The influence of organizational models on the implementation of internet-based cognitive behavior therapy in primary care: A mixed methods study using the RE-AIM framework.

Background: Internet-Based Cognitive Behavioral Therapy (iCBT) holds great potential in addressing mental health issues, yet its real-world implementation poses significant challenges. While prior research has predominantly focused on centralized care models, this study explores the implementation of iCBT in the context of decentralized organizational structures within the Swedish primary care setting, where all interventions traditionally are delivered at local Primary Care Centers (PCCs). Aim: This study aims to enhance our understanding of iCBT implementation in primary care and assess the impact of organizational models on the implementation's outcome using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Method: A mixed-methods research design was employed to identify the factors influencing iCBT implementation across different levels, involving patients, therapists and managers. Data spanning two years was collected and analyzed through thematic analysis and statistical tests. The study encompassed 104 primary care centers, with patient data (n = 1979) sourced from the Swedish National Quality Register for Internet-Based Psychological Treatment (SibeR). Additionally, 53 iCBT therapists and 50 PCC managers completed the Normalization Measure Development Questionnaire, and 15 leaders participated in interviews. Results: Our investigation identified two implementation approaches, one concentrated and one decentralized. Implementation effectiveness was evident through adherence rates suggesting that iCBT is a promising approach for treating mental ill-health in primary care, although challenges were observed concerning patient assessment and therapist drift towards unstructured treatment. Mandatory implementation, along with managerial and organizational support, positively impacted adoption. Results vary in terms of adherence to established protocols, with therapists working in concentrated model showing a significantly higher percentage of registration in the quality register SibeR (X2 (1, N = 2973) = 430.5774, p = 0.001). They also showed significantly higher means in cognitive participation (Z = -2.179, p = 0.029) and in reflective monitoring (Z = -2.548, p = 0.011). Discussion: Overall, the study results demonstrate that iCBT, as a complex and qualitatively different intervention from traditional psychological treatment, can be widely implemented in primary care settings. The study's key finding highlights the substantial advantages of the concentrated organizational model. This model has strengths in sustainability, encourages reflective monitoring among therapists, the use of quality registers, and enforces established protocols. Conclusion: In conclusion, this study significantly contributes to the understanding of the practical aspects associated with the implementation of complex internet interventions, particularly in the context of internet-based cognitive-behavioral therapy (iCBT). The study highlights that effective iCBT integration into primary care requires a multifaceted approach, taking into account organizational models, robust support structures, and a commitment to maintaining quality standards. By emphasizing these factors, our research aims to provide actionable insights that can enhance the practicability and real-world applicability of implementing iCBT in primary care settings.

Facing a new life-The healthy transition to motherhood: What individual and environmental factors are needed? A phenomenological-hermeneutic study.

OBJECTIVE: The aim of the study was to highlight first-time mothers' experiences of the transition to motherhood uncovering personal and environmental conditions facilitating or preventing the process of a healthy transition in a Swedish context. DESIGN: A qualitative study with interview data analyzed using a phenomenological hermeneutic method. SETTING AND PARTICIPANTS: Ten recent first-time mothers were selected from three primary healthcare centers in western Sweden. FINDINGS: Four themes emerged, and the transition could be divided into several phases, interpreted as facing a new life, while feeling unprepared for identity and existential issues. The experience of becoming a mother was described as oscillation between a loss of former identity from previous life, and on the other hand, the joy and expectations of forming a new family. The mothers had high demands of themselves, often influenced by social media and needed to value the flow of information and `let go of control` to be able to make adequate decisions. The close family of origin was invaluable in this process being able to provide confirmation in the new role, facilitating the development of their own security and self-confidence. KEY CONCLUSIONS: The vulnerability expressed by new mothers shows that support from the family of origin, partners and professionals are indispensable. The desired result after the transition to motherhood is a prosperous, maturity and confident mother. The main promoting factor in this process seems to be having a safe base that can provide required support. IMPLICATIONS FOR PRACTICE: The level of wellbeing after the transition is crucial and the possibility of a warm, responsive and secure parenting needs to be strengthened. The challenge to preventive health care will be to identify a lack of support and ensure that these mothers gain sufficient support to meet today´s demands and still feel that they are good enough mothers for their children.

Conceptualising migraine attacks from a biopsychosocial model using qualitative and functional behavioural analysis.

OBJECTIVE: The aim of this study was to explore patients' experiences and management of pain in connection with a migraine attack in episodic migraine. DESIGN, SETTING AND SUBJECTS: This qualitative study used a semi-structured interview format based on functional behavioural analysis as commonly used in cognitive behavioural therapy. We interviewed eight participants and analysed their responses using systematic text condensation. RESULTS: Participants' descriptions of their experiences and management of pain from episodic migraine were sorted into three description First physical sensations, Automatic reactions and Acts according to the interpretation. CONCLUSION: From a biopsychosocial perspective, a migraine attack is much more complex than just an experience of pain. The purely biological pain prompts a number of automatic reactions leading to strategies for pain management.

Functional behavioural analysis can increase our understanding of experiences during a migraine attack from a biopsychosocial pain perspective.Several pain mechanisms appear to be relevant during the experience of a migraine attack than are described in the diagnostic criteria for migraine.Pain management consists of a chain of behaviours, approaches to the migraine attack and medication and the consequences of pain management.Knowledge and understanding of patients' experiences of pain and pain management during a migraine attack is an important tool in the biopsychosocial model.

Effectiveness of and processes related to internet-delivered acceptance and commitment therapy for adolescents with anxiety disorders: a randomized controlled trial.

Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on theoretically derived and empirically tested key mechanisms in treatment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexibility and treatment outcomes and the relationship between participating adolescents' and therapists' perceived alliance and treatment outcomes. This was a randomized controlled trial comparing a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participating adolescents and therapists but showed no significant relationship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts.

Correction: Youths' and Parents' Experiences and Perceived Effects of Internet-Based Cognitive Behavioral Therapy for Anxiety Disorders in Primary Care: Mixed Methods Study.

[This corrects the article DOI: 10.2196/26842.].

Youths' and Parents' Experiences and Perceived Effects of Internet-Based Cognitive Behavioral Therapy for Anxiety Disorders in Primary Care: Mixed Methods Study.

BACKGROUND: Anxiety is common among youths in primary care. Face-to-face treatment has been the first choice for clinicians, but during the COVID-19 pandemic, digital psychological interventions have substantially increased. Few studies have examined young people's interest in internet treatment or the attitudes they and their parents have toward it. OBJECTIVE: This study aims to investigate adolescents' and parents' attitudes toward and experiences of internet-based cognitive behavioral anxiety treatment in primary care and its presumptive effects. METHODS: The study used mixed methods, analyzing qualitative data thematically and quantitative data with nonparametric analysis. Participants were 14 adolescents and 14 parents recruited in adolescent primary health care clinics. The adolescents and their parents filled out mental health questionnaires before and after treatment, and were interviewed during ongoing treatment. RESULTS: The quantitative data indicated that the internet-delivered cognitive behavioral therapy program used in this study was successful in reducing symptoms (χ22=8.333; P=.02) and that adolescents' motivation is essential to the treatment outcome (r=0.58; P=.03). The qualitative results show that youths highly value their independence and freedom to organize treatment work on their own terms. The parents expressed uncertainty about their role and how to support their child in treatment. It was important for parents to respect the youths' need for autonomy while also engaging with them in the treatment work. CONCLUSIONS: Internet treatment in primary care is accepted by both youths and their parents, who need clarification about the difference between their role and the therapist's role. Patient motivation should be considered before treatment, and therapists need to continue to develop the virtual alliance. Finally, primary care should be clearer in informing adolescents and their parents about the possibility of internet treatment.

Effects of patient-driven iCBT for anxiety in routine primary care and the relation between increased experience of empowerment and outcome: A randomized controlled trial.

BACKGROUND: The World Health Organization has declared that primary care should be organized to empower individuals, families, and communities to optimize health. Internet cognitive behavioral therapy (iCBT) tailored by psychologists' initial assessments to meet patients' specific needs have shown promising effects. However, few studies have evaluated patient involvement in decisions during iCBT. AIM: This study aimed to explore the effect of patient-driven iCBT compared to standard iCBT on perceived control over treatment, adherence, and level of anxiety symptoms. A secondary aim was to assess the relationship between changes in empowerment and changes in anxiety symptoms. METHOD: Participants were patients recruited form primary care and assessed as meeting the criterion for an anxiety disorder. Participants were randomized to patient-driven iCBT (n = 27) or standard iCBT (n = 28). Patient-driven iCBT was adapted to participants' preferences regarding for example focus of treatment program and order of modules. Participants randomized to the control condition received the standard iCBT program for anxiety disorders at the participating unit. The outcome measures were patients' perceived control over treatment, adherence to treatment, symptoms of anxiety, depression and general disability as well as the experience of empowerment. RESULTS: Participants in patient-driven iCBT had statistically higher perceived control over treatment (t(43) = 2.13, p = .04). Symptoms were significantly reduced in both arms with regards to anxiety, depression, and general disability. A significant time per condition interaction effect for anxiety symptoms was observed (df = 45.0; F = 3.055; p = .038), where the patient-driven condition had a significantly larger reduction in anxiety. For both groups a significant correlation of r = -0.47 was found between changes in empowerment and changes in anxiety. CONCLUSION: Results indicate that iCBT that is patient-driven, may have a greater effect on anxiety, than standard iCBT. The effect on perceived control over treatment might also be larger in patient-driven treatments than in standard iCBT. Internet-based therapies inherently promote as active agents of their own care and might be well suited for promoting perceived control and empowerment. Findings need to be replicated given the small sample size and the explorative nature of the study. CLINICAL TRIALS REGISTRATION: NCT04688567.

Transitioning from face-to-face treatment to iCBT for youths in primary care - therapists' attitudes and experiences.

BACKGROUND: To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care. METHODS: Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories. RESULTS: The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist. CONCLUSION: The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists' positive experiences support the introduction of iCBT for youths in routine primary care.

Primary Care Peer-Supported Internet-Mediated Psychological Treatment for Adults With Anxiety Disorders: Mixed Methods Study.

BACKGROUND: The effect of internet-delivered cognitive behavioral therapy (iCBT) on anxiety in adults is well-known. However, patient dropouts and poor adherence to treatment are common. Feelings of belonging and empowerment from the treatment might be key to the completion of iCBT. Peer support workers are people with a personal experience of mental health problems, trained to provide professional support to people who require mental health care. OBJECTIVE: This study aims to assess patient experiences; the feasibility, safety, and acceptability; and preliminary effectiveness on anxiety and depression, empowerment, and adherence to treatment in an 8-week peer-supported iCBT program for patients with anxiety disorders treated in primary care. METHODS: This was a single-arm mixed methods feasibility study. Participants were patients referred to a central unit for iCBT in primary care. Quantitative data were collected pre-, post-, and 3 months postintervention. Qualitative data were collected through semistructured interviews. RESULTS: A total of 9 participants completed the quantitative outcome assessment. Statistically significant improvements were observed in perceived empowerment at a 3-month follow-up, and significant decreases in anxiety, depression, and psychological distress at the end of the treatment were maintained at a 3-month follow-up. In total, 8 of the 9 patients showed improvement in the severity of their symptoms of anxiety. Adherence to treatment was good among the participants. No serious adverse events were reported. Eight participants were enrolled in the qualitative analysis. The qualitative results showed 3 main themes: (1) real contact in an online world, (2) empowering experiences, and (3) being behind the wheel. Qualitative results largely emphasized the personal relationship and supported the acceptability of adding peer support to iCBT. CONCLUSIONS: Peer support in digital treatment seems to be a safe and acceptable intervention. The preliminary results suggest the effectiveness of peer support on patient empowerment, anxiety, depression, psychological distress, and adherence to treatment. The results indicate the need for future studies to evaluate the effect of adding peer support to iCBT in larger randomized controlled trials.

Psychometric properties and validation of the Swedish Five Facet Mindfulness Questionnaire in a clinical and non-clinical sample among meditators and non-meditators.

Over a period of 15 years several attempts to conceptualize mindfulness have been presented and revised, but there is still no clear or agreed-upon definition. The use of mindfulness-based interventions has increased in clinical and research settings the last couple of years, including in Sweden. As a clinician it is crucial to know if a treatment works through the theoretically postulated mechanisms of change. Mindfulness is a concept that is difficult to measure. The overall aim of the current project was to examine the psychometric properties of the Swedish version of the Five Facet Mindfulness Questionnaire (FFMQ_SWE) using three different studies. To test the construct validity of the FFMQ_SWE a hierarchal confirmatory factor analysis was performed in a meditating non-clinical sample, to examine if all the five facets would load on an overall mindfulness construct. Psychometric properties of the instrument were examined in a non-clinical and a clinical sample, and discriminative relationships with other variables were analysed. The convergent validity was examined by analysing the correlations between FFMQ_SWE and Hospital Anxiety and Depression Scale, Sense of Coherence and Difficulties in Emotion Regulation Scale. Test-retest reliability was tested by distributing FFMQ_SWE at two occasions. The hierarchal confirmatory factor analysis showed good fit in a population of meditators. The FFMQ_SWE showed good convergent validity and test-retest reliability in both clinical and non-clinical populations. In sum, the Swedish version of the FFMQ showed good psychometric properties and can be a useful instrument as an evaluation of treatment effects in both health care settings and research settings.

A preliminary validation of the Swedish version of the Pain Catastrophizing Scale for Children (PCS-C) for children and adolescents with cancer.

Objectives: Pain is reported as one of the most common and difficult symptoms for children and adolescents with cancer to cope with. Pain catastrophizing has been identified as a process clearly related to pain intensity and disability. The Pain Catastrophizing Scale for Children (PCS-C) has been validated in several languages and populations but remains to be validated in pediatric oncology. The aim of the study was to validate a Swedish version of the PCS-C for children and adolescents with cancer. Methods: All children, 7-18 years of age, being treated for cancer in Sweden at the time of the study were invited to participate. Study material was sent out to the registered address. Internal consistency, test-retest reliability and convergent validity were calculated. Factor structure was examined using principal component analysis (PCA). Descriptive statistics were used to investigate background data and norm values. Results: 61 children/adolescents were included in the analyses. The results did not support the original three-factor structure of the PCS-C, but rather suggested that a two-factor structure excluding item 8 best represented the data. The internal consistency of that solution was good (α=0.87), the test-rest reliability was excellent (ICC=0.75) and convergent validity was demonstrated (r=0.46). The mean (SD) for the PCS-C in the sample was 19.1 (9.2), without item 8. A statistically significant difference was shown between genders, where girls reported a higher level of pain catastrophizing than boys. No difference was found with regard to age. Discussion: The Swedish version of the PCS-C is now preliminarily validated for children and adolescents with cancer, for whom gender- and age-specific norm values are now available. Questions remain regarding the optimal factor structure of the PCS-C.

Validation of the Swedish version of the Pain Catastrophizing Scale for Parents (PCS-P) for parents of children with cancer.

OBJECTIVES: Pain is reported as one of the most common and burdensome symptoms for children with cancer. Pain catastrophizing is clearly related to pain intensity and disability. Catastrophizing in parents is associated with both child functioning and parent distress. The Pain Catastrophizing Scale for Parents (PCS-P) remains to be validated for parents of children with cancer. The aim of the study was to validate the Swedish version of the PCS-P for parents of children with cancer experiencing pain. METHODS: Parents of all children who were being treated for cancer in Sweden at the time of the study were invited to participate. Study material was sent out to the registered address. Internal consistency, test-retest reliability, and convergent validity were calculated, and factor analysis was conducted. Descriptive statistics was used to investigate the background data and norm values. RESULTS: A total of 243 parents participated in the study. The results did not support the original three-factor structure of the PCS-P, but rather suggested that a two-factor structure best represented the data. The results showed excellent internal consistency (a=0.93), excellent temporal stability (intraclass correlation coefficient =0.86) and moderate convergent validity (r=0.57). The mean (SD) for the PCS-P in the sample was 28.3 (10.7). A statistically significant difference was found between mothers and fathers, where mothers reported a higher level of pain catastrophizing than fathers. CONCLUSION: The psychometric properties of the PCS-P has now been supported in a sample of parents of children with cancer, and norm values are now available. The factor structure does, however, deserve more investigation.

Internet-based acceptance and commitment therapy for psychological distress experienced by people with hearing problems: a pilot randomized controlled trial.

Psychological distress is common among people with hearing problems, but treatments that specifically target this aspect have been almost non-existent. In this pilot randomized controlled trial, an eight-week long Internet-based treatment, informed by Acceptance and Commitment Therapy, was administered to explore the feasibility and efficacy of such a treatment. Included participants were randomized to either treatment (n = 31) or wait-list control (n = 30) condition. All participants were measured prior to randomization and immediately after treatment ended using standardized self-report instruments measuring hearing-related emotional and social adjustment (Hearing Handicap Inventory for the Elderly - S, HHIE-S), quality of life (Quality of Life Inventory, QOLI), and symptoms of depression and anxiety (Patient health Questionnaire, PHQ-9 and Generalized Anxiety Disorder scale, GAD-7). Linear mixed effects regression analysis using the full intention-to-treat sample demonstrated that the treatment had superior outcomes on the main outcome measure as compared with the control group, Cohen's d = 0.93, 95% CI [0.24, 1.63]. The benefits of treatment over control were also evident in scores of depression, Cohen's d = 0.61, 95% CI [0.04, 1.19], and quality of life, Cohen's d = 0.88, 95% CI [0.14, 1.61]. The results provide preliminary support for Internet-delivered acceptance and commitment therapy as a potentially effective treatment of psychological symptoms associated with hearing problems.

Bridging the Gap Between Hearing Screening and Successful Rehabilitation: Research Protocol of a Randomized Controlled Trial of Motivational Interviewing via Internet.

PURPOSE: Studies point to low help-seeking after a failed hearing screening. This research forum article presents the research protocol for a randomized controlled trial of motivational interviewing via the Internet to promote help-seeking in people who have failed an online hearing screening. METHOD: Adults who fail a Swedish online hearing screening, including a speech-in-noise recognition test, will be randomized to either an intervention group (participating in motivational interviewing) or an active control group (reading a book on history of hearing aids). Both of the conditions will be delivered via the Internet. The primary outcome is experience with seeking health care and using hearing aids 9 months after the intervention. Secondary outcomes are changes in before and after measures of self-reported hearing difficulties, anxiety, depression, and quality of life. Stages of change and self-efficacy in hearing help-seeking are measured immediately after intervention and at a 9-month follow-up for the purpose of mediation analysis. RESULTS: The results of this randomized controlled trial may help bridge the gap between hearing screening and successful hearing rehabilitation. CONCLUSION: Although no large instantaneous benefits are expected, a slow change toward healthy behaviors­seeking health care and using hearing aids­would shed light on how to use the Internet to assist people with hearing impairment.

Internet-Based Acceptance and Commitment Therapy for Psychological Distress Experienced by People With Hearing Problems: Study Protocol for a Randomized Controlled Trial.

PURPOSE: Psychological distress and psychiatric symptoms are prevalent among people with hearing loss or other audiological conditions, but psychological interventions for these groups are rare. This article describes the study protocol for a randomized controlled trial for evaluating the effect of a psychological treatment delivered over the Internet for individuals with hearing problems and concurrent psychological distress. METHOD: Participants who are significantly distressed will be randomized to either an 8-week Internet-delivered acceptance-based cognitive behavioral therapy (i.e., acceptance and commitment therapy [ACT]), or wa it-list control. We aim to include measures of distress associated with hearing difficulties, anxiety, and depression. In addition, we aim to measure acceptance associated with hearing difficulties as well as quality of life. CONCLUSION: The results of the trial may further our understanding of how to best treat people who present problems with both psychological distress and hearing in using the Internet.

Measuring experiential avoidance in a bariatric surgery population--psychometric properties of AAQ-W.

BACKGROUND: Valid measures capturing underlying psychological processes post surgery for obesity are needed to help identify important clinical targets and develop psychosocial interventions in conjunction with surgery. The Acceptance and Action Questionnaire for Weight (AAQ-W) measures experiential avoidance and has never been evaluated in a bariatric surgery population. METHOD: Participants were recruited at a bariatric surgery clinic during follow-up care. The evaluation of psychometric properties of AAQ-W was done by repeated measurements of reliability (n = 62), convergent validity (n = 75 and n = 178), predictive validity (n = 61), factor analysis and calculation of internal consistency (n = 178). RESULTS: The AAQ-W was found to have satisfactory psychometric properties. Internal consistency was high (α = .86). Results showed good stability over time (r = .77) and validity coefficients ranging from r = .36 to .71. AAQ-W scores measured six months post surgery predicted satisfaction with life, negative emotional states, emotional eating and general eating pathology measured one year post surgery. However AAQ-W measured at six months did not predict percent excess BMI Loss at one year. Factor analysis showed that a five factor solution (Food as Control, Body Acceptance, Self-Stigma, Self-Efficacy and Emotional Avoidance) might be a good fit (n = 178). CONCLUSION: This study shows that the AAQ-W appears to be a psychometrically sound measure that can be used by researchers and clinicians in the context of bariatric surgery.

Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT.

SUMMARY: Bariatric surgery (BS) is rated as the best evidence based treatment for obesity with regard to weight loss and maintenance of weight loss evaluated to date. Although BS interventions are effective, 20-30% of BS patients start to regain weight within 24 months. Emotional eating is a behavior pattern which has been found to predict poor outcome. The aim of this study is to evaluate the effects of acceptance and commitment therapy (ACT) for patients who underwent BS, with regard to emotional eating, body dissatisfaction and quality of life. This study is a randomized controlled trial (n = 39) with two conditions (1) ACT including two face-to-face sessions and support via an Internet application and (2) treatment as usual (TAU) comprising the standard follow-up used by the BS team. Results show that participants in the ACT condition significantly improve on eating disordered behaviors, body dissatisfaction, quality of life and acceptance for weight related thoughts and feelings, as compared to those in the TAU group. This study shows that it is possible to improve effects of BS by specifically targeting emotional eating behavior.: