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  • 1. Andersson, Gerhard
    et al.
    Riper, Heleen
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Editorial: introducing Internet Interventions — A new Open Access Journal2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 1, p. 1-2Article in journal (Other academic)
  • 2.
    Boettcher, Johanna
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Freie Universitaet Berlin, Germany.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Side effects in Internet-based interventions for social anxiety disorder2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 1, p. 3-11Article in journal (Refereed)
    Abstract [en]

    Internet-based interventions are effective in the treatment of various mental disorders and have already been integrated in routine health care in some countries. Empirical data on potential negative effects of these interventions is lacking. This study investigated side effects in an Internet-based treatment for Social Anxiety Disorder (SAD).

    A total of 133 individuals diagnosed with SAD took part in an 11-week guided treatment. Side effects were assessed as open formatted questions after week 2 and at post-treatment after week 11. Answers were independently rated by two coders. In addition, rates of deterioration and non-response were calculated for primary social anxiety and secondary outcome measures (depression and quality of life).

    In total, 19 participants (14%) described unwanted negative events that they related to treatment. The emergence of new symptoms was the most commonly experienced side effect, followed by the deterioration of social anxiety symptoms and negative well-being. The large majority of the described side effects had a temporary but no enduring negative effect on participants' well-being. At post-treatment, none of the participants reported deterioration on social anxiety measures and 0–7% deteriorated on secondary outcome measures. Non-response was frequent with 32–50% for social anxiety measures and 57–90% for secondary outcomes at post-assessment.

    Results suggest that a small proportion of participants in Internet-based interventions experiences negative effects during treatment. Information about potential side effects should be integrated in patient education in the practice of Internet-based treatments.

  • 3. Dahlin, Mats
    et al.
    Ryberg, Marielle
    Vernmark, Kristofer
    Annas, Nina
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Internet-delivered acceptance-based behavior therapy for generalized anxiety disorder: A pilot study2016In: Internet Interventions, ISSN 2214-7829, Vol. 6, p. 16-21Article in journal (Refereed)
    Abstract [en]

    Objective: Internet-delivered cognitive behavior therapy (ICBT) has been developed and tested for treating persons with generalized anxiety disorder (GAD). A new form of CBT focuses on acceptance (of internal experiences or difficult psychological content), mindfulness and valued actions. To date this form of CBT has not been delivered via the internet for persons with GAD. The aim of this study was to describe the functionality of a new internet-delivered acceptance-based behavior therapy for GAD, and to test the effect of the intervention in an open pilot trial. Methods: Following exclusion of two patients we included 14 patients diagnosed with GAD from two primary care clinics. At 2–3 months follow-up after treatment 10 patients completed the outcome measures. The treatment lasted for an average of 15 weeks and consisted of acceptance-based techniques, behavior therapy components and homework assignments. Results: A majority of participants completed all modules during the treatment. Findings on the Penn State Worry Questionnaire showed a within-group improvement of Cohen's d = 2.14 at posttreatment. At the follow-up results were maintained. Client satisfaction ratings were high. Conclusions: We conclude that internet-delivered acceptance-based behavior therapy potentially can be a promising new treatment for GAD. A controlled trial of the program has already been completed.

  • 4. Foody, Mairéad
    et al.
    Samara, Muthanna
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    A review of cyberbullying and suggestions for online psychological therapy2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 3, p. 235-242Article in journal (Refereed)
    Abstract [en]

    Investigations of cyberbullying are beginning to emerge in the scientific literature because of their implications for child and adolescent development. In particular, cyberbullying victimisation has been associated with similar negative consequences to traditional or face-to-face bullying such as lower academic achievement, anxiety, and sometimes even suicide. Research has also started to emerge investigating the impact of such incidences on the life of adults. The literature in this area has been steadily growing over the last decade and this review highlights the current situation in terms of relevant features and the psychological impact on victims. The selection process consisted of a comprehensive search that was conducted in January 2015 in the following databases: PsychInfo, ERIC, Web of Science and Medline. A total of 19 papers were included. We conclude with suggestions for online psychological treatment for victims and bullies as a means of coping with the distress caused from cyberbullying experiences.

  • 5.
    Forsström, David
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Centre for Psychiatry Research, Sweden.
    Hesser, Hugo
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Experiences of Playscan: Interviews with users of a responsible gambling tool2017In: Internet Interventions, ISSN 2214-7829, Vol. 8, p. 53-62Article in journal (Refereed)
    Abstract [en]

    Online gambling, encompassing a wide variety of activities and around-the-clock access, can be a potential risk factor for gamblers who tend to gamble excessively. Yet, the advent of online gambling has enabled responsible gambling (RG) features that may help individuals to limit their gambling behaviour. One of these features is RG tools that track gamblers' behaviour, performs risk assessments and provides advice to gamblers. This study investigated users' views and experiences of the RG tool Playscan from a qualitative perspective using a semi-structured interview. The tool performs a risk assessment on a three-step scale (low, medium and high risk). Users from every risk category were included. Twenty interviews were carried out and analysed using thematic analysis. Two main themes with associated sub-themes were identified: “Usage of Playscan and the gambling site” and “Experiences of Playscan”. Important experiences in the sub-themes were lack of feedback from the tool and confusion when signing up to use Playscan. These experiences counteracted positive attitudes that should have promoted usage of the tool. Providing more feedback directly to users is a suggested solution to increase usage of the RG tool.

  • 6.
    Heinrich, Sarah
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Cotter, Katherine
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Weise, Cornelia
    Treating tinnitus distress via the Internet: A mixed methods approach of what makes patients seek help and stay motivated during Internet-based cognitive behavior therapy2016In: Internet Interventions, ISSN 2214-7829, Vol. 4, no 2, p. 120-130Article in journal (Refereed)
    Abstract [en]

    Background: Internet-based cognitive behavioral therapy (ICBT) has proven to be an effective treatment in improving patients' ability to cope with tinnitus. However, some patients prefer face-to-face therapy to ICBT, and a few studies have shown considerable dropout rates if the treatment is not guided. This renders it important to identify factors that contribute to the commencement and continuation of ICBT programs.

    Aims: Because treatment motivation and expectations are important factors in psychological treatment, the aim of our study was to investigate what leads tinnitus patients to seek out ICBT, what helps them to keep up with the treatment, and what (if any) impact these factors have on dropout rates and treatment outcomes.

    Method: 112 tinnitus patients taking part in ICBT for tinnitus responded to symptom-related questionnaires at three points in time (pre-treatment, post-treatment, and one-year-follow-up) and to a questionnaire consisting of open-ended questions about their treatment motivation and expectations before beginning treatment. Data were analyzed using qualitative content analysis, and the results were used to divide the participants into groups. The treatment outcomes of these groups were compared using t-tests, χ2-tests, and both one-factorial and mixed ANOVAs.

    Results: Four main categories emerged as factors conducive to starting treatment: 1) Targets participants wanted to address, 2) circumstances that led to participation, 3) attitudes towards the treatment, and 4) training features. Participants identified six facilitators for continuing the treatment: success, training, individual attitude, hope, evidence, and support. Naming specific tinnitus-associated problems as targets was associated with greater improvement from pre-treatment to 1-year-follow-up. Describing an active involvement in the treatment was related to increased improvement from post-treatment to follow-up.

    Conclusion: There are several motivational factors that tinnitus patients consider relevant for beginning and continuing ICBT. Particularly, focusing on specific targets that do not involve the tinnitus itself, and encouraging participants to take an active role in treatment may increase treatment effectiveness. However, further hypothesis-guided research is necessary to confirm our explorative results.

  • 7. Holländare, Fredrik
    et al.
    Gustafsson, Sanna Aila
    Berglind, Maria
    Grape, Frida
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Hadjistavropoulos, Heather
    Tillfors, Maria
    Therapist behaviours in internet-based cognitive behaviour therapy (ICBT) for depressive symptoms2016In: Internet Interventions, ISSN 2214-7829, Vol. 3, no 1, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Internet-based cognitive behaviour therapy (ICBT) is efficacious for treating depression, with therapist guidance identified as important for favourable outcomes. We have limited knowledge, however, about the fundamental components of therapist guidance in ICBT. The purpose of this study was to systematically examine therapist messages sent to patients during the course of ICBT for depressive symptoms in order to identify common “therapist behaviours” and the extent to which these behaviours correlate with completion of modules and improvements in symptoms at post-treatment, one- and two-year follow-up. A total of 664 e-mails from 5 therapists to 42 patients were analysed using qualitative content analysis. The most frequent behaviour was encouraging that accounted for 31.5% of the total number of coded behaviours. This was followed by affirming (25.1%), guiding (22.2%) and urging (9.8%). Less frequently the therapists clarified the internet treatment frameworkinformed about module contentemphasised the importance of patient responsibilityconfronted the patient and made self-disclosures. Six of the nine identified therapist behaviours correlated with module completion. Three behaviours correlated with symptom improvement. Affirmingcorrelated significantly (r = .42, p = .005) with improvement in depressive symptoms at post-treatment and after two years (r = .39, p = .014). Encouraging was associated with outcome directly after treatment (r = .52, p = .001). Self-disclosure was correlated with improvement in depressive symptoms at post-treatment (r = .44, p = .003). The study contributes to a better understanding of therapist behaviours in ICBT for depressive symptoms. Future directions for research are discussed.

  • 8. Ivarsson, David
    et al.
    Blom, Marie
    Hesser, Hugo
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Enderby, Pia
    Nordberg, Rebecca
    Andersson, Gerhard
    Guided internet-delivered cognitive behavior therapy for post-traumatic stress disorder: a randomized controlled trial2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 1, p. 33-40Article in journal (Refereed)
    Abstract [en]

    The aim of this randomized controlled trial was to investigate the effects of guided internet-based cognitive behavior therapy (ICBT) for posttraumatic stress disorder (PTSD). Sixty-two participants with chronic PTSD, as assessed by the Clinician-administered PTSD Scale, were recruited via nationwide advertising and randomized to either treatment (n = 31) or delayed treatment attention control (n = 31). The ICBT treatment consisted of 8 weekly text-based modules containing psychoeducation, breathing retraining, imaginal and in vivo exposure, cognitive restructuring, and relapse prevention. Therapist support and feedback on homework assignment were given weekly via an online contact handling system. Assessments were made at baseline, post-treatment, and at 1-year follow-up. Main outcome measures were the Impact of Events Scale — Revised (IES-R) and the Posttraumatic Stress Diagnostic Scale (PDS). Results showed significant reductions of PTSD symptoms (between group effect on the IES-R Cohen's d = 1.25, and d = 1.24 for the PDS) compared to the control group. There were also effects on depression symptoms, anxiety symptoms, and quality of life. The results at one-year follow-up showed that treatment gains were maintained. In sum, these results suggest that ICBT with therapist support can reduce PTSD symptoms significantly.

  • 9. Johansson, Olof
    et al.
    Bjärehed, Jonas
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    Lundh, Lars-Gunnar
    Effectiveness of guided internet-delivered cognitive behavior therapy for depression in routine psychiatry: A randomized controlled trial2019In: Internet Interventions, ISSN 2214-7829, Vol. 17, article id 100247Article in journal (Refereed)
    Abstract [en]

    Depression is one of the most common health problems worldwide but is often undertreated. Internet-delivered cognitive behavioral therapy(ICBT) appears to be an effective treatment option, with the potential to reach a larger proportion of individuals suffering from depression. While many studies have examined the efficacy of ICBT for depression in randomized controlled trials, fewer have focused on the effectiveness of ICBT when used as an integral part of routine health care. In this study the effectiveness of an 8-week ICBT program was examined when delivered in a routine psychiatric setting. A total of 108 patients were referred and 54 were then included and randomized to either ICBT or a waitlist control condition. The sample had a lower education level and a higher proportion of individuals were on sick leave than comparable previous efficacy trials of ICBT for depression conducted in Sweden. Measures assessing depression, anxiety and psychiatric symptoms were administered before and after treatment, follow up was performed at 6- and 12 months after treatment had ended. ICBT resulted in significant reductions of depressive symptoms in the treatment group when compared to a waitlist control group with a large effect size (Cohen's d = 1.6). Treatment gains were maintained at 6- and 12 months after the treatment had ended. In terms of clinical significance, 58% of the sample had improved or recovered after treatment. The study was small, and patients received general psychiatric care after the ICBT treatment had ended which limits the implications. We conclude that ICBT appears to be an effective treatment for depression when delivered as an integral part of routine psychiatric care.

  • 10.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Karolinska Institutet.
    Nyström, Markus B.T.
    Hassmén, Peter
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Who seeks ICBT for depression and how do they get there?: effects of recruitment source on patient demographics and clinical characteristics2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 2, p. 221-225Article in journal (Refereed)
    Abstract [en]

    Studies on internet-administered cognitive behavior therapy (ICBT) frequently use several different sources of recruitment, yet no study has investigated whether different recruitment sources produce different clinical and demographic profiles among participants. Using data from a large sample (n = 982) seeking ICBT for depression, we compared these characteristics on the basis of self-reported recruitment source. Recruitment sources that imply more active treatment-seeking behaviors (Google searches, viewing postings on mental health websites) presented more severe depression and anxiety than those recruited through more passive sources of information (newspaper advertisements, referrals by friends and family). In addition, a number of demographic differences between groups were found. These findings have important implications for ICBT research projects and clinical programs who employ open recruitment procedures and multi-modal recruitment strategies, and who wish to recruit representative samples or target specific subgroups. Replications in other countries will however be required to establish cross-cultural patterns.

  • 11. Lindner, Philip
    et al.
    Olsson, Elinor Linderot
    Johnsson, Amanda
    Dahlin, Mats
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    The impact of telephone versus e-mail therapist guidance on treatment outcomes, therapeutic alliance and treatment engagement in Internet-delivered CBT for depression: a randomised pilot trial2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 4, p. 182-187Article in journal (Refereed)
    Abstract [en]

    Background: Internet-administered cognitive behavioural therapy (iCBT) is an effective treatment of depression, yet much remains to be learned about the specific mechanisms influencing symptom reduction. Although previous research has consistently shown that therapist-guided iCBT is more effective than unguided iCBT, it is unknown whether the medium used for therapist-client communication has an impact on results.

    Methods: Thirty-eight subjects with major depression were recruited from the waiting list of another iCBT study and randomised to a guided iCBT program with therapist guidance either by telephone calls (n = 19) or e-mail correspondence (n = 19). Outcome measures were self-rated measures of depression, anxiety and quality of life.

    Results: At post-treatment, both groups showed significant and large symptom reductions yet did not differ from each other. Neither was there any between-group difference in client-rated therapeutic alliance or treatment engagement. Symptom reductions were maintained at a three-month follow-up.

    Conclusion: Therapist guidance by telephone does not appear to differ from therapist guidance by e-mail in iCBT for depression, although further research featuring larger samples is necessary to draw more definite conclusions.

  • 12. Ly, Kien Hoa
    et al.
    Janni, Elsa
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Wrede, Richard
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Sedem, Mina
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Donker, Tara
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Experiences of a guided smartphone-based behavioral activation therapy for depression: a qualitative study2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 1, p. 60-68Article in journal (Refereed)
    Abstract [en]

    Recently, a number of studies have investigated treatments administered via smartphones showing that this treatment format has a potential to be effective. However, we still have limited knowledge of how patients experience this treatment format. The objective of this study was to explore participants' views of a smartphone-based behavioral activation treatment. In-depth interviews were conducted with 12 strategically (participants with different overall experiences) selected participants, suffering from major depression according to the DSM-IV. The interview data were processed with the aid of thematic analysis. The analysis generated the three main themes: Commitment, Treatment and Lack of important components, with attached subthemes. In conclusion, the findings from the current study correspond with existing knowledge in the field of internet-based treatment. Considering that this kind of treatment is still quite new, the need for further research and development is considerable. Nevertheless, its availability, assimilation into users' everyday lives and possible motivational qualities speak of its potential.

  • 13.
    Miloff, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Marklund, Arvid
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    The challenger app for social anxiety disorder: New advances in mobile psychological treatment2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 4, p. 382-391Article in journal (Refereed)
    Abstract [en]

    Social anxiety disorder (SAD) is a common debilitating mental illness with large negative effects on quality of life and economic productivity. Modern psychotherapy treatments utilizing cognitive–behavioral theory are increasingly delivered over the Internet and more recently using smartphone applications. The Challenger App written natively for the Apple iPhone was developed at the Stockholm University Department of Psychology for the treatment of SAD and uses a number of advanced features not previously seen in past mental health applications; these include real-time location awareness, notifications, anonymous social interaction between users, a high-degree of personalization and use of gamification techniques. This paper explores design considerations for the various components of the app, their theoretical and evidence base, and research opportunities that exist for apps making use of these novel features.

  • 14.
    Miloff, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Savva, Andreas
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Cognitive bias measurement and social anxiety disorder: Correlating self-report data and attentional bias2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 3, p. 227-234Article in journal (Refereed)
    Abstract [en]

    Social anxiety disorder (SAD) and attentional bias are theoretically connected in cognitive behavioral therapeutic models. In fact, there is an emerging field focusing on modifying attentional bias as a stand-alone treatment. However, it is unclear to what degree these attentional biases are present before commencing treatment. The purpose of this study was to measure pre-treatment attentional bias in 153 participants diagnosed with SAD using a home-based Internet version of the dot-probe paradigm. Results showed no significant correlation for attentional bias (towards or away from negative words or faces) and the self-rated version of the Liebowitz Social Anxiety Scale (LSAS-SR). However, two positive correlations were found for the secondary measures Generalized Anxiety Disorder 7 (GAD-7) and Patient Health Questionnaire 9 (PHQ-9). These indicated that those with elevated levels of anxiety and depression had a higher bias towards negative faces in neutral–negative and positive–negative valence combinations, respectively. The unreliability of the dot-probe paradigm and home-based Internet delivery are discussed to explain the lack of correlations between LSAS-SR and attentional bias. Changes to the dot-probe task are suggested that could improve reliability.

  • 15. Nordgreen, Tine
    et al.
    Gjestad, Rolf
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    Havik, Odd E.
    The effectiveness of guided internet-based cognitive behavioral therapy for social anxiety disorder in a routine care setting2018In: Internet Interventions, ISSN 2214-7829, Vol. 13, p. 24-29Article in journal (Refereed)
    Abstract [en]

    Social anxiety disorder (SAD) is a common mental disorder with high persistence when untreated. As access to effective treatment is limited, guided internet-based cognitive behavioral therapy (ICBT) has been proposed as an effective alternative to face-to-face treatment. In this study, we examined the effectiveness of a 14-week therapist-guided ICBT program for patients with SAD undergoing routine care. From 2014 to 2017, 169 patients were included in the study, of which 145 started the treatment. The sample was all general practitioner-referred and had a lower educational level and higher rate of work absence compared to similar effectiveness studies. Regarding social anxiety symptoms, we identified significant within-group effect sizes (post-treatment: d = 1.00–1.10; six-month follow-up: d = 1.03–1.55). We also found significant effects on secondary depression symptoms (d = 0.67). Clinically significant improvement was reported by 66.2% of the participants, and 16.6% had a significant deterioration. Clinical implications of the current study are that guided ICBT for SAD is an effective treatment for the majority of the patients undergoing routine care. Future studies should explore interventions targeting non-responders and deteriorated patients.

  • 16. Nordmo, Magnus
    et al.
    Sinding, Aksel Inge
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Havik, Odd E.
    Nordgreen, Tine
    Internet-delivered cognitive behavioural therapy with and without an initial face-to-face psychoeducation session for social anxiety disorder: a pilot randomized controlled trial2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 4, p. 429-436Article in journal (Refereed)
    Abstract [en]

    Background: Guided Internet-delivered cognitive behavioural therapy (ICBT) is an effective treatment of social anxiety disorder (SAD). However, the treatment is not effective for all. The amount and type of therapist contact have been highlighted as a possible moderator of treatment outcome.

    Objective: The aim of this study was to examine whether treatment effects of ICBT are enhanced with an initial 90 min face-to-face psychoeducation (PE) session for university students with SAD.

    Method: University students with SAD (N = 37) were randomized into one out of two conditions: 1) an initial therapist-led face-to-face PE session followed by guided ICBT, 2) guided ICBT without an initial PE session. Data was analysed with an intent-to-treat approach.

    Results: Eight participants (21.6%) dropped out of treatment. A statistically significant reduction in symptoms was found for all outcome measures for both groups. There were no significant additional effects of adding the initial face-to-face PE. Moderate to large within-group effect sizes on self-rated social anxiety symptoms were found at post-treatment (d = 0.70–0.95) and at a six month follow-up (d = 0.70–1.00). Nearly half of the participants were classified as recovered.

    Conclusions: Notwithstanding limitations due to the small sample size, the findings indicate that guided ICBT is an effective treatment for students with SAD. Adding an initial face-to-face PE session to the guided ICBT did not lead to enhanced outcomes in the present study.

  • 17.
    Olsson Halmetoja, Camilla
    et al.
    Linköpings universitet.
    Malmquist, Anna
    Linköpings universitet.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Linköpings universitet och Karolinska Institutet.
    Experiences of internet-delivered cognitive behavior therapy for social anxiety disorder four years later: A qualitative study2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 3, p. 158-163Article in journal (Refereed)
    Abstract [en]

    The current study is a qualitative follow-up of a study on guided internet-delivered cognitive behavior therapy (ICBT) for social anxiety disorder (SAD), conducted four years after treatment completion. The main aim was to capture participants' description of their experiences of the treatment, their view on treatment effects, memories of the treatment, and whether they continued using the gained knowledge after treatment. Sixty participants were selected from the original study's treatment group. A criterion based sampling approach was used based on the obtained treatment effect, and with a minimum of five completed treatment modules. E-mail invitations were sent, with information about the follow-up and the instruction to respond if interested in participating. Twelve semi-structured interviews were made and the material was analyzed using an approach based on grounded theory. The results showed that all participants found the treatment to have some effect, but they also found it to be demanding, difficult, and hard. Many appreciated to hear of the experiences of other participants in the online forum. Under the theme of memory, most could describe the setup of the treatment in general terms. The exposure module was mentioned by all, cognitive restructuring by most, and some also reported memories of the psychoeducation. A core process was identified which involved how the attained treatment effect was viewed over the time, and how this view changed from treatment completion to current time. The findings outlined in this study describe how treatment effects can be sustained via an active approach to the treatment and the symptoms of SAD.

  • 18. Persson Asplund, Robert
    et al.
    Jäderlind, Anna
    Höijer Björk, Isabel
    Ljótsson, Brjánn
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Experiences of internet-delivered and work-focused cognitive behavioral therapy for stress: A qualitative study2019In: Internet Interventions, ISSN 2214-7829, Vol. 18, article id 100282Article in journal (Refereed)
    Abstract [en]

    Introduction: Stress is one of the major challenges of modern society, causing significant costs and personal problems. In the recent decade a growing body of research has provided support for the efficacy of internet interventions for stress. However, few studies have focused on how participants experience internet interventions for stress.

    Method: The current study was a qualitative follow-up study of an internet-delivered and work-focused cognitive behavioral treatment for stress. The aim was to capture participants' experiences of the treatment and their views on effects on health and well-being. Participants were selected from a controlled study (n = 27), using a criterion-based sampling approach selecting those participants who had completed all treatment modules. Nine semi-structured interviews were held, and the material was analyzed using Thematic Analysis.

    Results: The results indicated that most of the participants experienced positive effects on their mental health and well-being in both life and at work. All participants emphasized the importance of having access to therapist support. In line with previous research, participants found the intervention to be extensive and demanding and expressed the need for extended treatment time and therapist support.

    Conclusions: Considering the limitations of the present study, future research could examine the feasibility of reducing the length of each session, extending deadlines and increasing therapist support. This could improve treatment efficacy and further enhance utilization in the target population.

  • 19.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Boettcher, Johanna
    Ebert, David Daniel
    Cuijpers, Pim
    Knaevelsrud, Christine
    Ljótsson, Brjánn
    Kaldo, Viktor
    Titov, Nickolai
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Consensus statement on defining and measuring negative effects of Internet interventions2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 1, p. 12-19Article in journal (Refereed)
    Abstract [en]

    Internet interventions have great potential for alleviating emotional distress, promoting mental health, and enhancing well-being. Numerous clinical trials have demonstrated their efficacy for a number of psychiatric conditions, and interventions delivered via the Internet will likely become a common alternative to face-to-face treatment. Meanwhile, research has paid little attention to the negative effects associated with treatment, warranting further investigation of the possibility that some patients might deteriorate or encounter adverse events despite receiving best available care. Evidence from research of face-to-face treatment suggests that negative effects afflict 5–10% of all patients undergoing treatment in terms of deterioration. However, there is currently a lack of consensus on how to define and measure negative effects in psychotherapy research in general, leaving researchers without practical guidelines for monitoring and reporting negative effects in clinical trials. The current paper therefore seeks to provide recommendations that could promote the study of negative effects in Internet interventions with the aim of increasing the knowledge of its occurrence and characteristics. Ten leading experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialog and reach an agreement. The authors discuss the importance of conducting research on negative effects in order to further the understanding of its incidence and different features. Suggestions on how to classify and measure negative effects in Internet interventions are proposed, involving methods from both quantitative and qualitative research. Potential mechanisms underlying negative effects are also discussed, differentiating common factors shared with face-to-face treatments from those unique to treatments delivered via the Internet. The authors conclude that negative effects are to be expected and need to be acknowledged to a greater extent, advising researchers to systematically probe for negative effects whenever conducting clinical trials involving Internet interventions, as well as to share their findings in scientific journals.

  • 20.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Almquist Tangen, Josefine
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Experiences of undergoing Internet-based cognitive behavior therapy for procrastination: A qualitative study2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 3, p. 314-322Article in journal (Refereed)
    Abstract [en]

    Internet interventions constitute a promising and cost-effective treatment alternative for a wide range of psychiatric disorders and somatic conditions. Several clinical trials have provided evidence for its efficacy and effectiveness, and recent research also indicate that it can be helpful in the treatment of conditions that are debilitating, but do not necessarily warrant more immediate care, for instance, procrastination, a self-regulatory failure that is associated with decreased well-being and mental health. However, providing treatment interventions for procrastination via the Internet is a novel approach, making it unclear how the participants themselves perceive their experiences. The current study thus investigated participants' own apprehension of undergoing Internet-based cognitive behavior therapy for procrastination by distributing open-ended questions at the post-treatment assessment, for instance, “What did you think about the readability of the texts”, “How valuable do you believe that this treatment has been for you?”, and “The thing that I am most displeased with (and how it could be improved) is …”. In total, 75 participants (50%) responded, and the material was examined using thematic analysis. The results indicate that there exist both positive and negative aspects of the treatment program. Many participants increased their self-efficacy and were able to gain momentum on many tasks and assignments that had been deferred in their everyday life. Meanwhile, several participants lacked motivation to complete the exercises, had too many conflicting commitments, and were unable to keep up with the tight treatment schedule. Hence, the results suggest that Internet interventions for procrastination could profit from individual tailoring, shorter and more manageable modules, and that the content need to be adapted to the reading comprehension and motivational level of the participant.

  • 21.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Nilsson, Sam
    Rizzo, Angela
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Group versus Internet-based cognitive-behavioral therapy for procrastination: Study protocol for a randomized controlled trial.2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 2, p. 84-89Article in journal (Refereed)
    Abstract [en]

    Procrastination is defined as a voluntarily delay of an intended course of action despite expecting to be worse-off for the delay, and is considered a persistent behavior pattern that can result in major psychological suffering. About one-fifth of the adult population and half of the student population are presumed having substantial difficulties due to recurrent procrastination in their everyday lives. However, chronic and severe procrastinators seldom receive adequate care due to preconceptions and the lack of understanding regarding procrastination and the treatment interventions that are assumed beneficial. Cognitive-behavioral therapy is often deemed a treatment of choice, although the evidence supporting its use is scarce, and only one randomized controlled trial has been performed. The primary aim of the proposed study is therefore to test the efficacy of cognitive-behavioral therapy delivered as either a group intervention or via the Internet. Participants will consist of students recruited through the Student Health Centre at Karolinska Institutet. A randomized controlled trial with a sample size of 100 participants divided into blocks of thirty will be used, comparing an eight-week Internet-based cognitive-behavioral therapy intervention, and an eight-week group cognitive-behavioral therapy based intervention. It is believed that the proposed study will result in two important findings. First, different treatment interventions in cognitive-behavioral therapy are assumed to be helpful for people suffering from problems caused by procrastination. Second, both an Internet-based cognitive-behavioral therapy intervention and a group intervention are presumed suitable for administering treatment for procrastination, which is considered important as the availability of adequate care is limited, particularly among students. The proposed study will increase the knowledge regarding the efficacy of different treatments of procrastination, as well as enhance the overall comprehension of the difficulties related to dilatory behavior.

  • 22. Schuster, Raphael
    et al.
    Leitner, Isabella
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Laireiter, Anton-Rupert
    Exploring blended group interventions for depression: Randomised controlled feasibility study of a blended computer- and multimedia-supported psychoeducational group intervention for adults with depressive symptoms2017In: Internet Interventions, ISSN 2214-7829, Vol. 8, p. 63-71Article in journal (Refereed)
    Abstract [en]

    Background: Blended interventions aim to capitalise on the strengths of both computer-based and face-to-face therapy. Studies on this innovative treatment format remain scare. This especially accounts for the group treatment of depression.

    Method: The present study applied eclectic psychotherapy methods to an adult sample exhibiting a variety of depressive symptoms (N = 46). Participants were recruited by a newspaper inlet and randomised either to a treatment or a waiting list condition. Computer supported components were multimedia group sessions, e-learning, online videos and worksheets, remote therapist-patient communication and online pre-post-assessment.

    Results: Large between-group effect sizes on primary outcome depressiveness (CES-D) (F(1,44) = 4.88, p = 0.032; d = 0.87) and secondary outcome personal resources (resource scales) (F(1,44) = 9.04, p = 0.004; d = 0.73 to F(1,44) = 8.82 p = 0.005, d = 1.15) were found in the intention to treat analysis (ANOVA). Subjective evaluation of the intervention revealed high treatment adherence (91%) and high perceived relevance of supportive computer and multimedia components. Participants rated computer and multimedia components comparable to treatment elements such as group interaction or specific cognitive behavioural exercises, and 25% associated the utilisation of those components with treatment success. Depressiveness and age did not predict the utilisation and the appraisal of computer and multimedia components.

    Discussion: Results provide preliminary support for the acceptability and feasibility of the investigated blended treatment in a group with non-specific depressive symptoms. However, small sample size and lack of diagnostics restrict generalizability. Additional research in clinical settings is needed.

  • 23.
    Silfvernagel, Kristin
    et al.
    Linköping University.
    Gren-Landell, Malin
    Department of Child and Adolescent Psychiatry, and Department of Clinical and Experimental Medicine, Linköping.
    Emanuelsson, Marie
    Linköping University.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Linköping University & Karolinska Institutet.
    Individually tailored internet-based cognitive behavior therapy for adolescents with anxiety disorders: A pilot effectiveness study2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 3, p. 297-302Article in journal (Refereed)
    Abstract [en]

    This is the first study of adolescents suffering from anxiety disorder in Sweden to receive individually tailored internet-based treatment within a child and adolescent psychiatric clinic. The primary aim of this effectiveness study was to examine the effects of tailored internet-based cognitive behaviour therapy for adolescents.

    11 adolescents, aged 15-19 years, were allocated to treatment after assessment. Screening consisted of online questionnaires followed by a diagnostic face-to-face interview at the clinic. Treatment consisted of individually prescribed cognitive behaviour therapy (CBT) text modules adapted for the age group. Therapist guidance was via an online platform along with telephone support and face-to-face sessions if needed.

    Statistically significant improvements were found on all dependent measures immediately following treatment for the 8 adolescents who completed treatment. The within-group effect size on the Beck Anxiety Inventory, the primary outcome measure, was d = 2.51 at post-treatment and 80 percent (4/5) adolescents no longer met DSM-IV criteria for their primary anxiety disorder as measured by the Anxiety Disorders Interview Schedule for DSM- IV: Child and Parent Versions.

    Based on the results from this pilot study the tentative conclusion might be that tailored internet delivered CBT could be useful for adolescents with anxiety disorders along with standard treatment delivered in child and adolescent psychiatric clinics.

  • 24. Svartvatten, Natalie
    et al.
    Segerlund, Mattias
    Dennhag, Inga
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    A content analysis of client e-mails in guided internet-based cognitive behavior therapy for depression2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 2, p. 121-127Article in journal (Refereed)
    Abstract [en]

    The relationship between what a client writes when communicating with an online therapist and treatment outcome in internet-based cognitive behavior therapy (ICBT) is largely unknown. The aim of this study was to address if written correspondence from the client to the therapist correlates with outcome and treatment completion. A total of 29 participants with mild to moderate depression were included from an ongoing randomized controlled trial targeting depression. Content analysis involving ten categories was performed on all emails and module responses sent by the participants to their internet therapist. A total of 3756 meaning units were identified and coded. Significant positive correlations were found between change in depression and statements in the two categories “observing positive consequences” (r = .49) and “alliance” (r = .42). Treatment module completion correlated with seven categories. The result suggests that text dealing with alliance and observing positive consequences can be used as indicators of how the treatment is progressing. This study suggests that written correspondence from an online client can be divided into ten categories and the frequency of those can be used by internet therapists to individualize treatment and perhaps make ICBT more effective.

  • 25. Vlaescu, George
    et al.
    Alasjö, Alexander
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Features and functionality of the Iterapi platform for internet-based psychological treatment2016In: Internet Interventions, ISSN 2214-7829, Vol. 6, p. 107-114Article in journal (Refereed)
    Abstract [en]

    The purpose of this article is to describe an internet-based platform for improving symptoms and quality of life for people with psychological and behavioural health problems such as depression, anxiety, phobia, psychological trauma, hearing loss and tinnitus. The online platform, called Iterapi, was developed at the Department of Behavioural Sciences and Learning at Linköping University, Sweden and has been running for nearly two decades and used in many randomized controlled trials and outpatient treatments.

    The intention of this article is to share our experience with developing such a treatment solution and the process flow and elements of running internet-based psychological interventions. This will likely be of use to developers building similar services, therapists considering integrating such approaches in their practices and institutions, as well as researchers curious about the functions included on the platform and methodology used for running studies.

    We describe the security aspects of the platform, central concepts underlying its development, how the platform can be used in a study or treatment and the main features and functions the platform offers. We comment on practical considerations regarding blending of methods within the platform, such as self-help treatments with asynchronous communication and real-time text chat and video conversations. We also point out the advantages of using Internet-assisted treatments, the challenges that we have faced and future planned upgrades.

    Due to continuous development of the platform, its user-friendliness, accessibility across devices and numerous features, many research colleagues from Sweden as well as other countries such as Germany, United Kingdom, Romania and Israel have chosen to implement their own studies on the platform.

  • 26.
    Zetterberg, Molly
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    Andersson, Gerhard
    Berg, Matilda
    Shafran, Roz
    Rozental, Alexander
    Internet-based cognitive behavioral therapy of perfectionism: Comparing regular therapist support and support upon request2019In: Internet Interventions, ISSN 2214-7829, Vol. 17, article id 100237Article in journal (Refereed)
    Abstract [en]

    Perfectionism may be a clinically relevant problem on its own or as part of the etiology and maintenance of psychiatric disorders, e.g., anxiety disorders, depression, and eating disorders. Cognitive behavior therapyhas been shown to be a promising treatment for managing perfectionism and its associated problems, including when being administered via the Internet, i.e., Internet-based cognitive behavioral therapy (ICBT). In the current study, seventy-eight self-referred participants underwent ICBT after an initial eight-week wait-list period, i.e., second wave of treatment. These were randomized to receive regular support from a therapist (ICBT-support) or ICBT with support on request (ICBT-request), in an eight-week treatment of perfectionism. Assessments of perfectionism were made at pre-, mid-, and post-treatment, as well as six-month follow-up, using the Frost Multidimensional Perfectionism Scale, subscale Concern over Mistakes. Mixed effects models revealed large symptom reductions for both conditions; Concern over Mistakes, Cohen's d = 1.40, 95% Confidence Interval (CI) [0.85, 1.95] for ICBT-support, and d = 1.00, 95% CI [0.51, 1.47] for ICBT-request. The effects were maintained at six-month follow-up and there were no differences between the conditions in terms of the results, opened modules, or completed exercises. A total of 28 out of 70 participants (42.4%; ICBT-support, 37.8%; ICBT-request) were classified as improved at post-treatment. Both types of ICBT may thus be beneficial in treating perfectionism, suggesting that just having the opportunity to ask for support from a therapist, when regular support is not provided, could be sufficient for many participants undergoing ICBT. However, the study was underpowered to detect differences between the conditions. The lack of a cutoff also makes it difficult to differentiate a dysfunctional from a functional population in terms of perfectionism. In addition, the study design could have affected the participants' motivational level from start, given their initial eight-week wait-list period. Recommendations for future studies include recruiting a larger sample size, a clearer cutoff for perfectionism, and the use of a non-inferiority test with a predetermined margin of change.

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