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  • 1.
    Andersson, Erik
    et al.
    Karolinska Institute.
    Ljotsson, Brjann
    Karolinska Institute.
    Hedman, Erik
    Karolinska Institute.
    Kaldo, Viktor
    Karolinska Institute.
    Paxling, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Lindefors, Nils
    Karolinska Institute.
    Ruck, Christian
    Karolinska Institute.
    Internet-based cognitive behavior therapy for obsessive compulsive disorder: A pilot study2011In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 11, no 125Article in journal (Refereed)
    Abstract [en]

    Background: Cognitive behavior therapy (CBT) is widely regarded as an effective treatment for obsessive compulsive disorder (OCD), but access to CBT therapists is limited. Internet-based CBT (ICBT) with therapist support is a way to increase access to CBT but has not been developed or tested for OCD. The aim of this study was to evaluate ICBT for OCD. less thanbrgreater than less thanbrgreater thanMethod: An open trial where patients (N = 23) received a 15-week ICBT program with therapist support consisting of psychoeducation, cognitive restructuring and exposure with response prevention. The primary outcome was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which was assessed by a psychiatrist before and immediately after treatment. Secondary outcomes were self-rated measures of OCD symptoms, depressive symptoms, general functioning, anxiety and quality of life. All assessments were made at baseline and post-treatment. less thanbrgreater than less thanbrgreater thanResults: All participants completed the primary outcome measure at all assessment points. There were reductions in OCD symptoms with a large within-group effect size (Cohens d = 1.56). At post-treatment, 61% of participants had a clinically significant improvement and 43% no longer fulfilled the diagnostic criteria of OCD. The treatment also resulted in statistically significant improvements in self-rated OCD symptoms, general functioning and depression. less thanbrgreater than less thanbrgreater thanConclusions: ICBT with therapist support reduces OCD symptoms, depressive symptoms and improves general functioning. Randomized trials are needed to confirm the effectiveness of this new treatment format.

  • 2.
    Andersson, Erik
    et al.
    Karolinska Institute.
    Ljotsson, Brjann
    Karolinska Institute.
    Smit, Filip
    Vrije University Amsterdam Med Centre.
    Paxling, Björn
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Hedman, Erik
    Karolinska Institute.
    Lindefors, Nils
    Karolinska Institute.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Ruck, Christian
    Karolinska Institute.
    Cost-effectiveness of internet-based cognitive behavior therapy for irritable bowel syndrome: results from a randomized controlled trial2011In: BMC PUBLIC HEALTH, ISSN 1471-2458, Vol. 11, no 215Article in journal (Refereed)
    Abstract [en]

    Background: Irritable Bowel Syndrome (IBS) is highly prevalent and is associated with a substantial economic burden. Cognitive behavior therapy (CBT) has been shown to be effective in treating IBS. The aim of this study was to evaluate the cost-effectiveness of a new treatment alternative, internet-delivered CBT based on exposure and mindfulness exercises. Methods: Participants (N = 85) with IBS were recruited through self-referral and were assessed via a telephone interview and self-report measures on the internet. Participants were randomized to internet-delivered CBT or to a discussion forum. Economic data was assessed at pre-, post- and at 3-month and 1 year follow-up. Results: Significant cost reductions were found for the treatment group at $16,806 per successfully treated case. The cost reductions were mainly driven by reduced work loss in the treatment group. Results were sustained at 3-month and 1 year follow-up. Conclusions: Internet-delivered CBT appears to generate health gains in IBS treatment and is associated with cost-savings from a societal perspective.

  • 3.
    Andersson, Erik
    et al.
    Karolinska Institute.
    Walen, Christian
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Hallberg, Jonas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Paxling, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Dahlin, Mats
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Almlöv, Jonas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Källström, Reidar
    Linköping University, Department of Clinical and Experimental Medicine, Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Östergötland.
    Wijma, Klaas
    Linköping University, Department of Clinical and Experimental Medicine, Gender and medicine. Linköping University, Faculty of Health Sciences.
    Carlbring, Per
    Umeå University, Department Psychol, S-90187 Umeå, Sweden .
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    A Randomized Controlled Trial of Guided Internet-delivered Cognitive Behavioral Therapy for Erectile Dysfunction2011In: Journal of Sexual Medicine, ISSN 1743-6095, E-ISSN 1743-6109, Vol. 8, no 10, p. 2800-2809Article in journal (Refereed)
    Abstract [en]

    Introduction. Men with erectile dysfunction are often worried about their condition, have interpersonal difficulties, and have a reduced quality of life. Internet-delivered cognitive behavior therapy (ICBT) has been shown effective for a number of health problems but evidence is limited concerning the treatment of erectile dysfunction. less thanbrgreater than less thanbrgreater thanAim. The study investigated the effects of ICBT for erectile dysfunction. less thanbrgreater than less thanbrgreater thanMethods. Seventy-eight men were included in the study and randomized to either ICBT or to a control group, which was an online discussion group. Treatment consisted of a 7-week Web-based program with e-mail-based therapist support. Each therapist spent an average of 55 minutes per participant. less thanbrgreater than less thanbrgreater thanMain Outcome Measure. The International Index of Erectile Functioning five-item version was administered via the telephone at pretreatment, post-treatment, and 6 months after receiving ICBT. less thanbrgreater than less thanbrgreater thanResults. At post-treatment, the treatment group had significantly greater improvements with regard to erectile performance compared with the control group. Between-group differences at post-treatment were small (d = 0.1), but increased at the 6-month follow-up (d = 0.88). less thanbrgreater than less thanbrgreater thanConclusions. This study provides support for the use of ICBT as a possible treatment format for erectile dysfunction.

  • 4.
    Andersson, Gerhard
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.
    Bergström, Jan
    Buhrman, Monica
    Carlbring, Per
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.
    Holländare, Fredrik
    Kaldo, Viktor
    Nilsson-Ihrfelt, Elisabeth
    Paxling, Björn
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning.
    Ström, Lars
    Waara, Johan
    Development of a new approach to guided self-help via the Internet. The Swedish experience.2008In: Journal of technology in human services, ISSN 1522-8835, E-ISSN 1522-8991, Vol. 26, p. 161-181Article in journal (Refereed)
    Abstract [en]

    This article describes the development and empirical status of guided Internet-delivered self-help. The treatment approach combines the benefits of bibliotherapy with book-length text materials and the support given online via web pages and e-mail. Interactive features such as online registrations, tests, and online discussion forums are also included. Cognitive behavior therapy (CBT) guided the research and clinical implementations of this approach, as it lends itself more easily to the self-help format compared with other presently available psychotherapy approaches. We include an overview of the research, current issues and research in service delivery, lessons learned through a program of research, and directions for future investigations.

  • 5.
    Andersson, Gerhard
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Paxling, Björn
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Roch-Norlund, Pie
    Department of Psychology, Stockholm University.
    Östman, Gunnar
    Department of Psychology, Stockholm University.
    Norgren, Anna
    Department of Psychology, Stockholm University.
    Almlöv, Jonas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Georén, Lisa
    Department of Psychology, Uppsala University.
    Breitholtz, Elisabeth
    Department of Psychology, Stockholm University.
    Dahlin, Mats
    Psykologpartners, Linköping.
    Cuijpers, Pim
    Vrije University, Amsterdam, The Netherlands .
    Carlbring, Per
    Umeå University.
    Silverberg, Farrell
    Philadelphia School of Psychoanalysis and Private Practice, Philadelphia, USA.
    Internet-Based Psychodynamic versus Cognitive Behavioral Guided Self-Help for Generalized Anxiety Disorder: A Randomized Controlled Trial2012In: Psychotherapy and Psychosomatics, ISSN 0033-3190, E-ISSN 1423-0348, Vol. 81, no 6, p. 344-355Article in journal (Refereed)
    Abstract [en]

    Background: Guided Internet-based cognitive behavior therapy (ICBT) has been tested in many trials and found to be effective in the treatment of anxiety and mood disorders. Generalized anxiety disorder (GAD) has also been treated with ICBT, but there are no controlled trials on guided Internet-based psychodynamic treatment (IPDT). Since there is preliminary support for psychodynamic treatment for GAD, we decided to test if a psychodynamically informed self-help treatment could be delivered via the Internet. The aim of the study was to investigate the efficacy of IPDT for GAD and to compare against ICBT and a waiting list control group. Method: A randomized controlled superiority trial with individuals diagnosed with GAD comparing guided ICBT (n = 27) and IPDT (n = 27) against a no treatment waiting list control group (n = 27). The primary outcome measure was the Penn State Worry Questionnaire. Results: While there were no significant between-group differences immediately after treatment on the main outcome measure, both IPDT and ICBT resulted in improvements with moderate to large within-group effect sizes at 3 and 18 months follow-up on the primary measure in the completer analyses. The differences against the control group, although smaller, were still significant for both PDT and CBT when conforming to the criteria of clinically significant improvement. The active treatments did not differ significantly. There was a significant group by time interaction regarding GAD symptoms, but not immediately after treatment. Conclusions: IPDT and ICBT both led to modest symptom reduction in GAD, and more research is needed.

  • 6.
    Andersson, Gerhard
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Paxling, Björn
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Wiwe, Maria
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Vernmark, Kristofer
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Psykologpartners, Private Practice, Linköping.
    Felix, Christina Bertholds
    Uppsala University.
    Lundborg, Lisa
    Uppsala University.
    Furmark, Tomas
    Uppsala University.
    Cuijpers, Pim
    VU University Amsterdam, and EMGO Institute, The Netherlands.
    Carlbring, Per
    Umeå University.
    Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder2012In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 50, no 9, p. 544-550Article in journal (Refereed)
    Abstract [en]

    Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.

  • 7.
    Johansson, Olof
    et al.
    Department of Psychology, Lund University, Sweden.
    Michel, Teresa
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institute, Stockholm, Sweden.
    Paxling, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Experiences of non-adherence to Internet-delivered cognitive behavior therapy: A qualitative study2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 2, p. 137-142Article in journal (Refereed)
    Abstract [en]

    Many trials on Internet-delivered psychological treatments have had problems with nonadherence, but not much is known about the subjective reasons for non-adhering. The aim of this study was to explore participants' experiences of non-adherence to Internet-delivered psychological treatment. Grounded theory was used to analyze data from seven in-depth interviews with persons who had non-adhered to a study on Internet-delivered cognitive behavioral therapy for generalized anxiety disorder. The process of non-adherence is described as an interaction between patient factors and treatment factors. A working model theory was generated to illustrate the experience of nonadherence. The model describes a process where treatment features such as workload, text-content complexity and treatment process don't match personal prerequisites regarding daily routines, perceived language skills and treatment expectations respectively, resulting in the decision to nonadhere. Negative effects were also stated as a reason for non-adherence. Several common strategies used for increasing adherence to Internet-delivered therapy in general are by these non-completers regarded as factors directly related to their reason for non-adherence.

  • 8.
    Johansson, Robert
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Carlbring, Per
    Stockholm University, Sweden.
    Heedman, Åsa
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Paxling, Björn
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Depression, anxiety and their comorbidity in the Swedish general population: point prevalence and the effect on health-related quality of life2013In: PeerJ, ISSN 2167-8359, Vol. 1, p. e98-Article in journal (Refereed)
    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.

  • 9.
    Paxling, Björn
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    Carlbring, Per
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning.
    Andersson, Gerhard
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.
    Internet-delivered treatments with or without therapist input: Does the therapist factor have implications for efficacy and cost?2007In: Expert review of pharmacoeconomics & outcomes research, ISSN 1473-7167, E-ISSN 1744-8379, Vol. 7, no 3, p. 291-297Article in journal (Refereed)
    Abstract [en]

    Psychiatric problems such as mood and anxiety disorders are highly prevalent and are associated with high societal costs and individual suffering. Evidence-based psychological treatments obtain good results but are not available to the required extent due to the lack of practitioners with adequate training. One way to solve this problem is to provide minimal-contact self-help treatments, for example, with the assistance of computers. Recently, internet-delivered cognitive-behavioral treatment has been tested in a series of controlled trials. However, the interventions come in many forms with different levels and kinds of therapist input, which have implications for the costs of the treatments and possibly their effectiveness. In this review we found evidence for a strong correlation between therapist input and outcome. While emerging evidence attests to the efficacy of internet-delivered treatment when at least minimal therapist guidance is provided, most studies in the field have not included a formal evaluation of cost-effectiveness. Future research needs are discussed. © 2007 Future Drugs Ltd.

  • 10.
    Paxling, Björn
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Lundgren, Susanne
    Linköping University.
    Norman, Anita
    Linköping University.
    Almlöv, Jonas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Carlbring, Per
    Umeå University, Sweden .
    Cuijpers, Pim
    Vrije University of Amsterdam, Netherlands .
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Therapist Behaviours in Internet-Delivered Cognitive Behaviour Therapy: Analyses of E-Mail Correspondence in the Treatment of Generalized Anxiety Disorder2013In: Behavioural and Cognitive Psychotherapy, ISSN 1352-4658, E-ISSN 1469-1833, Vol. 41, no 3, p. 280-289Article in journal (Refereed)
    Abstract [en]

    Background: Internet-delivered cognitive behaviour therapy (iCBT) has been found to be an effective way to disseminate psychological treatment, and support given by a therapist seems to be important in order to achieve good outcomes. Little is known about what the therapists actually do when they provide support in iCBT and whether their behaviour influences treatment outcome. Aims: This study addressed the content of therapist e-mails in guided iCBT for generalized anxiety disorder. Method: We examined 490 e-mails from three therapists providing support to 44 patients who participated in a controlled trial on iCBT for generalized anxiety disorder. Results: Through content analysis of the written correspondence, eight distinguishable therapist behaviours were derived: deadline flexibility, task reinforcement, alliance bolstering, task prompting, psychoeducation, self-disclosure, self-efficacy shaping, and empathetic utterances. We found that task reinforcement, task prompting, self-efficacy shaping and empathetic utterances correlated with module completion. Deadline flexibility was negatively associated with outcome and task reinforcement positively correlated with changes on the Penn State Worry Questionnaire. Conclusions: Different types of therapist behaviours can be identified in iCBT, and though many of these behaviours are correlated to each other, different behaviours have an impact on change in symptoms and module completion.

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