured interviews with 17 licensed healthcare professionals (physicians and nurses) working in emergency care or cardiology. Data were analysed using inductive thematic analysis based on Braun and Clarke (2006). Result In Study I, no significant differences were found between the iCBT and control (psychoeducation) groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen’s d=0.31). A positive change score (≥11 points on the CAQ) was reported by 16 patients in the iCBT group (36%) compared to 13 patients (27%) in the control (psychoeducation) group, indicating a slightly greater improvement in cardiac anxiety in the iCBT group. However, the difference between the groups was non-significant (p=.213). Within-group analysis showed significant improvement in cardiac anxiety (p=.037) at the 3-month follow-up compared to the 5-week follow-up in the iCBT group, but not in the control (psychoeducation) group. In Study III, there was no statistically significant interaction effect of time and group between the iCBT and control (psychoeducation) groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p=.009) regarding chest pain frequency for the iCBT group and a group effect on health-related quality of life (p=.03) for the iCBT group. Furthermore, the regression analysis showed that higher scores of "avoidance" on the CAQ at baseline were associated with improvement in cardiac anxiety at the 12-month follow-up in both groups. In Study II, participants described their experiences, leading to three main categories: "driving factors for participation in the iCBT program", "the program as a catalyst" and "learning to live with chest pain." Participants described how pain impacted their lives, the struggle that led them to participate in the program, and how they found the program helpful, trustworthy, and viewed it as a tool for gaining the strength and skills they needed to live a normal life despite chest pain. In Study IV, healthcare professionals described their perception of digital care, resulting in four themes: "new ground to walk on”, "a challenge for the current healthcare system", "digital care has its potential" and "prerequisites for use in clinical practice". These themes describe healthcare professionals' knowledge and experience with digital care, the challenges associated with implementing digital care in the current healthcare system, the opportunities it presents, and identify facilitators for the implementation of digital care in clinical practice.ConclusionsIn studies I and III, iCBT was not superior to psychoeducation in reducing cardiac anxiety in patients with NCCP. However, both iCBT and psychoeducation have demonstrated utility as interventions for reducing cardiac anxiety in these patients. Moreover, patients with an increased propensity to avoid activities or situations they believe may trigger cardiac -related symptoms, were found to have reduced cardiac anxiety. Patients generally perceived the iCBT program positively, viewing it as a tailored and effective tool for confronting fears and restoring normalcy in their lives. Healthcare professionals express a mixture of caution and optimism towards digital care, emphasising the importance of clear leadership, education, technical competence, and positive attitudes to ensure successful implementation and maximise benefits for patients with NCCP.
5.	Johansson, Peter, 1962-, et al. (author) An internet-based cognitive behavioral therapy program adapted to patients with cardiovascular disease and depression : Randomized controlled trial 2019 In: Journal of Medical Internet Research. - Toronto, Canada : Journal of Medical Internet Research. - 1438-8871. ; 21:10, s. 1-14 Journal article (peer-reviewed)abstract Background: Depression is a common cause of reduced well-being and prognosis in patients with cardiovascular disease (CVD). However, there is a lack of effective intervention strategies targeting depression.Objective: The study aimed to evaluate the effects of a nurse-delivered and adapted internet-based cognitive behavioral therapy (iCBT) program aimed at reducing depression in patients with CVD.Methods: A randomized controlled trial was conducted. A total of 144 patients with CVD with at least mild depression (Patient Health Questionnaire–9 [PHQ-9] score ≥5) were randomized 1:1 to a 9-week program of iCBT (n=72) or an active control participating in a Web-based discussion forum (online discussion forum [ODF], n=72). The iCBT program, which included 7 modules, was adapted to fit patients with CVD. Nurses with an experience of CVD care provided feedback and a short introduction to cognitive behavioral therapy. The primary outcome, depression, was measured using PHQ-9. Secondary outcomes were depression measured using the Montgomery-Åsberg Depression Rating Scale–self-rating version (MADRS-S), health-related quality of life (HRQoL) measured using Short Form 12 (SF-12) survey and EuroQol Visual Analogue Scale (EQ-VAS), and the level of adherence. An intention-to-treat analysis with multiple imputations was used. Between-group differences in the primary and secondary outcomes were determined by the analysis of covariance, and a sensitivity analysis was performed using mixed models. Results: Compared with ODF, iCBT had a significant and moderate treatment effect on the primary outcome depression (ie, PHQ-9; mean group difference=−2.34 [95% CI −3.58 to −1.10], P<.001, Cohen d=0.62). In the secondary outcomes, compared with ODF, iCBT had a significant and large effect on depression (ie, MADRS-S; P<.001, Cohen d=0.86) and a significant and moderate effect on the mental component scale of the SF-12 (P<.001, Cohen d=0.66) and the EQ-VAS (P<.001, Cohen d=0.62). Overall, 60% (n=43) of the iCBT group completed all 7 modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study owing to a high risk of suicide or deterioration in depression.Conclusions: Nurse-delivered iCBT can reduce depression and improve HRQoL in patients with CVD, enabling treatment for depression in their own homes and at their preferred time.
6.	Johansson, Peter, 1962-, et al. (author) Internet-Based Cognitive Behavioral Therapy and its Association With Self-efficacy, Depressive Symptoms, and Physical Activity : Secondary Analysis of a Randomized Controlled Trial in Patients With Cardiovascular Disease 2022 In: JMIR Cardio. - Toronto, Canada : JMIR Publications, Inc.. - 2561-1011. ; 6:1 Journal article (peer-reviewed)abstract Background: In patients with cardiovascular disease (CVD), knowledge about the associations among changes in depressivesymptoms, self-efficacy, and self-care activities has been requested. This is because such knowledge can be helpful in the designof behavioral interventions aimed to improve self-efficacy, reduce depressive symptoms, and improve performance of self-careactivities in CVD patients.Objective: We aim to evaluate if internet-based cognitive behavioral therapy (iCBT) improves self-efficacy and explore therelationships among changes in depressive symptoms, self-efficacy, and physical activity, as well as the influence of iCBT onthese relationships.Methods: This study received funding in January 2015. Participant recruitment took place between January 2017 and February2018, and the main findings were published in 2019. This study is a secondary analysis of data collected in a randomized controlledstudy evaluating the effects of a 9-week iCBT program compared to an online discussion forum (ODF) on depressive symptomsin patients with CVD (N=144). Data were collected at baseline and at the 9-week follow-up. Analysis of covariance was used toevaluate the differences in self-efficacy between the iCBT and ODF groups. Structural equation modeling explored the relationshipsamong changes in depressive symptoms, self-efficacy, and physical activity, as well as the influence of iCBT on these relationships.Results: At follow-up, a significant difference in the increase in self-efficacy favoring iCBT was found (P=.04, Cohen d=0.27).We found an indirect association between changes in depressive symptoms and physical activity (ß=–.24, P<.01), with the changein self-efficacy acting as a mediator. iCBT had a direct effect on the changes in depressive symptoms, which in turn influencedthe changes in self-efficacy (ß=.23, P<.001) and physical activity (ß=.12, P<.001).Conclusions: Self-efficacy was improved by iCBT. However, the influence of iCBT on self-efficacy and physical activity wasmostly mediated by improvements in depressive symptoms.Trial Registration: ClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074
7.	Johansson, Peter, 1962-, et al. (author) Psychological distress in patients with cardiovascular disease : time to do something about it? 2021 In: European Journal of Cardiovascular Nursing. - : Oxford University Press. - 1474-5151 .- 1873-1953. ; 20:4, s. 293-294 Journal article (other academic/artistic)
8.	Mourad, Ghassan, 1974-, et al. (author) Cost-effectiveness of internet-delivered cognitive behavioural therapy in patients with cardiovascular disease and depressive symptoms: secondary analysis of an RCT 2022 In: BMJ Open. - London, United Kingdom : BMJ Publishing Group Ltd. - 2044-6055. ; 12:4 Journal article (peer-reviewed)abstract Introduction Cost-effectiveness evaluations of psychological interventions, such as internet-delivered cognitive behavioural therapy (iCBT) programmes, in patients with cardiovascular disease (CVD) are rare. We recently reported moderate to large effect sizes on depressive symptoms in CVD outpatients following a 9-week iCBT programme compared with an online discussion forum (ODF), in favour of iCBT. In this paper, we evaluate the cost-effectiveness of this intervention.Methods Cost-effectiveness analysis of a randomised controlled trial. The EQ-5D-3L was used to calculate quality-adjusted life-years (QALYs). Data on healthcare costs were retrieved from healthcare registries.Results At 12-month follow-up, the QALY was significantly higher in iCBT compared with the ODF group (0.713 vs 0.598, p=0.007). The mean difference of 0.115 corresponds with 42 extra days in best imaginable health status in favour of the iCBT group over the course of 1 year. Incremental cost-effectiveness ratio (ICER) for iCBT versus ODF was euro18 865 per QALY saved. The cost-effectiveness plane indicated that iCBT is a cheaper and more effective intervention in 24.5% of the cases, and in 75% a costlier and more effective intervention than ODF. Only in about 0.5% of the cases, there was an indication of a costlier, but less effective intervention compared with ODF.Conclusions The ICER of euro18 865 was lower than the cost-effectiveness threshold range of euro23 400-euro35 100 as proposed by the NICE guidelines, suggesting that the iCBT treatment of depressive symptoms in patients with CVD is cost-effective.
9.	Mourad, Ghassan, 1974-, et al. (author) Depressive symptoms and health care utilization : -a comparison between patients with non-cardiac chest pain and patients with ischemic heart disease 2012 Conference paper (other academic/artistic)abstract Background: More than half of patients admitted to hospital for acute chest pain are diagnosed as having non-cardiac chest pain (NCCP). While there are well established guidelines for diagnosing and treating patients with ischemic heart disease (IHD), an international consensus approach to treat patients with NCCP is lacking. This lack of structured care may possibly cause mental distress in patients and increased health care utilization.Objectives: To compare depressive symptoms and health care utilization in patients admitted for NCCP and patients with acute myocardial infarction (AMI) and angina pectoris (AP) post-hospitalization and at one-year follow-up.Methods: A cross-sectional, descriptive and comparative design was used. In total 131 patients with NCCP, 66 with AMI and 70 with AP completed two depression screening questionnaires 2-3 weeks after the hospital stay and one year later. Data on health care utilization were collected from a population-based diagnose-related database.Results: Depressive symptoms were found in 27% of the participants post-hospitalization and in 26% one year later. At follow-up, 17 patients had recovered from their depressive symptoms, 37 patients had continuous depressive symptoms, and 26 patients had developed depressive symptoms. No difference in depressive symptoms was found between the different diagnose groups neither at baseline nor at follow-up. Patients diagnosed with NCCP visited health care providers in primary care as often as patients diagnosed with AMI, but had fewer hospital admissions. Patients with AP and patients with depressive symptoms utilized most health care services.Conclusion: Persisting depressive symptoms are frequently seen among patients with NCCP as well as in patients with IHD. NCCP patients utilize as much primary care resources as AMI patients. This might imply a need for interventions targeting depressive symptoms in patients with both NCCP and IHD.
10.	Mourad, Ghassan, et al. (author) Depressive symptoms and healthcare utilization in patients with noncardiac chest pain compared to patients with ischemic heart disease 2012 In: Heart & Lung. - : Elsevier. - 0147-9563 .- 1527-3288. ; 41:5, s. 446-455 Journal article (peer-reviewed)abstract OBJECTIVES: We compared depressive symptoms and healthcare utilization in patients admitted for noncardiac chest pain, acute myocardial infarction, and angina pectoris after hospitalization and at 1-year follow-up. METHODS: One hundred and thirty-one patients with noncardiac chest pain, 66 with acute myocardial infarction, and 70 with angina pectoris completed a depression screening questionnaire and the Montgomery Åsberg Depression Rating Scale. Healthcare utilization data were collected from a population-based, diagnosis-related database. RESULTS: More than 25% of respondents reported depressive symptoms, regardless of diagnosis. At follow-up, 9% had recovered, 19% were still experiencing depressive symptoms, and 13% had developed depressive symptoms. Noncardiac patients with chest pain had similar primary care contacts, but fewer hospital admissions, than patients with an acute myocardial infarction. Patients with angina pectoris and depressive symptoms used the most healthcare services. CONCLUSIONS: Depressive symptoms were common. Patients with noncardiac chest pain used as much primary care as did patients with an acute myocardial infarction. Interventions should focus on identifying and treating depressive symptoms.
11.	Mourad, Ghassan, 1974-, et al. (author) Depressive Symptoms, Cardiac Anxiety, and Fear of Body Sensations in Patients with Non-Cardiac Chest Pain, and Their Relation to Healthcare-Seeking Behavior : A Cross-Sectional Study 2016 In: The patient. - : ADIS INT LTD. - 1178-1653. ; 9:1, s. 69-77 Journal article (peer-reviewed)abstract BACKGROUND: Patients with non-cardiac chest pain (NCCP) suffer from recurrent chest pain and make substantial use of healthcare resources.OBJECTIVE: To explore the prevalence of depressive symptoms, cardiac anxiety, and fear of body sensations in patients discharged with a NCCP diagnosis; and to describe how depressive symptoms, cardiac anxiety, and fear of body sensations are related to each other and to healthcare-seeking behavior.METHODS: Cross-sectional design. Data were collected between late October 2013 and early January 2014 in 552 patients with NCCP from four hospitals in southeast Sweden, using the Patient Health Questionnaire-9, Cardiac Anxiety Questionnaire, and Body Sensations Questionnaire.RESULTS: About 26 % (n = 141) of the study participants reported at least moderate depressive symptoms, 42 % (n = 229) reported at least moderate cardiac anxiety, and 62 % (n = 337) reported some degree of fear of body sensations. We found strong positive relationships between depressive symptoms and cardiac anxiety (r s = 0.49; P < 0.01), depressive symptoms and fear of body sensations (r s = 0.50; P < 0.01), and cardiac anxiety and fear of body sensations (r s = 0.56; P < 0.01). About 60 % of the participants sought care because of chest pain once, 26 % two or three times, and the rest more than three times. In a multivariable regression analysis, and after adjustment for multimorbidity, cardiac anxiety was the only variable independently associated with healthcare-seeking behavior.CONCLUSION: Patients with NCCP and many healthcare consultations had high levels of depressive symptoms and cardiac anxiety, and moderate levels of fear of body sensations. Cardiac anxiety had the strongest relationship with healthcare-seeking behavior and may therefore be an important target for intervention to alleviate suffering and to reduce healthcare use and costs.
12.	Mourad, Ghassan, 1974-, et al. (author) Guided Internet-delivered cognitive behavioral therapy in patients with non-cardiac chest pain : a pilot randomized controlled study 2015 Other publication (other academic/artistic)abstract Background: Patients with recurrent episodes of non-cardiac chest pain (NCCP) may suffer from cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain.Objective: To test the feasibility of a short guided Internet-delivered CBT intervention and the effects on chest pain, cardiac anxiety, fear of body sensations and depressive symptoms in patients with NCCP compared to usual care.Methods: A pilot randomized controlled study was conducted. Fifteen patients, nine men and six women with a median age of 66 years (range 22-76), were randomly assigned to either intervention (n=7) or control (n=8) group. Patients had recurrent episodes of non-cardiac chest pain and suffered from cardiac anxiety and/or fear of body sensations. The intervention consisted of a four-session guided Internet-delivered CBT program containing psychoeducation, physical activity, and relaxation. The control group received usual care. All patients completed a web-based questionnaire on socio-demographic variables, chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms.Results: Five out of the seven patients in the intervention group completed all sessions as planned and two joined only parts of the program. The program was perceived as userfriendly with understandable language, adequate and varied content, and manageable homework assignments. The patients were engaged in the program for about 60 minutes per day and about 22 minutes’ therapist time was required to guide, support and give feedback to each patient through the program. Participating in the program, particularly being guided and supported, empowered and motivated many of the patients to be active and complete the program. In general, patients in both intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but there were no significant differences between the groups.Conclusions: A short guided Internet-delivered CBT program was feasible. Patients in both intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. Patients should be followed-up for longer periods to measure the long-term effects of the intervention.
13.	Mourad, Ghassan, et al. (author) Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain - a pilot randomized controlled study 2016 In: Trials. - : BioMed Central. - 1745-6215. ; 17, s. 1-12 Journal article (peer-reviewed)abstract Background: Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care. Methods: A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22-76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention. Results: Five of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. Conclusions: The Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period.
14.	Mourad, Ghassan, 1974-, et al. (author) Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain: -a pilot randomized controlled study 2016 In: Abstract book. - : Sage Publications. ; , s. S44-S44 Conference paper (other academic/artistic)abstract Background: Patients with recurrent episodes of non-cardiac chest pain (NCCP) suffer from cardiac anxiety as they misinterpret the pain as being cardiac-related and avoid physical activity that they think could threaten their life. This could lead to increased healthcare utilization and costs. These patients might benefit from help and support to evaluate the perception and management of their chest pain. Objective: To test the feasibility of a short guided Internet-delivered cognitive behavioural intervention and the effects on chest pain, cardiac anxiety, fear of body sensations and depressive symptoms in patients with NCCP compared to usual care.Methods: A pilot randomized controlled study was conducted. Fifteen patients, 9 men and 6 women between the age of 22 and 76 (median age of 66 years, q1-q3 57-73) were randomly assigned to either intervention (n=7) or control (n=8) group. Patients had recurrent NCCP and suffered from cardiac anxiety or fear of body sensations. The intervention consisted of a 4-session guided Internet-delivered cognitive behavioural therapy program containing psychoeducation, exposure to physical activity, and relaxation. The control group received usual care. All patients completed a web-based questionnaire on socio-demographic variables, chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. Results: Five out of the 7 patients in the intervention group completed all sessions as planned and two completed only parts of the program. The program was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. The patients were engaged in the program for about 45-60 minutes per day and about 22 minutes’ therapist time was required to guide, support and give feedback to each patient throughout the program. Participating in the program empowered and motivated many of the patients to be active and complete the program. In general, patients in both the intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but there were no significant differences between the groups. Conclusions: A short guided Internet-delivered cognitive behavioural therapy program was feasible. Patients in both the intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. Patients should be followed-up for longer periods to measure the long-term effects of the intervention.
15.	Mourad, Ghassan, 1974-, et al. (author) Healthcare use in patients with cardiovascular disease and depression – the impact of internet-delivered cognitive behavioural therapy 2020 Conference paper (other academic/artistic)abstract Background: Depressive symptoms in patients with cardiovascular disease (CVD) seem to induce higher healthcare use and thereby causing a burden on society. Thus, interventions aiming to decrease depressive symptoms in these patients could decrease the use of healthcare resources. In a previous study we have shown that a 9-week internet-delivered cognitive behavioural therapy (iCBT) program (n=72) compared to an online discussion forum (ODF) (n=72) had moderate to large effect on depressive symptoms in CVD outpatients. However, the effect on healthcare use was not evaluated in that study.Objectives: To describe and compare the iCBT and ODF groups with regard to healthcare use. Methods: Data on healthcare use was retrieved from a population-based diagnose-related administrative database. Patients were predominantly males with a mean age of 61±13 and 64±12 years in the iCBT and ODF respectively. The groups did not differ significantly. Collected data was divided into outpatient clinic and/or primary care contacts, and hospital admissions.Results: The year before the intervention, the iCBT group had a mean of 31±31 contacts per patient compared with 21±25 the year after the intervention. The corresponding number of contacts for the ODF group were 37±31 and 25±23. No between group differences were found, but in both groups, there were a statistically significant decrease (p<0.01) after the intervention. In both groups, most contacts were to physicians and nurses, but also rehabilitation staff.The iCBT group had 0.8±1.5 admissions per patient the year before and 0.6±1.6 the year after the intervention, and the ODF group had 1.1±1.6 admissions the year before and 0.6±2.2 the year after the intervention. There were no significant differences between the groups regarding number of admissions. Only the ODF group showed a significant decrease in number of admissions the year after compared to the year before the intervention. Improvement in depressive symptoms was not associated with decreased healthcare use.Conclusion: Despite decreased depressive symptoms by iCBT, the program was not superior compared to ODF in decreasing healthcare use.
16.	Mourad, Ghassan, et al. (author) Healthcare use in patients with cardiovascular disease and depressive symptoms - The impact of a nurse-led internet-delivered cognitive behavioural therapy program. A secondary analysis of a RCT 2024 In: Internet Interventions. - : ELSEVIER. - 2214-7829. ; 35 Journal article (peer-reviewed)abstract Background: Depressive symptoms in patients with cardiovascular disease (CVD) can lead to increased healthcare use. In a randomized controlled trial (ClinicalTrials.gov, NCT02778074), we reported that a 9-week internet-delivered cognitive behavioural therapy (iCBT) program (n = 72) compared to an online discussion forum (ODF) (n = 72) had moderate to large effect on depression in CVD outpatients. In this secondary analysis, we aimed to describe and compare the effect of iCBT compared to ODF regarding healthcare use and to identify factors impacting healthcare use in these groups.Methods: Data on healthcare use were retrieved from care data registries in five hospitals in Southeastern Sweden.Results: The year prior to intervention, the iCBT group had a mean of 31 outpatient clinic/primary care contacts per patient compared with 21 contacts the year after. The corresponding numbers for the ODF group were 37 and 25. The decrease was 32 % in both groups and did not differ significantly (p = 0.261 and p = 0.354) between the groups. Regarding hospital admissions, the iCBT group had 0.8 admissions per patient the year before and 0.6 the year after the intervention, a decrease by 25 %, whereas the ODF group had 1.1 and 0.6 admissions respectively, a decrease by 45 %. The difference was not statistically significant (p = 0.270 and p = 0.883) between the groups. Improvement in depressive symptoms post intervention were significantly (Beta = 0.459, p = 0.047) associated with a decrease in number of outpatient contacts in the iCBT group. In the ODF group, better mental health -related quality of life post intervention was significantly (Beta = -0.429, p = 0.045) associated with a decrease in number of hospital admissions.Conclusion: Reduced depressive symptom scores following intervention were associated with lower outpatient service use, but iCBT was not superior compared to ODF. This implicates that reducing depression in CVD pa-tients, regardless of the type of internet-delivered intervention used, is important since it may reduce healthcare use in these patients.
17.	Mourad, Ghassan, 1974-, et al. (author) Hälsorelaterad livskvalitet och psykisk ohälsa hos patienter med icke-kardiell bröstsmärta 2020 In: BestPractice Nordic, Primärvård. ; :2 Journal article (pop. science, debate, etc.)abstract Återkommande icke-kardiell bröstsmärta har negativ inverkan på psykiskt välmående och hälsorelaterad livskvalitet (HRQoL). Detta gäller i synnerhet patienter med tidigare hjärtsjukdom vilka visar signifikant lägre HRQoL än patienter med icke-kardiell bröstsmärta utan tidigare hjärtsjukdom.Många patienter som söker akut på grund av bröstsmärta blir utskrivna utan någon förklaring, annat än att akut hjärtsjukdom uteslutits, så kallad icke-kardiell bröstsmärta.1,2 Återkommande bröstsmärta kan påverka patienternas psykiska välbefinnande och hälsorelaterade livskvalitet (HRQoL) negativt.3-6 En stor andel av dessa patienter kan ha haft hjärtsjukdom sedan tidigare.7 Det råder i dag brist på studier som undersökt HRQoL bland patienter med icke-kardiell bröstsmärta samt hur tidigare erfarenhet av hjärtsjukdom påverkar sambandet mellan psykiskt välbefinnande och HRQoL hos dessa patienter. Syftet med denna studie var därför att beskriva HRQoL bland patienter med icke-kardiell bröstsmärta, med eller utan tidigare hjärtsjukdom. Vidare var syftet att undersöka sambandet mellan HRQoL och psykisk ohälsa, vilket i denna studie omfattade hjärtrelaterad ångest, depressiva symtom, rädsla för kroppsliga sensationer och somatisering. Metod Sammanlagt 552 patienter som vårdats för bröstsmärta och skrivits ut från fyra sjukhus i sydöstra Sverige med icke-kardiell bröstsmärta som diagnos (ICD 10–diagnoskoder: R07.2, R07.3, R07.4 och Z03.4) deltog i studien. Patienterna var 64 ± 17 år gamla, huvudsakligen gifta/sambo och jämnt fördelade avseende kön. Patienter med tidigare hjärtsjukdom var äldre än de utan (71 år respektive 60 år) och bestod av fler män än kvinnor (60 procent respektive 44 procent). HRQoL undersöktes med frågeformuläret EuroQol-5D-5L (EQ-5D),8 hjärtrelaterad ångest med Cardiac Anxiety Questionnaire (CAQ),9 depressiva symtom med Patient Health Questionnaire-9 (PHQ-9),10 rädsla för kroppsliga sensationer med Body Sensations Questionnaire (BSQ)11 och somatisering med Patient Health Questionnaire-15 (PHQ-15).12 Resultat Omkring hälften av patienterna rapporterade minst måttliga problem avseende smärtor/besvär och en av fyra rapporterade minst måttliga problem i HRQoL–dimensionerna rörlighet, vanliga aktiviteter och oro/nedstämdhet. Avseende personlig vård var det åtta procent som rapporterade problem. EQ-5D VAS och EQ-5D index var 0,7 ± 0,2 respektive 0,7 ± 0,3 för den totala studiepopulationen. Patienter med icke-kardiell bröstsmärta och tidigare hjärtsjukdom rapporterade signifikant lägre HRQoL (p ≤0,05) jämfört med patienter med icke-kardiell bröstsmärta utan tidigare hjärtsjukdom. Hjärtrelaterad ångest, depressiva symtom och somatisering hade i den totala studiepopulationen svaga signifikanta negativa samband (beta = 0,187–0,284, p <0,001) med HRQoL. Hos patienter med tidigare hjärtsjukdom var sambandet mellan depressiva symtom och HRQoL måttligt (beta = -0,339, p <0,001), jämfört med svagt samband hos patienter utan tidigare hjärtsjukdom (beta = -0,193, p <0,001). Å andra sidan var sambandet mellan hjärtrelaterad ångest och HRQoL svagt hos både patienter med tidigare hjärtsjukdom (beta = -0,156, p = 0,05) och patienter utan tidigare hjärtsjukdom (beta = -0,229, p <0,001). Slutsatser Patienter med icke-kardiell bröstsmärta, särskilt de med tidigare hjärtsjukdom, rapporterade låga nivåer av HRQoL och en stor andel uppvisade problem med smärtor/besvär och oro/nedstämdhet. Hjärtrelaterad ångest, depressiva symtom och somatisering hade negativ inverkan på HRQoL, men skiljde sig en del mellan dem som haft eller inte haft hjärtsjukdom sedan tidigare. Detta bör beaktas vid utveckling av psykologiska interventioner som syftar till att förbättra HRQoL hos patienter med icke-kardiell bröstsmärta.Referenser 1. spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. Journal of the Royal Society of Medicine. 2003;96(3):122-125. 2. Leise MD, Locke GR, 3rd, Dierkhising RA, et al. Patients dismissed from the hospital with a diagnosis of noncardiac chest pain: cardiac outcomes and health care utilization. Mayo Clinic proceedings. Mayo Clinic. 2010;85(4): 323-330. 3. Eslick GD. Health care seeking behaviors, psychological factors, and quality of life of noncardiac chest pain. Disease-a-month : DM. 2008;54(9): 604-612. 4. Mol KA, Smoczynska A, Rahel BM, et al. Non-cardiac chest pain: prognosis and secondary healthcare utilisation. Open Heart. 2018;5(2): e000859. 5. Mourad G, Stromberg A, Johansson P, et al. Depressive Symptoms, Cardiac Anxiety, and Fear of Body Sensations in Patients with Non-Cardiac Chest Pain, and Their Relation to Healthcare-Seeking Behavior: A Cross-Sectional Study. The Patient. 2016;9(1): 69-77.6. Fagring AJ, Gaston-Johansson F, Kjellgren KI, et al. Unexplained chest pain in relation to psychosocial factors and health-related quality of life in men and women. European journal of cardiovascular nursing : Journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology. 2007;6(4): 329-336. 7. Mourad G, Jaarsma T, Stromberg A, et al. The associations between psychological distress and healthcare use in patients with non-cardiac chest pain: does a history of cardiac disease matter? BMC Psychiatry. 2018;18(1): 172. 8. EuroQolGroup. EQ-5D 2017. Available from: www.euroqolgroup.org, accessed 2017-11-06. 9. Eifert GH, Thompson RN, Zvolensky MJ, et al. The cardiac anxiety questionnaire: development and preliminary validity. Behaviour Research and Therapy. 2000;38(10): 1039-1053. 10. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;16(9): 606-613.11. Chambless DL, Caputo GC, Bright P, et al. Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology. 1984;52(6): 1090-1097. 12. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine. 2002;64(2): 258-266.
18.	Mourad, Ghassan, 1974- (author) Improving care for patients with non-cardiac chest pain : Description of psychological distress and costs, and evaluation of an Internet-delivered intervention 2015 Doctoral thesis (other academic/artistic)abstract Introduction: More than half of all patients seeking care for chest pain do not have a cardiac cause for this pain. Despite recurrent episodes of chest pain, many patients are discharged without a clear explanation of the cause for their pain. A lack of explanation may result in a misinterpretation of the pain as being cardiac-related, causing worry and uncertainty, which in turn leads to substantial use of healthcare resources. Psychological distress has been associated with non-cardiac chest pain (NCCP), but there is limited research regarding the relationship between different psychological factors and their association with healthcare utilization. There is a need for interventions to support patients to manage their chest pain, decrease psychological distress, and reduce healthcare utilization and costs.Aim: The overall aim of this thesis was to improve care for patients with non-cardiac chest pain by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention.Designs and methods: This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. The studies used the same initial cohort. Patients were consecutively approached within 2 weeks from the day of discharge from a general hospital in southeast Sweden. In study I, 267 patients participated (131 with NCCP, 66 with acute myocardial infarction (AMI), and 70 with angina pectoris (AP)). Out of these, 199 patients (99 with NCCP, 51 with AMI, 49 with AP) participated in study II. Participants were predominantly male (about 60 %) with a mean age of 67 years. Data was collected on depressive symptoms (Study I), healthcare utilization (Study I, II), and societal costs (Study II). Study III had a cross-sectional explorative and descriptive design. Data was collected consecutively on depressive symptoms, cardiac anxiety and fear of body sensations in 552 patients discharged with diagnoses of NCCP (51 % women, mean age 64 years) from four hospitals in southeast Sweden. Patients were approached within one month from the day of discharge. Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years, who were randomly assigned to an intervention (n=7) or control group (n=8). The intervention consisted of a four-session guided Internet-delivered cognitive behavioural therapy (CBT) program containing psychoeducation, exposure to physical activity, and relaxation. The control group received usual care. Data was collected on chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms.Results: Depressive symptoms were prevalent in 20 % (Study IV) and 25 % (Study I, III) of the patients, and more than half of the patients still experienced depressive symptoms one year later (Study I). There were no significant differences in prevalence and severity of depressive symptoms between patients diagnosed with NCCP, AMI or AP. Living alone and younger age were independently related to more depressive symptoms (Study I). Cardiac anxiety was reported by 42 % of the patients in study III and 67 % of the patients in study IV. Fear of body sensations was reported by 62 % of the patients in study III and 93 % of the patients in study IV. On average, patients with NCCP had 54 contacts with primary care or the outpatient clinic per patient during the two-year study period. This was comparable to the number of contacts among patients with AMI (50 contacts) and AP (65). Patients with NCCP had on average 2.6 hospital admissions during the two years, compared to 3.6 for patients with AMI and 3.9 for patients with AP (Study II). Four out of ten patients reported seeking healthcare at least twice during the last year due to chest pain (Study III). On average, 14 % of patients with NCCP were on sick-leave annually, compared to 18 % for patient with AMI and 25 % for patient with AP. About 11-12 % in each group received a disability pension. The mean annual societal costs for patients with NCCP, AMI and AP were €10,068, €15,989 and €14,737 (Study II). Depressive symptoms (Study I, III), cardiac anxiety (Study III) and fear of body sensations (Study III) were related to healthcare utilization. Cardiac anxiety was the only variable independently associated with healthcare utilization (Study III). In the intervention study (Study IV), almost all patients in both the intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. There was no significant difference between the groups. The intervention was perceived as feasible and easy to manage, with comprehensible language, adequate and varied content, and manageable homework assignments.Conclusions: Patients with NCCP experienced recurrent and persistent chest pain and psychological distress in terms of depressive symptoms, cardiac anxiety and fear of body sensations. The prevalence and severity of depressive symptoms in patients with NCCP did not differ from patients with AMI and patients with AP. NCCP was significantly associated with healthcare utilization and patients had similar amount of primary care and outpatient clinic contacts as patients with AMI. The estimated cumulative annual national societal cost for patients with NCCP was more than double that of patients with AMI and patients with AP, due to a larger number of patients with NCCP. Depressive symptoms, cardiac anxiety and fear of body sensations were related to increased healthcare utilization, but cardiac anxiety was the only variable independently associated with healthcare utilization. These findings imply that screening and treatment of psychological distress should be considered for implementation in the care of patients with NCCP. By reducing cardiac anxiety, patients may be better prepared to handle chest pain. A short guided Internet-delivered CBT program seems to be feasible. In the pilot study, patients improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but this did not differ from the patients in the control group who received usual care. Larger studies with longer follow-up are needed to evaluate both the short and long- term effects of this intervention.
19.	Mourad, Ghassan, 1974-, et al. (author) Internet-based CBT in patients with non-cardiac chest pain - design of a randomized controlled pilot study 2014 Conference paper (other academic/artistic)abstract Introduction: The majority of the patients seeking medical care due to chest pain are admitted for in-hospital cardiac "rule out" observation, but only one third of all patients have ischemic heart disease. More than half of these patients are diagnosed as "non-cardiac chest pain" (NCCP). Patients with NCCP utilize a substantial amount of healthcare resources, and contribute to high costs for society. Patients with NCCP may be suffering from pain-related fear and inappropriate health beliefs leading to avoidance of physical activities that they think could be harmful to their hearts. We hypothesize that these patients will gain from evaluating the accuracy and usefulness of their thoughts, and shifting their cognitive appraisals from unhealthy and maladaptive to constructive and adaptive.Purpose: To test the feasibility and effectiveness of an intervention based on CBT supporting patients to handle chest pain and related emotions, reactions and thoughts.Methods: A total of twenty patients will be recruited to this randomized controlled pilot study planned to start in April 2014. Eligible for the study will be persons over the age of 18 who during the last 6 months had sought care at least twice due to non-cardiac chest pain, and who screened positive for bodily sensations and/or avoidance of physical activity. The intervention will be a guided 4 weeks internet-based CBT programme with the following content: •Information to increase patients’ knowledge of chest pain and its impact on daily life. •Reflection upon the strategies patients use and how these can change to facilitate management of chest pain, and related emotions, reactions and thoughts. •Tailored moderate physical activity, 30 minutes per day, to get reassured that the heart tolerates physical activity and to decrease pain-related fear. •Relaxation exercise, 15 minutes per day, that can be used to cope with general stress and if appropriate to use in relation to chest pain. The control group will receive "care as usual".Outcomes: The primary outcome will be "fear of bodily sensations" measured with the Bodily sensations questionnaire. The secondary outcomes will be "illness perception, pain, anxiety, depressive symptoms, quality of life, healthcare utilization and costs".Study significance: This study will reveal if the intervention is feasible and what effects it has on how patients perceive and handle chest pain. In case of positive outcomes, the study participants as well as the patient group will benefit in terms of better health. In the long term, society will also benefit from a reduction in healthcare utilization and costs.
20.	Mourad, Ghassan, 1974- (author) Psychological distress and healthcare use in patients with non-cardiac chest pain: does a history of cardiac disease matter? 2017 Conference paper (other academic/artistic)abstract Objective: To explore and model the associations between somatization, fear of body sensations, cardiac anxiety, depressive symptoms, and healthcare use in patients with NCCP with or without history of cardiac disease (CD). Methods: Data was collected in 552 NCCP patients (mean age 64±17 years, 51% women) within one month from discharge using the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, and Patient Health Questionnaire-9. Structural Equation Modelling analyses were used to explore the relationships between somatization, fear of body sensations, cardiac anxiety, depressive symptoms and healthcare use in NCCP patients with or without history of CD. Results: 34% of the NCCP patients had a previous diagnosis of CD. Patients with NCCP and a history of CD were mainly males, older (71 vs. 60 years), had more co-morbidities (4.7 vs. 2.8), and reported significantly higher scores in somatization (p=0.007), cardiac anxiety (p<0.001), and depressive symptoms (p=0.002), and greater healthcare use (p<0.001).In both groups, depressive symptoms were not directly associated with healthcare use (Chi-Square=75.94, df=10, p<0.001: RMSEA=0.110: and CFI=0.95). The impact of depressive symptoms on healthcare use was mainly mediated by somatization, fear of body sensations, and cardiac anxiety (Chi-Square=9.69, df=10, p=0.47, RMSEA=0.000, and CFI=0.99), but the effects were significantly weaker in patients with no history of CD (Chi-Square=4.25, df=7, p=0.75, RMSEA=0.000, and CFI=0.99). Additionally, the direct and indirect effects between depressive symptoms, somatization, fear of body sensations, cardiac anxiety, and healthcare use were significantly stronger in patients with a history of CD. Finally, the direct effects of depressive symptoms on cardiac anxiety were about the same in both groups. Conclusions: The associations between psychological distress and healthcare use were similar for all patients, although the effects were significantly stronger in patients with a history of CD. In both groups, depressive symptoms had no direct association with healthcare use.
21.	Mourad, Ghassan, 1974-, et al. (author) Psychological distress and healthcare use in patients with non-cardiac chest pain: does a history of cardiac disease matter? 2017 In: Abstract book. - : Sage Publications. ; , s. S3-S3 Conference paper (other academic/artistic)abstract Background: Patients with non-cardiac chest pain (NCCP) suffer psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms, which can increase healthcare use. It is unknown how these variables are related and whether the relationships differ between patients with or without history of cardiac disease.Objective: To explore and model the associations between somatization, fear of body sensations, cardiac anxiety, depressive symptoms, and healthcare use in patients with NCCP with or without history of cardiac disease.Methods: Data were collected in Sweden in 670 patients (mean age 65±16 years, 51% women) within one month from discharge using the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, and Patient Health Questionnaire-9. Structural Equation Modelling analyses were used to explore the relationships between somatization, fear of body sensations, cardiac anxiety, depressive symptoms and healthcare use in NCCP patients with or without history of cardiac disease.Results: About 40% of the NCCP patients had previous diagnosis of cardiac disease. Patients with NCCP and a history of cardiac disease were older (71 vs. 60 years), had more comorbidities (4.7 vs. 2.8), and reported significantly higher scores in somatization (p=0.02), cardiac anxiety (p<0.001), and depressive symptoms (p=0.02), and greater healthcare use (p<0.001). Depressive symptoms were not directly associated with healthcare use (Chi-Square=68.28, df=10, P-value=0.000, RMSEA=0.099, CFI=0.96). In patients with history of cardiac disease, the impact of depressive symptoms on healthcare use was mediated by somatization, fear of body sensations, and cardiac anxiety (Chi-Square=7.61, df=8, P-value=0.48, RMSEA=0.000, CFI=0.99). In patients with no history of cardiac disease, the impact of depressive symptoms on healthcare use was directly mediated by cardiac anxiety (Chi-Square=4.17, df=7, P-value=0.76, RMSEA=0.000, CFI=0.99).Conclusions: The associations between psychological distress and healthcare use were different for patients with or without cardiac disease. In both groups depressive symptoms had no direct association with healthcare use.
22.	Mourad, Ghassan, 1974-, et al. (author) Self-reported health and quality of life among patients with non-cardiac chest pain 2014 Conference paper (other academic/artistic)abstract Introduction: Chest pain is a common reason for patients to attend emergency departments and be admitted to coronary care units. However, the cause of pain is non-cardiac in more than 50 % of these patients and many patients remain undiagnosed and symptomatic. Patients with non-cardiac chest pain do not differ from the general population in terms of long-term mortality, but they suffer from recurrent chest pain and frequently seek both primary and emergency care. There is therefore a need for targeted interventions in order to support patients with non-cardiac chest pain and minimize healthcare utilization and costs. Previous studies point out different psychosocial factors to be related to non-cardiac chest pain. However, to date there are few models taking into account the complex relationship between different clinical and psychosocial components that may cause non-cardiac chest pain.Purpose: To study the prevalence of and relationship between pain, depressive symptoms, anxiety, somatization, fear of bodily sensations, illness perception and quality of life in patients with non-cardiac chest pain in order to design a treatment programme.Methods: The study will have a descriptive design. Eligible for the study will be patients over the age of 18 who have been diagnosed with non-cardiac chest pain in four hospitals within a region in southeast Sweden. One thousand patients will be recruited, through patient registers provided by the hospitals, within one month from the day of admission. Data collection will start in the fall of 2013. Study information, written informed consent, all questionnaires, and a pre-stamped envelope will be sent to all eligible patients. Two reminders will be sent to patients who do not respond within 3 weeks from mail-out.Outcomes: The study will report on the relationship between chest pain, depressive symptoms, anxiety, somatization, fear of bodily sensations, illness perception, and quality of life. Data will be collected using the Brief Pain Inventory-Short Form, Patient Health Questionnaire-9, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-15, Bodily Sensations Questionnaire, Brief Illness Perception Questionnaire, and EuroQol 5D.Study significance: This study will survey the complex relationship between different psychosocial factors and non-cardiac chest pain. This information will be of great interest when designing the optimal interventional programme in order to support patients with non-cardiac chest pain.
23.	Mourad, Ghassan, 1974-, et al. (author) Societal costs of non-cardiac chest pain 2013 Conference paper (other academic/artistic)abstract Introduction: More than 50 % of patients suffering from acute chest pain are diagnosed with non-cardiac chest pain (NCCP). These patients often seek care due to recurrent chest pain and psychological distress due to worries about suffering from an undetected serious disease. Patients with NCCP use outpatient health-care to the same extent as cardiac patients. There is no research on the societal costs of patients with NCCP.Purpose: To describe the societal costs of patients with NCCP in relation to patients with acute myocardial infarction (AMI) and angina pectoris (AP) in Sweden.Methods: A longitudinal descriptive design was used, including 199 patients (99 with NCCP, 51 with AMI and 49 with AP). Patients had a mean age of 67 years and 59% were men. Data regarding health-care utilization and societal costs was collected one year before including index admission and one year after. Societal costs comprised direct health-care costs within primary, outpatient and hospital care, and indirect costs due to production loss because of sick-leave and disability. To obtain data, we used a regional care-database for health-care utilization, the cost-per-patient database for direct costs, and the social insurance office database for indirect costs.Results: Patients with NCCP, AMI, and AP had on average 54, 50 and 65 primary care contacts and 3, 4 and 4 hospital admissions respectively during the two years. All groups had significantly more primary care contacts, but fewer admissions the year after index admission compared to the year of the index admission. Patients with NCCP, AMI, and AP had a length of stay of 6, 11 and 11 days respectively during the two years. Patients with AMI and AP had significantly longer hospital stay the year after the index admission than the year of the index admission. On average 14, 18, and 25 % of the patients with NCCP, AMI and AP were on sick-leave annually, and about 12 % of patients per group were receiving disability pension. The mean annual societal cost of patients with NCCP, AMI and AP were approximately € 9500, € 15000 and € 14000 per patient.Conclusion and implications: All participants utilized a significant amount of health-care and were substantially absent from work. The annual societal cost of patients with NCCP was the lowest of the three groups. But due to high prevalence of NCCP, the cumulative annual national cost of these patients could be more than double as for AMI and AP. Targeted interventions based on psycho-educational support to patients with NCCP to help them handle their chest pain and thereby reduce health-care utilization and costs are needed.
24.	Mourad, Ghassan, et al. (author) Societal costs of non-cardiac chest pain compared with ischemic heart disease - a longitudinal study 2013 In: BMC Health Services Research. - : BioMed Central. - 1472-6963. ; 13:1, s. 403- Journal article (peer-reviewed)abstract BackgroundNon-cardiac chest pain (NCCP) is a common complaint. Our aim was to present a detailed description of the costs of patients with NCCP compared to patients with acute myocardial infarction (AMI) and Angina Pectoris (AP) from a societal perspective.MethodsData on healthcare utilization and annual societal costs, including direct healthcare costs and indirect costs due to productivity loss, were collected from different databases. The participants consisted of 199 patients from a general hospital in Sweden (99 with NCCP, 51 with AMI, 49 with AP), mean age of 67 years, 59% men.ResultsNCCP, AMI, and AP patients had on average 54, 50 and 65 primary care contacts and 3, 4, and 4 hospital admissions during a period of 2 years. Length of hospital stay was 6, 11 and 11 days. On average, 14%, 18%, and 25% of NCCP, AMI and AP patients were on sick-leave annually, and about 12% in each group received a disability pension. The mean annual societal costs of NCCP, AMI and AP patients were €10,068, €15,989 and €14,737.ConclusionsAlthough the annual societal cost of NCCP patients was lower than in AMI and AP patients, the cost was still considerable (€10,068). Taken into account the high prevalence of NCCP, the cumulative annual national cost of these patients could be more than the double of AMI and AP if all patients incurred the same costs as in this study. Targeted interventions are important in order to support patients with NCCP and minimize healthcare utilization and costs.
25.	Mourad, Ghassan, 1974-, et al. (author) Somatization in women and men with non-cardiac chest pain compared to the general Swedish population 2022 In: Psychiatry Research Communications. - : Elsevier. - 2772-5987. ; 2:2 Journal article (peer-reviewed)abstract We compare the prevalence of somatization in women and men with NCCP in relation to the general Swedish population, analyze the overlap between somatization, cardiac anxiety, and depressive symptoms, and explore variables associated with somatization. A cross sectional design is implemented with data collected between late October 2013 and early January 2014 from 552 patients with NCCP (mean age of 64 ± 17 years, 51% women) from four hospitals in southeast Sweden. Somatization was measured with the Patient Health Questionnaire-15, cardiac anxiety with the Cardiac Anxiety Questionnaire, and depressive symptoms with the Patient Health Questionnaire-9. Data were self-reported. The general population consists of 1898 females and 1508 males. Compared to the general population, somatization was significantly (p < .001) more common in both women and men with NCCP. Women with NCCP had significantly (p = .003) higher prevalence of somatization than men with NCCP. In patients with NCCP, 12% had only somatization, whereas 39% also reported cardiac anxiety and depressive symptoms. Younger age in women tended to be associated with somatization (OR = 0.98, p < .073), but also being non-worker (OR = 0.40, p = .024). In men, somatization tended to be associated with increased healthcare contacts (OR = 1.82, p = .051). Furthermore, in both women and men, number of co-morbidities (OR = 9.69 p < .001 and OR = 3.45, p = .002), cardiac anxiety (OR = 2.93 and OR = 2.09, p < .001), and depressive symptoms (OR = 8.71 and OR = 4.44, p < .001) were significantly associated with somatization. Our study demonstrates that somatization is very common among patients with NCCP, especially in women. Patients with NCCP have higher somatization and greater overlap with psychological distress compared to the general population.
26.	Mourad, Ghassan, 1974-, et al. (author) Symptoms of anxiety and depression and the role of social support in patients with chest pain. 2010 Conference paper (peer-reviewed)abstract Background and aim: Being admitted to a coronary care unit due to chest pain is stressful. Limited data is available on anxiety and depression in chest pain patients during the acute phase. Social support may act as a buffer to the psychological impact of an acute cardiac event. Therefore, the aim of this study was to describe the prevalence of symptoms of anxiety and depression and their relationship to social support in patients admitted to a coronary care unit (CCU) for acute chest pain. Methods: The study had a descriptive, cross sectional design based on data collected by standardised questionnaires. Data was collected consecutively at a university hospital in central Sweden between October 2006 and October 2007. Eligible for the study were patients younger than 75 years, hospitalized due to chest pain at the CCU, who spoke and read Swedish and were in a general state of health to participate in the study. Patients were asked to answer three different questionnaires: State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS) and Medical Outcome Study-Social Support Survey (MOS-SSS) within 24 hours after being admitted to CCU. Results:A total of 337 patients were included in the study (mean age 60.5 years, 73 % men, 73 % married). Only two patients were free from symptoms of anxiety and depression, while 7 % of the patients had clinically significant levels of both anxiety and depression. A total 71 % had a clinically significant or severe level of anxiety and 22 % were at a borderline level for anxiety. A total of 14 % had a clinically significant level of depression and 67 % were at a borderline level of depression. Regression analysis showed that social support was independently related to anxiety and depression. Conclusion: Patients admitted to CCU experience extreme levels of psychological distress in the acute phase and social support seems to play an important role. Assessment of anxiety and depression as well as interventions including support and information should be considered in the CCU setting in order to improve mental well-being of patients with chest pain.
27.	Mourad, Ghassan, et al. (author) Symptoms of anxiety and depression and the role of social support in patients with chest pain 2010 In: EUROPEAN HEART JOURNAL. - : Oxford University Press. ; , s. 229-229 Conference paper (peer-reviewed)abstract n/a
28.	Mourad, Ghassan, 1974-, et al. (author) The association between somatization and health care utilization in patients with non-cardiac chest pain 2015 In: Abstracts. - : Oxford University Press. ; , s. 283-283 Conference paper (other academic/artistic)abstract Background: Chest pain is one of the most common reasons for care-seeking, but often patients are diagnosed as non-cardiac (NCCP). NCCP patients suffer from cardiac anxiety, defined as fear of cardiac-related stimuli and sensations, which is strongly associated with increased healthcare utilization. Research indicates that somatization, defined as report of somatic symptoms that have no pathophysiological cause, is a relatively common cause in chest pain patients. The prevalence of somatization in NCCP patients and its association with cardiac anxiety and healthcare utilization needs further investigation.Purpose: To describe the prevalence of somatization and its association with cardiac anxiety and healthcare utilization in NCCP patients.Methods: Data in this cross sectional study was collected from 552 patients diagnosed with NCCP in four Swedish hospitals within one month from discharge. Patients had a mean age of 64±17 years, and 51% were women. Somatization was measured with the Patient Health Questionnaire-15 and cardiac anxiety with the Cardiac Anxiety Questionnaire. Healthcare utilization, i.e. number of healthcare contacts the year before study inclusion was self-reported by the patients. To determine the association between somatization, cardiac anxiety and healthcare utilization, a logistic hierarchical regression analysis was used with cardiac anxiety inserted in the first block, somatization in the second block, and a variable where these two were multiplied in the third block.Results: In total, 283 (51%) patients reported at least moderate levels of somatization and 229 (42%) patients reported cardiac anxiety. Of the total, 89 (16%) had only somatization; 88 (16%) had only cardiac anxiety; and 194 (35%) had both somatization and cardiac anxiety. Somatization was strongly related to cardiac anxiety (r=.54, p<.010). About 26% of the patients reported 2-3 healthcare contacts and 14% reported more than 3 healthcare contacts due to chest pain. Both somatization (r=.37, p<.010) and cardiac anxiety (r=.46, p<.010) were significantly related to number of healthcare contacts. The logistic hierarchical regression showed that cardiac anxiety (OR=1.09, CI=1.07-1.11, p< .001) and somatization (OR=1.08, CI=1.03-1.13, p< .001) were associated with increased healthcare utilization. The multiplicative interaction term between these variables was not significant (OR=1.09, CI=0.996-1.00, p .901).Conclusions: Somatization was frequently reported by NCCP patients and associated with cardiac anxiety and increased healthcare contacts. Somatization may therefore be important to target with interventions.
29.	Mourad, Ghassan, et al. (author) The associations between psychological distress and health-related quality of life in patients with non-cardiac chest pain 2020 In: Health and Quality of Life Outcomes. - : BioMed Central. - 1477-7525. ; 18:1 Journal article (peer-reviewed)abstract Background Recurrent chest pain episodes with no clear explanation may affect patients psychological wellbeing and health-related quality of life (HRQoL) negatively. Despite the fact that a significant amount of patients with non-cardiac chest pain (NCCP) might have a history of Cardiac Disease (CD), there is today a lack of knowledge on how CD influences the association between psychological wellbeing and HRQoL in patients with NCCP. Therefore, the aim of this study is to describe HRQoL in patients with NCCP, with or without history of CD, and to explore the association between HRQoL and cardiac anxiety, depressive symptoms, fear of body sensations and somatization. Methods Five hundred fifty-two patients discharged with NCCP from four hospitals in Southeast Sweden completed the EQ-5D, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9, Body Sensations Questionnaire, and Patient Health Questionnaire-15. Results Fifty precent reported at least moderate problems regarding pain/discomfort and 25% reported at least moderate problems in the HRQoL dimensions mobility, usual activities, and anxiety/depression. Patients with NCCP and history of CD reported significantly lower HRQoL (p amp;lt;= 0.05) compared to patients with NCCP without CD. In the total study population, cardiac anxiety, depressive symptoms, and somatization had weak significant negative associations (beta = 0.187-0.284, p amp;lt; 0.001) with HRQoL. In patients with history of CD, the association between depressive symptoms and HRQoL was moderate (beta = - 0.339, p amp;lt; 0.001), compared to weak association in patients without CD (beta = - 0.193, p amp;lt; 0.001). On the other hand, the association between cardiac anxiety and HRQoL was weak in both patients with history of CD (beta = - 0.156, p = 0.05), and in those without (beta = - 0.229, p amp;lt; 0.001). Conclusions Patients with NCCP, in particular those with history of CD, reported low levels of HRQoL, which was associated with psychological distress. This should be considered when developing psychological interventions aiming to improve HRQoL in patients with NCCP.
30.	Mourad, Ghassan, 1974-, et al. (author) The associations between psychological distress and healthcare use in patients with non-cardiac chest pain : does a history of cardiac disease matter? 2018 In: BMC Psychiatry. - : Springer Science and Business Media LLC. - 1471-244X. ; 18:1 Journal article (peer-reviewed)abstract BACKGROUND: Psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms is common among patients with non-cardiac chest pain, and this may lead to increased healthcare use. However, the relationships between the psychological distress variables and healthcare use, and the differences in relation to history of cardiac disease in these patients has not been studied earlier. Therefore, our aim was to explore and model the associations between different variables of psychological distress (i.e. somatization, fear of body sensations, cardiac anxiety, and depressive symptoms) and healthcare use in patients with non-cardiac chest pain in relation to history of cardiac disease.METHODS: In total, 552 patients with non-cardiac chest pain (mean age 64 years, 51% women) responded to the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9 and one question regarding number of healthcare visits. The relationships between the psychological distress variables and healthcare visits were analysed using Structural Equation Modeling in two models representing patients with or without history of cardiac disease.RESULTS: A total of 34% of the patients had previous cardiac disease. These patients were older, more males, and reported more comorbidities, psychological distress and healthcare visits. In both models, no direct association between depressive symptoms and healthcare use was found. However, depressive symptoms had an indirect effect on healthcare use, which was mediated by somatization, fear of body sensations, and cardiac anxiety, and this effect was significantly stronger in patients with history of cardiac disease. Additionally, all the direct and indirect effects between depressive symptoms, somatization, fear of body sensations, cardiac anxiety, and healthcare use were significantly stronger in patients with history of cardiac disease.CONCLUSIONS: In patients with non-cardiac chest pain, in particular those with history of cardiac disease, psychological mechanisms play an important role for seeking healthcare. Development of interventions targeting psychological distress in these patients is warranted. Furthermore, there is also a need of more research to clarify as to whether such interventions should be tailored with regard to history of cardiac disease or not.
31.	Mourad, Ghassan, et al. (author) The Effect of Internet-Delivered Cognitive Behavioral Therapy Versus Psychoeducation Only on Psychological Distress in Patients With Noncardiac Chest Pain : Randomized Controlled Trial 2022 In: Journal of Medical Internet Research. - : JMIR Publications Inc. - 1438-8871. ; 24:1 Journal article (peer-reviewed)abstract Background: Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain. Objective: This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP. Methods: Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score >= 24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes. Results: No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (>= 11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group. Conclusions: iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions.
32.	Mourad, Ghassan, 1974- (author) The relationship between depressive symptoms, cardiac anxiety and fear of body sensations, and healthcare seeking behaviour in patients with non-cardiac chest pain 2015 Conference paper (other academic/artistic)abstract Background: Patients with non-cardiac chest pain (NCCP) suffer from recurrent chest pain and use a substantial amount of healthcare resources.Objective: To explore the prevalence of depressive symptoms, cardiac anxiety and fear of body sensations in patients discharged with a NCCP diagnosis. Additionally, to explore how depressive symptoms, cardiac anxiety and fear of body sensations are related to each other and to healthcare seeking behaviour.Methods: Cross-sectional descriptive design. Data were collected from 552 patients diagnosed with NCCP in four Swedish hospitals within one month from discharge using the Patient Health Questionnaire-9, Cardiac Anxiety Questionnaire and Body Sensations Questionnaire. Healthcare seeking behaviour the year before study inclusion (i.e. the number of healthcare contacts) was self-reported by the patients.Results: Of the study population, 141 (26 %) reported at least moderate depressive symptoms, 229 (42 %) reported at least moderate cardiac anxiety, and 337 (62 %) reported some degree of fear of body sensations. There were strong positive relationships between depressive symptoms and cardiac anxiety (rs=.49, p<.01), depressive symptoms and fear of body sensations (rs=.50, p<.01), and cardiac anxiety and fear of body sensations (rs=.56, p<.01). 26 % of the study participants reported 2-3 healthcare contacts and 14 % reported more than 3 healthcare contacts due to chest pain. In a multivariable regression analysis, and after adjusting for multi-morbidity, cardiac anxiety was the only variable independently associated with healthcare seeking behaviour.Conclusions: Symptoms of psychological distress were more frequently reported by the patients with NCCP that had more healthcare contacts. Cardiac anxiety had the strongest relationship with healthcare seeking behaviour, and may therefore be an important target for intervention. The results from this study will guide the development of a web-based intervention targeting cardiac anxiety to improve patient outcomes and reduce healthcare use and costs.
33.	Mourad, Ghassan, 1974-, et al. (author) The relationship between depressive symptoms, cardiac anxiety and fear of body sensations, and healthcare seeking behaviour in patients with non-cardiac chest pain 2015 In: EuroHeartCare 2015. - : Sage Publications. ; , s. 41-41 Conference paper (other academic/artistic)abstract Background: Chest pain is one of the most common reasons for hospital admissions and more than 50 % of the patients admitted are diagnosed as non-cardiac and discharged without a clear explanation of the underlying cause for the chest pain. A number of patients with non-cardiac chest pain (NCCP) suffer from recurrent chest pain and use a substantial amount of healthcare resources leading to high healthcare and societal costs. Although depressive symptoms, anxiety, and fear of body sensations are prevalent in these patients and may have an impact on patients´ healthcare seeking behaviour, the relationship between these psychological factors and healthcare seeking behaviour is not fully elucidated. Objective: To investigate the prevalence of depressive symptoms, cardiac anxiety and fear of body sensations in patients acutely admitted to hospital due to chest pain and discharged with a NCCP diagnosis. Additionally, to explore how depressive symptoms, cardiac anxiety and fear of body sensations are related to each other and to healthcare seeking behaviour. Methods: Cross-sectional descriptive design. Data were collected from 552 patients diagnosed with NCCP in four Swedish hospitals within one month from discharge using the Patient Health Questionnaire-9, Cardiac Anxiety Questionnaire and Body Sensations Questionnaire. Healthcare seeking behaviour the year before study inclusion (i.e. the number of healthcare contacts) was self-reported by the patients. Results: Of the study population, 141 (26 %) reported at least moderate depressive symptoms, 229 (42 %) reported at least moderate cardiac anxiety, and 337 (62 %) reported some degree of fear of body sensations. There were strong positive relationships between depressive symptoms and cardiac anxiety (rs=.49, p<.01), depressive symptoms and fear of body sensations (rs=.50, p<.01), and cardiac anxiety and fear of body sensations (rs=.56, p<.01). 26 % of the study participants reported 2-3 healthcare contacts and 14 % reported more than 3 healthcare contacts due to chest pain. In a multivariable regression analysis, cardiac anxiety was the only variable independently associated with healthcare seeking behaviour. Conclusions: Symptoms of psychological distress were more frequently reported by the patients with NCCP that had more healthcare contacts. Especially cardiac anxiety was associated with healthcare seeking behaviour, and may therefore be an important target for intervention. The results from this study will guide the development of a web-based intervention targeting cardiac anxiety to improve patient outcomes and reduce healthcare use and costs.
34.	Mourad, Ghassan, 1974-, et al. (author) What are patients with heart failure willing to pay for an exergame intervention? 2019 Conference paper (peer-reviewed)abstract Background: Regular physical activity in patients with heart failure (HF) improves physical capacity and quality of life, and may reduce health care utilization. One low-cost effective physical activity intervention to increase exercise capacity is exergaming. Exploring patients’ willingness to pay (WTP) for treatments/interventions is a way to obtain a monetary value for the health consequences of an intervention. This can further be used in economic evaluations.Aim: The aim of this study was to describe patients´ WTP for an exergame intervention and to determine factors influencing the WTP.Methods: This is a substudy of the Swedish cohort of the HF-Wii study (evaluating the effect of exergaming on exercise capacity in patients with HF; clinicaltrial.gov NCT01785121) including 34 patients who finished the 1-year follow-up. Structured telephone interviews were conducted focusing on WTP for the exergame intervention they received during the study including an exergame platform, an introduction lesson, installation of the exergame computer, and telephone follow-ups, and with an estimated cost of ∼€440 per patient. The WTP methodology used was adjusted for this specific study.Patients were also asked to rate their level of satisfaction with the intervention on a Numeric Rating Scale (NRS) from 0-10. In addition, information on background variables and income was collected during the interview, while data on six minute walk test (6MWT) and quality of life was retrieved from previous data collection in the main study.Results: In total, 29 patients with HF participated in this substudy, mean age 68±9 years, 69% males, and with a mean household disposable income/month of ∼€2700 (±1360). Ten patients (34.5%) had a clinically significant effect of the exergaming and improved more than 30 meters on the 6MWT.The average WTP for the exergame intervention was ∼€160 (range €0-580). Most patients were satisfied with the exergame intervention and the median score was 8 on the NRS. The satisfaction level was significantly related to WTP (rs=0.468, p=0.012). Patients with higher satisfaction levels were willing to pay more (€210±165) for the exergame intervention than those with lower satisfaction levels (€60±70), p=0.015. Income, changes in 6MWT, and quality of life showed no significant relationship to WTP.Conclusions: The WTP for an exergame intervention varied largely in patients with HF despite high satisfaction level with the intervention. The satisfaction level was the only factor influencing patients´ WTP. On average, patients were willing to pay about one-third of the cost of the exergame intervention. Future studies should focus on the cost-effectiveness of this intervention.
35.	Teske, Christofer, 1982-, et al. (author) Mobile care - a possible future for emergency care in Sweden 2023 In: BMC Emergency Medicine. - : BMC. - 1471-227X. ; 23:1 Journal article (peer-reviewed)abstract IntroductionProvision of mobile care at the home of patients appears to become necessary as the population becomes increasingly older. But there are challenges in moving emergency care from hospitals to the home of patients. The aim of the study was therefore to describe the experiences of the mobile care in Sweden.MethodSemi structured interviews were conducted with 12 persons with experience of mobile care in Sweden, such as nurses, physicians, civil servants and politicians. Qualitative latent content analysis was used as an analysis method.ResultThe results show that cooperation is of utmost importance to achieve functioning mobile care. Cooperation both on an inter-organizational level and on a close team-work is required for all of the involved parties in mobile care to take on a joint responsibility for the patient. As mobile care is primarily provided to elderly multimorbid patients, a comprehensive view on patient care is required in which the patient and their relatives experience security.ConclusionMobile care is seen as a moving care that comes to the seeking person and not the other way around. The resources are distributed where they make the most use, that is, closest to the individual. Mobile care is seen as a complement to the traditional hospital care. This means a different way of working that requires close collaboration between different categories of personnel and organizations, where there should not be any discussions about boundaries, rather, the discussion should include patients needs and situation instead.
36.	Verheijden Klompstra, Leonie, 1982-, et al. (author) Costs of an Off-the-Shelve Exergame Intervention in Patients with Heart Failure 2023 In: Games for Health Journal. - : MARY ANN LIEBERT, INC. - 2161-783X .- 2161-7856. ; 12:3, s. 242-248 Journal article (peer-reviewed)abstract Objectives: Exergaming is promising for patients with heart failure who are less inclined to start or maintain exercise programs involving traditional modes of physical activity. Although no effect on exercise capacity was found for an off-the-shelf exergame, it is important to gain insights into aspects related to costs to develop such interventions further.Materials and Methods: In a randomized controlled trial, the Heart Failure Wii study (HF-Wii study), the intervention group (exergame group) received an introduction to the exergame, the exergame was installed at home and help was offered when needed for 3 months. Patients received telephone follow-ups at 2, 4, 8, and 12 weeks after the installation. The control group (motivational support group) received activity advice and telephone follow-ups at 2, 4, 8, and 12 weeks. We collected data on hospital use and costs, costs of the exergame intervention, patient time-related costs, and willingness to pay.Results: No significant differences were found between the exergame group (n = 300) versus the motivational support group (n = 305) in hospital use or costs (1-year number of hospitalizations: P = 0.60, costs: P = 0.73). The cost of the intervention was 190 Euros, and the patient time-related costs were 98 Euros. Of the total estimated costs for the intervention, 287 Euros, patients were willing to pay, on average, 58%.Conclusion: This study shows that the costs of an intervention using an off-the-shelve exergame are relatively low and that the patients were willing to pay for more than half of the intervention costs. The trial is registered in ClinicalTrials.gov (NCT01785121).
37.	Verheijden Klompstra, Leonie, 1982-, et al. (author) The Appropriateness and Presentation of Commonly Available Cardiovascular Web Pages Providing Information About Cardiovascular Diseases 2019 In: Computers, Informatics, Nursing. - : Lippincott Williams & Wilkins. - 1538-2931 .- 1538-9774. ; 37:10, s. 493-497 Journal article (peer-reviewed)
38.	Westas, Mats, et al. (author) Effects of Internet-delivered cognitive behavioural therapy adapted for patients with cardiovascular disease and depression : a long-term follow-up of a randomized controlled trial at 6 and 12 months posttreatment. 2022 In: European Journal of Cardiovascular Nursing. - : Oxford University Press. - 1474-5151 .- 1873-1953. ; 21:6, s. 559-567 Journal article (peer-reviewed)abstract BACKGROUND: Internet-based cognitive behavioural treatment (iCBT) has shown positive short-term effects on depression in patients with cardiovascular disease (CVD). However, knowledge regarding long-term effects and factors that may impact the effect of iCBT is lacking.AIMS: This study therefore sought (i) to evaluate the effect of iCBT on depression in CVD patients at 6- and 12-month follow-ups and (ii) to explore factors that might impact on the effect of iCBT on change in depression at 12-month follow-up.METHODS AND RESULTS: A longitudinal follow-up study of a randomized controlled trial evaluating the effects of a 9-week iCBT programme compared to an online discussion forum (ODF) on depression in CVD patients (n = 144). After 9 weeks, those in the ODF group were offered the chance to take part in the iCBT programme. The Patient Health Questionnaire (PHQ-9) and the Montgomery-Åsberg Depression Rating Scale-self-rated version (MADRS-S) measured depression at baseline, 9 weeks, 6 months, and 12 months. Linear mixed model and multiple regression analysis were used for statistical computing. The iCBT programme significantly improved depression at 9-week follow-up and this was stable at 6- and 12-month follow-ups (PHQ-9 P = 0.001, MADRS-S P = 0.001). Higher levels of depression at baseline and a diagnosis of heart failure were factors found to impact the effect of iCBT on the change in depression.CONCLUSION: A 9-week iCBT programme in CVD patients led to long-term improvement in depression. Higher levels of depression scores at baseline were associated with improvement in depression, whereas heart failure had opposite effect.CLINICAL TRIAL: The trial is registered at ClinicalTrials.gov, NCT02778074.
39.	Westas, Mats, et al. (author) How Healthcare Professionals in Cardiac Care Address Depressive Symptoms : Experiences of Patients With Cardiovascular Disease 2021 In: Journal of Cardiovascular Nursing. - : Lippincott Williams & Wilkins. - 0889-4655 .- 1550-5049. ; 36:4, s. 340-348 Journal article (peer-reviewed)abstract BACKGROUND: Depressive symptoms are common in patients with cardiovascular disease (CVD) and are associated with a poorer quality of life and prognosis. Despite the high prevalence and negative consequences, the recognition of depressive symptoms is low. More knowledge about patients' perceptions of how depressive symptoms are addressed by healthcare professionals is therefore needed.OBJECTIVES: The aim of this study was to explore the experiences of patients with CVD of how healthcare professionals address and manage depressive symptoms in clinical cardiac care encounters.METHODS: A qualitative, semistructured interview study was performed. Data were analyzed using inductive thematic analysis.RESULTS: In total, 20 patients with CVD previously treated for depressive symptoms were included (mean age, 62 [range, 34-79] years; 45% women). Three main themes emerged: (1) "not being seen as a whole person," (2) "denying depressive symptoms," and (3) "being provided with help." The patients perceived that healthcare professionals mainly focused on somatic symptoms and disregarded their need for help for depressive symptoms when patients raised the issue. Some patients stated that they received help for depressive symptoms, but this depended on the patients' own ability to communicate their needs and/or having social support that could alert them to the importance of doing so. Patients also described that they downplayed the burden of depressive symptoms and/or did not recognize themselves as having depressive symptoms.CONCLUSION: Depressive symptoms were overlooked in patients with CVD, and psychological needs had not been met. A good ability to address needs and having good social support were useful for receiving help with depressive symptoms.
40.	Westas, Mats, 1972- (author) Internet-based cognitive behavioural therapy for depression : Effects and experiences among patients with cardiovascular disease 2022 Doctoral thesis (other academic/artistic)abstract Depressive symptoms are common in patients with cardiovascular disease (CVD). CVD has a negative impact on patients’ prognosis and health-related quality of life (HRQoL). Guidelines for the treatment of CVD recommend treatment of depressive symptoms. However, the detection rate of depressive symptoms in CVD care is low and patients are therefore at risk of not receiving treatment. The reason for the low detection rate in CVD patients has not been fully explored, but may be related to healthcare professionals or the patients themselves. CVD patients’ experience of how depressive symptoms are discussed or managed by healthcare providers has not currently been fully explored. Today, cognitive behavioural therapy (CBT) is the recommended treatment for mild to moderate depressive symptoms and has been found to be effective in CVD patients. One problem with CBT is the low access to the treatment, which is mainly due to a lack of psychotherapists. A solution could be to use the internet to provide CBT (iCBT), since this has been shown to be effective in the treatment of depressive symptoms in non- CVD populations and is as effective as regular CBT. At the time when this thesis was planned there was a lack of iCBT studies on patients with CVD and depressive symptoms, and more research regarding iCBT in CVD has been called for in the literature. AimThe overall aim of this thesis was to generate knowledge which can lead to improvements in the care of patients with CVD and depressive symptoms. This is done by exploring how depressive symptoms are managed in the healthcare setting from the patient’s perspective, and by evaluating the effects and experiences of an iCBT programme for depressive symptoms in patients with CVD. Design and methodsThis thesis represents two quantitative and two qualitative studies that were performed on the same cohort of participants (n=144) recruited to a randomised controlled trial (RCT) aiming to evaluate a nine-week iCBT programme (n=72) adapted for patients with CVD and depressive symptoms. In the RCT, the comparator was a nine-week online discussion forum (n=72). These participants were recruited via an invitation letter sent to patients diagnosed with CVD (i.e. coronary heart disease, atrial fibrillation/atrial flutter or heart failure) who had contacted four hospitals in southeast Sweden during the past year. Study I had a qualitative study design with an inductive semantic approach. The sample (n=20) was recruited from those who had performed iCBT and had completed at least one module of the treatment programme. The interviews were conducted by telephone using a semi-structured interview guide. Study II was designed as an RCT, and compared the effect of a nine-week iCBT programme adapted for CVD (n=72) with nine weeks of ODF (n=72) on depressive symptoms in CVD patients. Data regarding depressive symptoms and HRQoL was collected at baseline and at nine weeks post-intervention. Study III used the same cohort as study I, and had a qualitative study design with an inductive latent approach. Study IV used a quantitative longitudinal and explorative design. Data regarding depressive symptoms was collected at baseline, at nine weeks post-intervention and at six- and twelve-month follow-ups. ResultsThe mean age of the participants in studies II and IV was 63 years, and 61% (n=89) were men. Atrial fibrillation/flutter was found in 56% (n=81), 44% (n=63) had coronary heart disease and 26% (n=38) had heart failure. The mean age of the participants in studies I and III (n=20) was 62 years, and 55% (n=11) were men. The patients experienced how depressive symptoms were addressed and managed in clinical cardiac care encounters under three main themes: “Not being seen as a whole person”; “Denying depressive symptoms”; and “I was provided with help”. The RCT study showed that iCBT after nine weeks was more effective than ODF in terms of decreasing depressive symptoms and improving HRQoL. At six- and twelve-month follow-ups, the improvements in depressive symptoms in the iCBT group were sustained. At the twelve-month follow-up, it was those who had more depressive symptoms at baseline who also experienced more improvements in depressive symptoms through iCBT, whereas those with heart failure were less likely to improve. The experience of participating in the iCBT programme was perceived as: taking control of the disease; not just a walk in the park; and feeling a personal engagement with the iCBT programme. ConclusionsCVD patients experienced that healthcare professionals focused on somatic symptoms and did not address their depressive symptoms. On the other hand, CVD patients did not always understand that they had depressive symptoms – or denied having depressive symptoms – when meeting healthcare professionals. Those who had received treatment had taken the initiative to address this by themselves or through support from family or friends. A nine-week iCBT programme adapted for CVD and guided by nurses with clinical experience of CVD and psychiatry and a brief education in iCBT seems to be useful for decreasing depressive symptoms and improving HRQoL. The effect of iCBT seems to be more beneficial in CVD patients with higher levels depressive symptoms, whereas the effect of iCBT on heart failure patients is less certain. The iCBT programme adapted to CVD seems to provide knowledge, and was experienced by patients as helpful for taking control of their disease. A CVD-adapted iCBT programme including feedback from nurses with clinical experience of CVD and psychiatry was helpful for engaging with and motivating carrying out the iCBT programme. Participating in the iCBT programme can be demanding and emotionally challenging, but is sometimes necessary to achieve improvements in depressive symptoms.
41.	Westas, Mats, et al. (author) The effects of internet-based cognitive behaviour therapy for depression in cardiovascular disease on symptoms of anxiety: a secondary analysis of a randomized trial 2023 In: European Journal of Cardiovascular Nursing. - : OXFORD UNIV PRESS. - 1474-5151 .- 1873-1953. Journal article (peer-reviewed)abstract Aims The aims of this study were to evaluate: (i) the short- and long-term effects of the internet-based cognitive behaviour (iCBT) programme on symptoms of distress and fear disorder in cardiovascular disease (CVD) patients, and (ii) the association between changes in depression and changes in symptoms of distress and fear disorder from baseline to 12-month follow-up.Methods and results Secondary analysis of data collected in a randomized controlled study evaluating the effects on depression of an iCBT programme compared to an online discussion forum (ODF) in CVD patients (n = 144). Data were collected at baseline, at post-intervention (9 weeks), and at 6- and 12-month follow-ups. The results showed that symptoms of distress disorder were statistically significantly more reduced in the iCBT group than in the ODF group. For symptoms of the fear disorder, no differences were found except for avoidance, which showed a statistically significant reduction in the iCBT group. The long-term analysis in the iCBT group showed that CAQ total score and fear decreased from baseline to 6- and 12-month follow-ups, respectively. Avoidance and attention both decreased statistically significantly from baseline to post-intervention, but not between post-intervention and 12-month follow-up.Methods and results Secondary analysis of data collected in a randomized controlled study evaluating the effects on depression of an iCBT programme compared to an online discussion forum (ODF) in CVD patients (n = 144). Data were collected at baseline, at post-intervention (9 weeks), and at 6- and 12-month follow-ups. The results showed that symptoms of distress disorder were statistically significantly more reduced in the iCBT group than in the ODF group. For symptoms of the fear disorder, no differences were found except for avoidance, which showed a statistically significant reduction in the iCBT group. The long-term analysis in the iCBT group showed that CAQ total score and fear decreased from baseline to 6- and 12-month follow-ups, respectively. Avoidance and attention both decreased statistically significantly from baseline to post-intervention, but not between post-intervention and 12-month follow-up.Conclusion The results suggest that the iCBT programme targeted depression in CVD patients successfully reduced symptoms of distress disorder and to a lesser extent symptoms of fear disorder. Change in depression was more strongly associated with a change in distress than a change in fear disorder.Registration ClinicalTrials.gov: NCT02778074 Graphical Abstract
42.	Westas, Mats, et al. (author) The experience of participating in an internet-based cognitive behavioral therapy program among patients with cardiovascular disease and depression : a qualitative interview study 2022 In: BMC Psychiatry. - London, United Kingdom : BioMed Central (BMC). - 1471-244X. ; 22:1 Journal article (peer-reviewed)abstract Background: Depression in conjunction with cardiovascular disease (CVD) is associated with worsening in CVD, higher mortality, and poorer quality of life. Despite the poor outcomes there is a treatment gap of depression in CVD patients. Recently we found that an Internet-based cognitive behavioral therapy (iCBT) tailored for CVD patients led to reduced symptoms of depression. However, we still have little knowledge about CVD patients’ experiences of working with iCBT. The aim of this study was therefore to explore CVD patients’ experiences of engaging in a tailored iCBT program. Methods: A qualitative interview study using inductive thematic analysis. Data was obtained from 20 patients with CVD and depressive symptoms who had participated in a randomized controlled trial (RCT) evaluating the impact of a nine-week iCBT program on depression. Results: Three main themes emerged: (1) Taking control of the disease, (2) Not just a walk in the park, and (3) Feeling a personal engagement with the iCBT program. The first theme included comments that the tailored program gave the patients a feeling of being active in the treatment process and helped them achieve changes in thoughts and behaviors necessary to take control of their CVD. The second theme showed that patients also experienced the program as demanding and emotionally challenging. However, it was viewed as helpful to challenge negative thinking about living with CVD and to change depressive thoughts. In the third theme patients reported that the structure inherent in the program, in the form of organizing their own health and the scheduled feedback from the therapist created a feeling of being seen as an individual. The feeling of being acknowledged as a person also made it easier to continuously work with the changes necessary to improve their health. Conclusions: Engaging in an iCBT program tailored for patients with CVD and depression was by the patients perceived as helpful in the treatment of depression. They experienced positive changes in emotions, thoughts, and behaviors which a result of learning to take control of their CVD, being confirmed and getting support. The patients considered working with the iCBT program as demanding and emotionally challenging, but necessary to achieve changes in emotions, thoughts, and behaviors.

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