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Treating depression and its comorbidity: From individualized Internet-delivered cognitive behavior therapy to affect-focused psychodynamic psychotherapy
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Att behandla depression och dess komorbiditet : Från individanpassad internetbaserad kognitiv beteendeterapi till affektfokuserad psykodynamisk psykoterapi (Swedish)
Abstract [en]

The overarching goal of this thesis has been to enhance Internet-delivered psychological treatments for depression and its comorbidity. To this end, three randomized controlled trials (Study II, III and IV) with a total of 313 participants were conducted. A prevalence study (Study I) was also conducted to provide an up-to-date estimate of the prevalence of depression, anxiety disorders, and their comorbidity in the Swedish general population.

Study I showed that more than every sixth individual in Sweden suffers from symptoms of depression and/or anxiety. Comorbidity between depression and anxiety was substantial and associated with higher symptom burden and lower health-related quality of life. Study II showed that a tailored Internet-based CBT protocol (ICBT) was effective in reducing symptoms of depression when compared to a control group. Among individuals with more severe depression and comorbidities, the tailored ICBT treatment worked better than standardized ICBT. Study III showed that a psychodynamic Internet-based psychotherapy was highly effective in the treatment of depression, when compared to a group who received psychoeducation and online support. In Study IV, an Internet-delivered affect-focused psychodynamic psychotherapy proved to have a large effect on depression and a moderately large effect on anxiety disorders.

In conclusion, this thesis shows that in the context of treating depression and its comorbidity, Internet-delivered psychological treatments can be potentially enhanced by psychodynamic psychotherapy and by individualization.

Abstract [sv]

Det övergripande syftet med denna avhandling har varit att vidareutveckla internetbaserad psykologisk behandling för depression och dess komorbiditet. Tre randomiserade kontrollerade studier (Studie II, III och IV) med totalt 313 deltagare genomfördes i linje med detta syfte. En prevalensstudie (Studie I) genomfördes också för att tillhandahålla ett uppdaterat estimat av prevalensen av depression, ångest och deras komorbiditet i Sverige.

Studie I visade att mer än var sjätte individ i Sverige lider av symptom på depression och/eller ångest. Det fanns påtaglig komorbiditet mellan depression och ångest, vilket var associerat med högre symptombörda och lägre livskvalitét. Studie II visade att en skräddarsydd internetbaserad KBT-behandling var effektiv för att reducera symptom på depression, i jämförelse med en kontrollgrupp. Bland individer med svårare depression och komorbiditet, fungerade den skräddarsydda interventionen bättre än en standardiserad. Studie III visade att psykodynamisk internetbehandling var effektiv vid behandling av depression, i jämförelse med en grupp som fick psykoedukation och stödsamtal online. I Studie IV visades att en affektfokuserad psykodynamisk internetbehandling hade stor effekt vad gällde att reducera symptom på depression, och medelstor effekt vad gällde att reducera symptom på ångest.

Sammanfattningsvis visar denna avhandling att internetbaserad psykologisk behandling kan potentiellt vidareutvecklas av psykodynamisk psykoterapi och individanpassning, vid behandling av depression och dess komorbiditet.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 104 p.
Series
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 596Linköping Studies in Behavioural Science, ISSN 1654-2029 ; 179
Keyword [en]
Depression, comorbidity, psychological treatment, psychotherapy, Internet, Internet-delivered treatment, cognitive behavior therapy, psychodynamic psychotherapy
Keyword [sv]
Depression, komorbiditet, psykologisk behandling, psykoterapi, Internet, internetbaserad behandling, kognitiv beteendeterapi, psykodynamisk psykoterapi
National Category
Psychology
Identifiers
URN: urn:nbn:se:liu:diva-100385DOI: 10.3384/diss.diva-100385ISBN: 978-91-7519-467-7 (print)OAI: oai:DiVA.org:liu-100385DiVA: diva2:661733
Public defence
2013-12-06, VAL, Hus Vallfarten, Campus Valla, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2013-11-04 Created: 2013-11-04 Last updated: 2014-11-28Bibliographically approved
List of papers
1. Depression, anxiety and their comorbidity in the Swedish general population: point prevalence and the effect on health-related quality of life
Open this publication in new window or tab >>Depression, anxiety and their comorbidity in the Swedish general population: point prevalence and the effect on health-related quality of life
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2013 (English)In: PeerJ, ISSN 2167-8359, Vol. 1, e98- p.Article in journal (Refereed) Published
Abstract [en]

Background. Depression and anxiety disorders are major world-wide problems. There are no or few epidemiological studies investigating the prevalence of depression, generalized anxiety disorder and anxiety disorders in general in the Swedish population.

Methods. Data were obtained by means of a postal survey administered to 3001 randomly selected adults. After two reminders response rate was 44.3%. Measures of depression and general anxiety were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). The PHQ-9 identified participants who had experienced clinically significant depression (PHQ-9 ≥ 10), and who had a diagnosis of major depression (defined by using a PHQ-9 scoring algorithm). Clinically significant anxiety was defined as having a GAD-7 score ≥ 8. To specifically measure generalized anxiety disorder, the Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV) was used with an established cut-off. Health-related quality of life was measured using the EuroQol (EQ-5D). Experiences of treatments for psychiatric disorders were also assessed.

Results. Around 17.2% (95% CI: 15.1–19.4) of the participants were experiencing clinically significant depression (10.8%; 95% CI: 9.1–12.5) and clinically significant anxiety (14.7%; 95% CI: 12.7–16.6). Among participants with either clinically significant depression or anxiety, nearly 50% had comorbid disorders. The point prevalence of major depression was 5.2% (95% CI: 4.0–6.5), and 8.8% (95% CI: 7.3–10.4) had GAD. Among those with either of these disorders, 28.2% had comorbid depression and GAD. There were, generally, significant gender differences, with more women having a disorder compared to men. Among those with depression or anxiety, only between half and two thirds had any treatment experience. Comorbidity was associated with higher symptom severity and lower health-related quality of life.

Conclusions. Epidemiological data from the Swedish community collected in this study provide point prevalence rates of depression, anxiety disorders and their comorbidity. These conditions were shown in this study to be undertreated and associated with lower quality of life, that need further efforts regarding preventive and treatment interventions.

National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-96837 (URN)10.7717/peerj.98 (DOI)23862109 (PubMedID)
Available from: 2013-08-27 Created: 2013-08-27 Last updated: 2014-11-28
2. Tailored vs. Standardized Internet-Based Cognitive Behavior Therapy for Depression and Comorbid Symptoms: A Randomized Controlled Trial
Open this publication in new window or tab >>Tailored vs. Standardized Internet-Based Cognitive Behavior Therapy for Depression and Comorbid Symptoms: A Randomized Controlled Trial
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2012 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 7, no 5Article in journal (Refereed) Published
Abstract [en]

Background and Aims: Major depression can be treated by means of cognitive behavior therapy, delivered via the Internet as guided self-help. Individually tailored guided self-help treatments have shown promising results in the treatment of anxiety disorders. This randomized controlled trial tested the efficacy of an Internet-based individually tailored guided self-help treatment which specifically targeted depression with comorbid symptoms. The treatment was compared both to standardized (non-tailored) Internet-based treatment and to an active control group in the form of a monitored online discussion group. Both guided self-help treatments were based on cognitive behavior therapy and lasted for 10 weeks. The discussion group consisted of weekly discussion themes related to depression and the treatment of depression. Methods: A total of 121 participants with diagnosed major depressive disorder and with a range of comorbid symptoms were randomized to three groups. The tailored treatment consisted of a prescribed set of modules targeting depression as well as comorbid problems. The standardized treatment was a previously tested guided self-help program for depression. Results: From pre-treatment to post-treatment, both treatment groups improved on measures of depression, anxiety and quality of life. The results were maintained at a 6-month follow-up. Subgroup analyses showed that the tailored treatment was more effective than the standardized treatment among participants with higher levels of depression at baseline and more comorbidity, both in terms of reduction of depressive symptoms and on recovery rates. In the subgroup with lower baseline scores of depression, few differences were seen between treatments and the discussion group. Conclusions: This study shows that tailored Internet-based treatment for depression is effective and that addressing comorbidity by tailoring may be one way of making guided self-help treatments more effective than standardized approaches in the treatment of more severe depression.

Place, publisher, year, edition, pages
Public Library of Science, 2012
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-79824 (URN)10.1371/journal.pone.0036905 (DOI)000305336300049 ()
Available from: 2012-08-14 Created: 2012-08-14 Last updated: 2017-12-07
3. Psychodynamic Guided Self-Help for Adult Depression through the Internet: A Randomised Controlled Trial
Open this publication in new window or tab >>Psychodynamic Guided Self-Help for Adult Depression through the Internet: A Randomised Controlled Trial
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2012 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 7, no 5, e38021- p.Article in journal (Refereed) Published
Abstract [en]

Background and aims

Psychodynamic psychotherapy (PDT) is an effective treatment for major depressive disorder (MDD), but not all clients with MDD can receive psychotherapy. Using the Internet to provide psychodynamic treatments is one way of improving access to psychological treatments for MDD. The aim of this randomised controlled trial was to investigate the efficacy of an Internet-based psychodynamic guided self-help treatment for MDD.

Methods

Ninety-two participants who were diagnosed with MDD according to the Mini-International Neuropsychiatric Interview were randomised to treatment or an active control. The treatment consisted of nine treatment modules based on psychodynamic principles with online therapist contact. The active control condition was a structured support intervention and contained psychoeducation and scheduled weekly contacts online. Both interventions lasted for 10 weeks. The primary outcome measure was the Beck Depression Inventory-II (BDI-II).

Results

Mixed-effects model analyses of all randomised participants showed that participants receiving Internet-based PDT made large and superior improvements compared with the active control group on the BDI-II (between-group Cohen's d = 1.11). Treatment effects were maintained at a 10-month follow-up.

Conclusions

Internet-based psychodynamic guided self-help is an efficacious treatment for MDD that has the potential to increase accessibility and availability of PDT for MDD.

National Category
Psychology Psychiatry
Identifiers
urn:nbn:se:liu:diva-77847 (URN)10.1371/journal.pone.0038021 (DOI)000305349600055 ()
Note

http://dx.plos.org/10.1371/journal.pone.0038021

Available from: 2012-05-31 Created: 2012-05-31 Last updated: 2017-12-07
4. Affect-focused psychodynamic psychotherapy for depression and anxiety through the Internet: a randomized controlled trial
Open this publication in new window or tab >>Affect-focused psychodynamic psychotherapy for depression and anxiety through the Internet: a randomized controlled trial
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2013 (English)In: PeerJ, ISSN 2167-8359, Vol. 1, e102- p.Article in journal (Refereed) Published
Abstract [en]

Background. Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders.

Methods. One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up.

Results. Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen’s d = 0.77 (95% CI: 0.37–1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08–0.87) was found on the GAD-7. The number of patients who recovered (had no diagnoses of depression and anxiety, and had less than 10 on both the PHQ-9 and the GAD-7) were at post-treatment 52% in the treatment group and 24% in the control group. This difference was significant, χ2(N = 100, df = 1) = 8.3, p < .01. From post-treatment to follow-up, treatment gains were maintained on the PHQ-9, and significant improvements were seen on the GAD-7.

Conclusion. This study provides initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.

Keyword
Depression, Anxiety, Psychotherapy, Psychodynamic therapy, Internet, Affect, Emotion, Internet-delivered treatments, e-health
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-96838 (URN)10.7717/peerj.102 (DOI)23862104 (PubMedID)
Available from: 2013-08-27 Created: 2013-08-27 Last updated: 2014-11-28
5. Using the Internet to Provide Psychodynamic Psychotherapy
Open this publication in new window or tab >>Using the Internet to Provide Psychodynamic Psychotherapy
2013 (English)In: Psychodynamic Psychiatry, ISSN 2162-2590, Vol. 41, no 4, 513-540 p.Article in journal (Refereed) Published
Abstract [en]

Over the last 15 years, there has been a substantial increase in research and clinical implementations of Internet-delivered, cognitive behavioral therapy (ICBT). Several studies on ICBT have been in the format of guided self-help where a therapist guides the patient throughout the whole treatment. ICBT is typically in the form of self-help material (e.g., text or video) which is provided to a client over the Internet with additional therapist contact by e-mail. ICBT has been shown to be effective for various conditions and, in some studies, has shown to be as effective as face-to-face cognitive behavioral therapy for mild to moderate depression, anxiety disorders, and somatic problems. Recently, the field has expanded to include other orientations including psychodynamic psychotherapy. Currently, there are three randomized controlled trials that have tested the efficacy of psychodynamic psychotherapy delivered in this format. The latest published trial focused on an affect-focused, psychodynamic psychotherapy delivered to a sample of participants with mixed depression and anxiety disorders. This article aims to provide a deeper understanding of the process of providing psychodynamic psychotherapy via the Internet. We will give a detailed description of our latest manual and show how psychotherapeutic work is conducted utilizing this text. Furthermore, we provide examples of dialogue between therapist and client from the online environment. Similarities and differences between psychodynamic psychotherapy delivered over the Internet and in face-to-face formats are discussed.

Place, publisher, year, edition, pages
Guilford Press, 2013
National Category
Psychology
Identifiers
urn:nbn:se:liu:diva-100384 (URN)10.1521/pdps.2013.41.4.513 (DOI)
Available from: 2013-11-04 Created: 2013-11-04 Last updated: 2014-11-28Bibliographically approved

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