Early symptom improvement and other clinical predictors of response to repetitive transcranial magnetic stimulation for depression.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is a rapidly emerging treatment for depression, but outcome prediction is still a challenge. This study aimed to identify predictors of response to rTMS among baseline clinical factors and early symptomatic improvements. METHODS: This cohort study comprised 136 patients with a unipolar or bipolar depressive episode referred for clinical intermittent theta-burst stimulation or right-sided 1 Hz rTMS at the Uppsala Brain Stimulation Unit. The co-primary outcomes used for logistic regression were response, defined as ≥50 % reduction of Montgomery and Åsberg Depression Rating Scale Self-assessment (MADRS-S) total score, and 1-2 points on the Clinical Global Impression Improvement (CGI-I) scale. Early improvement was defined as ≥20 % reduction in the MADRS-S total score, or ≥ 1 point reduction in each MADRS-S item, after two weeks of treatment. RESULTS: The response rates were 21 % for MADRS-S and 45 % for CGI-I. A depressive episode >24 months had lower odds for MADRS-S response compared to ≤12 months. Early improvement of the MADRS-S total score predicted CGI-I response (95 % CI = 1.35-9.47, p = 0.011), Initiative6 predicted MADRS-S response (95 % CI = 1.08-9.05, p = 0.035), and Emotional involvement7 predicted CGI-I response (95 % CI = 1.03-8.66, p = 0.044). LIMITATIONS: No adjustment for concurrent medication. CONCLUSIONS: A depressive episode ≤12 months and early improvement in overall depressive symptoms, as well as the individual items, Initiative6 and Emotional involvement7, predicted subsequent rTMS response in a naturalistic sample of depressed patients. This could facilitate the early identification of patients who will benefit from further rTMS sessions.

The Swedish version of the Motivation and Pleasure Scale self-report (MAP-SR): psychometric properties in patients with schizophrenia or depression.

PURPOSE: Negative symptoms are commonly regarded as a symptom dimension belonging to schizophrenia spectrum disorders but are also present in depression. The recently developed Clinical Assessment Interview for Negative Symptoms (CAINS) has shown to be reliable and valid. A corresponding self-report questionnaire has also been developed, named the Motivation and Pleasure Scale - Self Report (MAP-SR). The purpose was to evaluate the psychometric properties of the Swedish version of the MAP-SR in patients with either schizophrenia or depression. MATERIALS AND METHODS: The MAP-SR was translated to Swedish. Participants were 33 patients with schizophrenia spectrum disorders and 52 patients with a depressive disorder and they completed the MAP-SR, the CAINS and other measures assessing adjacent psychopathology, functioning and cognition. RESULTS: The internal consistency for the MAP-SR was adequate in both groups (schizophrenia spectrum α = .93, depressive disorder α = .82). Furthermore, the MAP-SR had a large correlation to the motivation and pleasure subscale of the CAINS in patients with schizophrenia disorders (r = -0.75, p < .001), however among patients with depression this correlation was medium-to-large (r = -0.48, p < 0.001). CONCLUSIONS: Findings suggest that the Swedish version of the MAP-SR shows promise as a useful measure of motivation and pleasure, especially in patients with schizophrenia spectrum disorders. Furthermore, results also suggest that the MAP-SR does not assess negative symptoms specifically, but that there is an overlap between depressive and negative symptoms.

Cognitive Function and Variability in Antipsychotic Drug-Naive Patients With First-Episode Psychosis: A Systematic Review and Meta-Analysis.

Importance: Cognitive impairment contributes significantly to clinical outcome and level of function in individuals with psychotic disorders. These impairments are present already at psychosis onset at a group level; however, the question of heterogeneity in cognitive function among patients has not been systematically investigated. Objective: To provide an updated quantification of cognitive impairment at psychosis onset before patients receive potentially confounding antipsychotic treatment, and to investigate variability in cognitive function compared with healthy controls. Data Sources: In this systematic review and meta-analysis, PubMed articles were searched up to September 15, 2022. Study Selection: Original studies reporting data on cognitive function in antipsychotic drug-naive patients with first-episode psychosis (FEP) were included. Data Extraction and Synthesis: Data were independently extracted by 2 researchers. Cognitive tasks were clustered according to 6 domains of the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery and the domain of executive function. Random-effects model meta-analyses of mean differences and coefficient of variation ratios (CVRs) were performed, as well as meta-regressions, assessment of study quality, and publication bias. Main Outcomes and Measures: The main outcome measure was Hedges g for mean differences in cognition and CVR for within-group variability. Results: Fifty studies were included in the analysis with a total of 2625 individuals with FEP (mean [SD] age, 25.2 [3.6] years, 60% male; 40% female) and 2917 healthy controls (mean [SD] age, 26.0 [4.6]; 55% male; 45% female). In all cognitive domains, the FEP group displayed significant impairment compared with controls (speed of processing: Hedges g = -1.16; 95% CI, -1.35 to -0.98; verbal learning: Hedges g = -1.08; 95% CI, -1.28 to -0.88; visual learning: Hedges g = -1.05; 95% CI, -1.27 to -0.82; working memory: Hedges g = -1.04; 95% CI, -1.35 to -0.73; attention: Hedges g = -1.03; 95% CI, -1.24 to -0.82; reasoning/problem solving: Hedges g = -0.90; 95% CI, -1.12 to -0.68; executive function: Hedges g = -0.88; 95% CI, -1.07 to -0.69). Individuals with FEP also exhibited a larger variability across all domains (CVR range, 1.34-1.92). Conclusions and Relevance: Results of this systematic review and meta-analysis identified cognitive impairment in FEP before the initiation of antipsychotic treatment, with large effect sizes. The high variability within the FEP group suggests the need to identify those individuals with more severe cognitive problems who risk worse outcomes and could benefit the most from cognitive remediation.

Psychometric properties of the Clinical Assessment Interview for Negative Symptoms (CAINS) in patients with depression and its relationship to affective symptoms.

BACKGROUND: There is a conceptual overlap between negative and depressive symptoms, requiring further exploration to advance the understanding of negative symptoms. The aim of this study was to examine psychometric properties of the Clinical Assessment Interview for Negative Symptoms (CAINS) in patients with depression, and to explore the relationship between the negative and affective symptoms domains. METHODS: Fifty-one patients with a depressive episode were included and interviewed with the CAINS and the Brief Psychiatric Rating Scale-Expanded (BPRS-E). Self-reported depressive symptoms were collected with the Montgomery-Asberg Depression Rating Scale (MADRS-S). Inter-rater agreement, internal consistency and validity measures were examined, as were correlations between negative and affective symptoms. RESULTS: The intraclass correlation for the CAINS motivation and pleasure subscale (CAINS-MAP) was 0.98 (95% CI 0.96-0.99) and that for the expressional subscale (CAINS-EXP) was 0.81 (95% CI 0.67-0.89). Cronbach's alpha was 0.71 (95% CI 0.57-0.82) for the CAINS-MAP and 0.86 (95% CI 0.79-0.92) for the CAINS-EXP. The correlation with the negative symptoms subscale of the BPRS-E was 0.35 (p = 0.011, blinded/different raters) or 0.55 (p < 0.001, not blinded/same rater). The CAINS-MAP correlated with the affective symptoms subscale of the BPRS-E (r = 0.39, p = 0.005) and the MADRS-S total score (r = 0.50, p < 0.001), but not with anxiety symptoms. CONCLUSIONS: Negative symptoms in depression can be assessed with the CAINS with good inter-rater agreement and acceptable internal consistency and validity. There are associations between negative and depressive symptoms that call for further exploration.

Longitudinal follow-up of the randomized controlled trial of access to the trauma-focused self-management app PTSD Coach.

Apps that target posttraumatic stress are rarely evaluated and long-term examination of symptom change is rare. In a waitlist-controlled randomized controlled trial, we found that the Swedish version of the self-management app PTSD Coach confers benefits on posttraumatic stress and depressive symptoms after three months use. Here, we aimed to evaluate between-group effects on functional disability as well as within-group changes on mental health, somatic illness and functional disability after access to the Swedish PTSD Coach app during 9 months. In addition, we described negative effects, helpfulness and satisfaction with the app. Among the 179 trauma-exposed adults (92 % women) randomized to instant access or delayed access to PTSD Coach, symptoms of posttraumatic stress, depression, somatic illness and functional disability decreased and were maintained within 3 to 9 months of app access. Posttraumatic stress continued to improve during follow-up. PTSD Coach was considered slightly to moderately helpful and satisfactory and 43 % reported any negative effect related to using the app. PTSD Coach is an effective self-management intervention for trauma-related distress. Future research should investigate mechanisms of change, as well as individual characteristics that predict symptom reduction after access to PTSD Coach in order to inform clinical practice.

Correction: Efficacy, Benefits, and Harms of a Self-management App in a Swedish Trauma-Exposed Community Sample (PTSD Coach): Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/31419.].

Efficacy, Benefits, and Harms of a Self-management App in a Swedish Trauma-Exposed Community Sample (PTSD Coach): Randomized Controlled Trial.

BACKGROUND: Self-guided interventions may complement and overcome obstacles to in-person treatment options. The efficacy of app interventions targeting posttraumatic stress disorder (PTSD) is unclear, and results from previous studies on PTSD Coach-an app for managing trauma-related distress-are inconsistent. OBJECTIVE: This study investigates whether access to the Swedish version of the PTSD Coach affects posttraumatic stress, depressive, and somatic symptoms. In addition, we aim to assess the perceived helpfulness, satisfaction, negative effects, response, and remission related to PTSD Coach. METHODS: Adults who had experienced potentially traumatic events in the past 2 years were randomized (1:1) to have access to PTSD Coach (n=89) or be on the waitlist (n=90). We assessed clinical characteristics at baseline (semistructured interviews and self-rating scales) and after 3 months (self-rating scales). We analyzed the data in R software using linear mixed effects models, chi-square tests, and Fisher exact test. RESULTS: Intention-to-treat analyses indicated that access to PTSD Coach decreased posttraumatic stress and depressive symptoms but not somatic symptoms. More participants who had access to PTSD Coach responded with clinically significant improvement and fewer instances of probable PTSD after 3 months compared with waitlist controls. Overall, participants found that PTSD Coach was slightly to moderately helpful and moderately satisfactory. Half of the intervention group (36/71, 51%) reported at least one negative reaction related to using PTSD Coach (eg, disappointment with the app or its results, arousal of stress, or distressing memories). CONCLUSIONS: Using PTSD Coach may trigger symptoms among a few users; however, most of them perceived PTSD Coach as helpful and satisfactory. This study showed that having access to PTSD Coach helped improve psychological trauma-related symptoms. In addition, we have discussed implications for future research and clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT04094922; https://clinicaltrials.gov/ct2/show/NCT04094922.

A blinded validation of the Swedish version of the Clinical Assessment Interview for Negative Symptoms (CAINS).

PURPOSE: The Clinical Assessment Interview for Negative Symptoms (CAINS) was developed in order to advance the assessment of negative symptoms. The aim of this study was to validate the Swedish version of the CAINS. MATERIALS AND METHODS: Thirty-four out-patients with a schizophrenia spectrum disorder were recruited. All patients were videotaped while interviewed with the CAINS and the Brief Psychiatric Rating Scale (BPRS). Another rater watched the video recordings in the reverse order, enabling a blinded design. The patients also filled in self-reported measures of depression, quality of life, and social and vocational functioning. We calculated inter-rater agreement and internal consistency for the CAINS. We also calculated validity measures by correlating the subscales Motivation and Pleasure (CAINS-MAP) and Expression (CAINS-EXP) to subscales of the BPRS. RESULTS: The blinded inter-rater agreement for the CAINS total score was high (ICC = 0.92) but slightly lower for the expression subscale (ICC = 0.76). Cronbach's alpha was 0.84 for the total score. Convergent validity with the negative symptoms subscale of BPRS was different for the blinded and the unblinded data, with a CAINS-MAP correlation of 0.10 (p = 0.580) and a CAINS-EXP correlation of 0.48 (p = 0.004) in the blinded data. The unblinded data had a CAINS-MAP correlation of 0.38 (p = 0.026) and a CAINS-EXP correlation of 0.87 (p < 0.001). Self-rated measures of anhedonia correlated to CAINS-MAP with a coefficient of 0.68 (p < 0.001), while the CAINS-EXP only had a correlation of 0.16 (p = 0.366) to these measures. CONCLUSION: The Swedish version of the CAINS displays adequate psychometric properties in line with earlier validation studies.

Ecological momentary assessment of self-rated health, daily strategies and self-management app use among trauma-exposed adults.

Background: The process whereby trauma-exposed people benefit from self-management apps to increase health is poorly understood. Objective: We investigated whether access to a self-management smartphone app for posttraumatic stress (PTSD Coach) improved momentary self-rated health (SRH) and if use of a self-management app or specific strategies related to SRH. Method: Participants were 179 adults in Sweden with trauma exposure in the past 2 years who were enrolled in a randomized trial of PTSD Coach versus waitlist. Ecological momentary assessments (EMA) were collected twice daily during 21 consecutive days from participants in both groups, with questions about momentary SRH as well as self-management app use and use of strategies (social support, distress management, monitoring of discomfort and seeking information) in the preceding 12 hours. Results: Overall, neither access to PTSD Coach nor reported use of an app in the preceding hours was related to SRH. Even so, people with access to PTSD Coach reported using more social support over time. Socializing and use of social support predicted greater SRH. Use of other strategies was associated with worse short-term SRH. Conclusions: Momentarily improved health relates to utilization of social support. However, the directionality of the day-to-day associations is unclear; uncertainty remains around the timing for assessing these relationships.

Antecedentes: El proceso por el cual las personas expuestas al trauma se benefician de las aplicaciones de autogestión para mejorar la salud es poco conocido.Objetivo: Investigamos si el acceso a una aplicación de autogestión para teléfonos inteligentes, para el estrés postraumático (PTSD Coach) mejora la salud autoevaluada del momento (SRH en su sigla en inglés) y si el uso de una aplicación de autogestión o estrategias específicas se relacionan con la SRH.Método: Los participantes fueron 179 adultos en Suecia con exposición a trauma en los últimos dos años que se inscribieron en un ensayo aleatorio de PTSD Coach versus lista de espera. Las evaluaciones ecológicas momentáneas (EMA en su sigla en inglés) se recopilaron dos veces al día durante 21 días consecutivos en los participantes de ambos grupos, con preguntas sobre SRH del momento, así como el uso de aplicaciones de autogestión y el uso de estrategias (apoyo social, manejo del estrés, monitoreo del malestar y búsqueda de información) en las 12 horas anteriores.Resultados: En general, ni el acceso a PTSD Coach ni el uso informado de una aplicación en las horas anteriores se relacionaron con la SRH. Aun así, las personas con acceso a PTSD Coach informaron que usaron más apoyo social a lo largo del tiempo. La socialización y el uso del apoyo social predijeron una mayor SRH. El uso de otras estrategias se asoció con peor SRH a corto plazo.Conclusiones: La mejoría en salud del momento se relaciona con la utilización del apoyo social. Sin embargo, la direccionalidad de las asociaciones del día a día no está clara y persiste la incertidumbre sobre el momento para evaluar estas relaciones.

Heeding the psychological concerns of young cancer survivors: a single-arm feasibility trial of CBT and a cognitive behavioral conceptualization of distress.

BACKGROUND: A subgroup of adolescent and young adult (AYA) survivors of cancer during adolescence report high levels of psychological distress. To date, evidence-based psychological interventions tailored to the cancer-related concerns experienced by this population are lacking. The present study aimed to (1) examine the feasibility and preliminary efficacy of an individualized cognitive behavioral therapy (CBT) intervention for AYA survivors of cancer during adolescence; and (2) identify and conceptualize cancer-related concerns as well as maintaining factors using cognitive-behavioral theory. METHODS: A single-arm trial, whereby AYA survivors of cancer during adolescence (aged 17-25 years) were provided individualized face-to-face CBT at a maximum of 15 sessions. Clinical outcomes were assessed at baseline, post-intervention, and three-month follow-up. Intervention uptake, retention, intervention delivery, and reliable change index scores were examined. An embedded qualitative study consisted of two unstructured interviews with each participant pre-intervention. Along with individual behavioral case formulations developed to guide the intervention, interview data was analyzed to identify and conceptualize cancer-related concerns and potential maintaining factors. RESULTS: Ten out of 213 potential participants invited into the study were included, resulting in an overall participation rate of 4.7%. Nine participants completed the intervention, with respectively seven and eight participants completing the post-intervention and three month follow-up assessment. The majority of reported cancer-related concerns and maintaining factors were conceptualized into four themes: social avoidance, fear of emotions and bodily symptoms, imbalance in activity, and worry and rumination. CONCLUSIONS: Given significant recruitment difficulties, further research is required to examine barriers to help-seeking in the AYA cancer survivor population. However, the conceptualization of cancer-related concerns and maintaining factors experienced by the population may represent an important first step in the development of psychological support tailored toward AYA cancer survivors' unique needs.

Trajectories of prolonged grief one to six years after a natural disaster.

BACKGROUND: The long-term trajectories of prolonged grief are poorly understood. The aims were to examine the course of grief among bereaved disaster survivors up to six years post loss and factors predicting worse bereavement outcome. A third aim was to explore differences in grief indicators between trajectories. METHODS: Bereaved Swedish tourists who survived the 2004 Indian Ocean tsunamis responded to surveys including the Inventory of Complicated Grief 1 to 6 years after the disaster. Latent growth mixture modeling was used to identify longitudinal trajectories of grief. Multinomial logistic regression analysis was used to examine predictors of class membership. RESULTS: Three trajectories were identified: resilient (41% of the sample), recovering (48%), and chronic (11%). The strongest predictor of chronic grief was the loss of one's child. When examining grief indicators, the chronic trajectory was characterized by not accepting the loss, while yearning was common in all trajectories. CONCLUSIONS: This study highlights the importance of considering how traumatically bereaved individuals can be affected by loss for several years after a disaster, especially after losing one's child. An inability to accept the loss, more so than yearning, appears to characterize bereaved survivors at risk of a chronic trajectory of grief.

Attitudes and Preferences Toward a Hypothetical Trial of an Internet-Administered Psychological Intervention for Parents of Children Treated for Cancer: Web-Based Survey.

BACKGROUND: Clinical trials are often challenged with issues of recruitment and retention. Little is known concerning general attitudes and preferences toward trial design and willingness to participate among parents of children treated for cancer. Furthermore, willingness to participate in internet-administered psychological interventions remains unexplored. In this study, we examined attitudes and preferences of the population regarding study procedures for a hypothetical trial of an internet-administered psychological intervention. In addition, differences in the response rate between modes of study invitation and willingness to engage in internet-administered interventions were examined. OBJECTIVE: The primary objective of this study was to examine attitudes and preferences toward participating in an internet-administrated psychological intervention. The secondary objective was to examine the response rates and help-seeking behavior among parents of children treated for cancer. METHODS: A cross-sectional, Web-based survey was conducted with parents of children who had completed cancer treatment. This Web-based survey examined self-reported emotional distress, prior help-seeking and receipt of psychological support, past research participation, attitudes toward research, preferences concerning recruitment procedures, and attitudes toward different types of trial design. RESULTS: Of all the parents invited, 32.0% (112/350) completed the survey, with no difference in response rate between modes of study invitation (χ21=0.6, P=.45). The majority (80/112, 71.4%) of parents responded that they had experienced past emotional distress. Responses indicated high (56/112, 50.0%) or somewhat high trust in research (51/112, 45.5%), and the majority of parents would accept, or maybe accept, internet-administered psychological support if offered (83/112, 74.1%). In addition, responses showed a preference for postal study invitation letters (86/112, 76.8%), sent by a researcher (84/112, 75.0%) with additional study information provided on the Web via text (81/112, 72.3%) and video (66/112, 58.9%). Overall, parents responded that trials utilizing a waiting list control, active alternative treatment control, or a patient-preference design were acceptable. CONCLUSIONS: Parents of children treated for cancer appear willing to participate in trials examining internet-administered psychological support. Findings of this study will inform the design of a feasibility trial examining internet-administered psychological support for the population.

PTSD Coach around the world.

Posttraumatic stress disorder (PTSD) is a global public health problem. Unfortunately, many individuals with PTSD do not receive professional care due to a lack of available providers, stigma about mental illness, and other concerns. Technology-based interventions, including mobile phone applications (apps) may be a viable means of surmounting such barriers and reaching and helping those in need. Given this potential, in 2011 the U.S Veterans Affairs National Center for PTSD released PTSD Coach, a mobile app intended to provide psycho-education and self-management tools for trauma survivors with PTSD symptoms. Emerging research on PTSD Coach demonstrates high user satisfaction, feasibility, and improvement in PTSD symptoms and other psychosocial outcomes. A model of openly sharing the app's source code and content has resulted in versions being created by individuals in six other countries: Australia, Canada, The Netherlands, Germany, Sweden, and Denmark. These versions are described, highlighting their significant adaptations, enhancements, and expansions to the original PTSD Coach app as well as emerging research on them. It is clear that the sharing of app source code and content has benefited this emerging PTSD Coach community, as well as the populations they are targeting. Despite this success, challenges remain especially reaching trauma survivors in areas where few or no other mental health resources exist.

Study protocol for a feasibility study of an internet-administered, guided, CBT-based, self-help intervention (ENGAGE) for parents of children previously treated for cancer.

INTRODUCTION: A subgroup of parents of children previously treated for cancer report long-term psychological distress after end of treatment. However, needs for psychological support are commonly unmet and there is a lack of evidence-based treatments tailored to the specific needs of this population. An internet-administered, guided, cognitive-behavioural therapy-based, self-help intervention (ENGAGE) for parents of children previously treated for cancer may provide a solution. The aim is to examine the feasibility and acceptability of the intervention ENGAGE and the study procedures for a future controlled trial. METHODS AND ANALYSIS: The study has an uncontrolled within-group design with an embedded qualitative and quantitative process evaluation. Potential participants are parents of children previously treated for cancer, living in Sweden, recruited via their child's personal identification number (via the Swedish Childhood Cancer Registry and the Swedish Tax Agency). Parents are invited randomly with information packs sent to home addresses. Further interest in participating can be registered via information on relevant websites. The study aims to recruit 50 parents who will receive the intervention ENGAGE which is designed to be delivered over a 10-week period, and comprises one introductory chapter followed by up to 10 intervention modules addressing key concerns identified for the population. Consistent with feasibility study objectives, primary outcomes relate to recruitment, attrition, data collection, study resources, intervention delivery and acceptability. Clinical outcomes (post-traumatic stress, depression, anxiety, fear of cancer recurrence, psychological inflexibility and experiential avoidance, depressed inactivity, fatigue, quality of life and self-compassion) will be measured at baseline, post-treatment (12 weeks) and 6-month follow-up. ETHICS AND DISSEMINATION: The Regional Ethical Review Board in Uppsala, Sweden has granted approval for the study (Dnr: 2017/527). Results will be disseminated to relevant healthcare and patient communities, in peer-reviewed and popular science journals, and at scientific and clinical conferences. TRIAL REGISTRATION NUMBER: ISRCTN57233429; Pre-results.

A pilot study of user satisfaction and perceived helpfulness of the Swedish version of the mobile app PTSD Coach.

Background: There is a need for accessible interventions in the aftermath of traumatic events with documented efficacy for preventing or reducing negative mental health consequences. The PTSD Coach is a mobile app that has shown to be effective in reducing symptoms of posttraumatic stress (PTSS). Objective: The purpose of the current study was to evaluate the user satisfaction, perceived helpfulness and potential reductions of PTSS and symptoms of depression among participants using the Swedish version of the PTSD Coach. Method: This was an uncontrolled pre-test post-test open trial including participants recruited from the community via advertisement and from an ongoing observational study who had experienced a potentially traumatic event in the last five years. Participants had access to the Swedish PTSD Coach app for four weeks. Results: Eleven participants (mean age = 38.6, female = 8) completed the study. Nine of the participants met criteria for full or partial PTSD. Results from the PTSD Coach Survey indicated that participants found the app slightly to moderately helpful and were slightly to moderately satisfied with the app. Nominal but not statistically significant reductions of medium effect sizes in PTSS (PCL-5) and depression (PHQ-9) from pre- to post-assessment were found. In interviews, participants indicated that they found elements such as learning about PTSD, breathing exercises and monitoring symptoms helpful in managing symptoms. However, several participants indicated that they had not used the app as much as they had intended to. Participants also had suggestions for improvements such as enhanced app structure and better guidance regarding how to use the app. Conclusions: The perceived helpfulness and user satisfaction were slightly lower compared to research on the original version of the app. Experiences from the study are discussed and a future controlled study of the Swedish version of the PTSD Coach is suggested.

Antecedentes: Existe una necesidad por intervenciones accesibles en el periodo subsiguiente a los eventos traumáticos que presenten una eficacia documentada en prevenir o reducir las consecuencias negativas de salud mental. El entrenador TEPT (PTSD Coach en sus siglas en inglés) es una aplicación de teléfono celular que ha mostrado ser efectiva en reducir los síntomas de estrés postraumático (SEPT). Objetivo: El propósito del presente estudio fue evaluar la satisfacción del usuario, la utilidad percibida, y las potenciales reducciones de los SEPT y síntomas de depresión entre los participantes de una versión sueca del Entrenador TEPT. Método: Este fue un ensayo abierto no-controlado de evaluación pre y post-intervención, incluyendo participantes que fueron reclutados desde la comunidad usando anuncios y desde un estudio observacional en proceso con quienes han experimentado un evento potencialmente traumático en los últimos cinco años. Los participantes tuvieron acceso a la aplicación móvil Entrenador TEPT sueca durante 4 semanas. Resultados: 11 participantes (edad media = 38.6, mujeres = 8) completaron el estudio. Nueve de los participantes cumplieron los criterios completa o parcialmente para TEPT. Los resultados de la Encuesta de Entrenador TEPT indicó que los participantes encontraron que la aplicación móvil fue desde ligera a moderadamente útil y estuvieron desde ligera a moderadamente satisfechos con la aplicación. Reducciones significativas nominales, pero no estadísticamente significativas, y de efecto de tamaño mediano en TEPT (PCL-5) y depresión (PHQ-9) fueron encontradas desde pre a post-evaluación. En entrevistas, los participantes indicaron que encontraron que elementos tales como aprender sobre TEPT, ejercicios de respiración, y monitorear síntomas; fueron útiles en manejar los síntomas. Sin embargo, varios participantes indicaron que ellos no habían usado la aplicación tanto como ellos habían intentado hacerlo. Los participantes también tuvieron algunas sugerencias para realizar mejoras, tales como una estructura mejorada de la aplicación y mejor guía en cuanto a cómo usar la aplicación. Conclusiones: La utilidad percibida y la satisfacción del usuario fueron levemente más bajas en comparación a la investigación de la versión original de la aplicación. Las experiencias a partir de este estudio son discutidas, y un estudio controlado futuro de la versión sueca del Entrenador TEPT es sugerido.

An open trial of individualized face-to-face cognitive behavior therapy for psychological distress in parents of children after end of treatment for childhood cancer including a cognitive behavioral conceptualization.

OBJECTIVE: A subgroup of parents of children who have been treated for childhood cancer report high levels of psychological distress. To date there is no empirically supported psychological treatment targeting cancer-related psychological distress in this population. The aim of the current study was to test the feasibility and preliminarily evaluate the effect of individualized face-to-face cognitive behavior therapy (CBT) for parents of children after the end of treatment for childhood cancer. A secondary aim was to present a cognitive behavioral conceptualization of cancer-related distress for these parents. METHODS: An open trial was conducted where 15 parents of children who had completed successful treatment for cancer three months to five years earlier and who reported psychological distress related to a child's previous cancer disease were provided CBT at a maximum of 15 sessions. Participants were assessed at baseline, post-intervention, and three-month follow-up using self-reported psychological distress (including posttraumatic stress symptoms (PTSS), depression, and anxiety) and the diagnostic Mini-International Neuropsychiatric Interview. Feasibility outcomes relating to recruitment, data collection, and delivery of the treatment were also examined. Individual case formulations for each participant guided the intervention and these were aggregated and presented in a conceptualization detailing core symptoms and their suggested maintenance mechanisms. RESULTS: A total of 93% of the participants completed the treatment and all of them completed the follow-up assessment. From baseline to post-assessment, parents reported significant improvements in PTSS, depression, and anxiety with medium to large effect sizes (Cohen's d = 0.65-0.92). Results were maintained or improved at a three-month follow-up. At baseline, seven (47%) participants fulfilled the diagnostic criteria for major depressive disorder and four (29%) fulfilled the criteria for posttraumatic stress disorder, compared to none at a post-assessment and a follow-up assessment. The resulting cognitive behavioral conceptualization suggests traumatic stress and depression as the core features of distress, and avoidance and inactivity is suggested as the core maintenance mechanisms. CONCLUSION: The treatment was feasible and acceptable to the participants. Significant improvements in distress were observed during the study. Overall, results suggest that the psychological treatment for parents of children after end of treatment for childhood cancer used in the current study is promising and should be tested and evaluated in future studies.

Development of an Internet-Administered Cognitive Behavior Therapy Program (ENGAGE) for Parents of Children Previously Treated for Cancer: Participatory Action Research Approach.

BACKGROUND: Parenting a child through cancer is a distressing experience, and a subgroup of parents report negative long-term psychological consequences years after treatment completion. However, there is a lack of evidence-based psychological interventions for parents who experience distress in relation to a child's cancer disease after end of treatment. OBJECTIVE: One aim of this study was to develop an internet-administered, cognitive behavior therapy-based, psychological, guided, self-help intervention (ENGAGE) for parents of children previously treated for cancer. Another aim was to identify acceptable procedures for future feasibility and efficacy studies testing and evaluating the intervention. METHODS: Participatory action research methodology was used. The study included face-to-face workshops and related Web-based exercises. A total of 6 parents (4 mothers, 2 fathers) of children previously treated for cancer were involved as parent research partners. Moreover, 2 clinical psychologists were involved as expert research partners. Research partners and research group members worked collaboratively throughout the study. Data were analyzed iteratively using written summaries of the workshops and Web-based exercises parallel to data collection. RESULTS: A 10-week, internet-administered, cognitive behavior therapy-based, psychological, guided, self-help intervention (ENGAGE) was developed in collaboration with parent research partners and expert research partners. The content of the intervention, mode and frequency of e-therapist support, and the individualized approach for feedback were modified based on the research partner input. Shared solutions were reached regarding the type and timing of support from an e-therapist (eg, initial video or telephone call, multiple methods of e-therapist contact), duration and timing of intervention (eg, 10 weeks, 30-min assessments), and the removal of unnecessary support functions (eg, removal of chat and forum functions). Preferences for study procedures in future studies testing and evaluating the intervention were discussed; consensus was not reached for all aspects. CONCLUSIONS: To the best of our knowledge, this study is the first use of a participatory action research approach to develop a psychological intervention for parents of children previously treated for cancer and to identify acceptable study procedures. Involvement of parents with lived experience was vital in the development of a potentially relevant and acceptable intervention for this population.

Perceptions of support among Swedish parents of children after end of successful cancer treatment: a prospective, longitudinal study.

INTRODUCTION: Most children survive childhood cancer, however parenting a child diagnosed with cancer is a major challenge. The main aim of the current study was to describe Swedish parents' need, opportunity and benefit of support from healthcare professionals and significant others after end of a child's successful cancer treatment. MATERIAL AND METHODS: Data was collected from approximately one week after end of successful treatment/six months after transplantation (T4, n = 212) up to five years thereafter (T7, n = 137). Parents answered questions via telephone about need, opportunity and benefit of talking to psychologists, social workers, partners and friends. RESULTS: The proportion reporting need of support from healthcare professionals varied between 73% (mothers' need of support from social workers, T4) and 7% (fathers' need of support from psychologists/social workers, T7). Need of support from significant others varied between 99% (mothers' and fathers' need of support from partners, T4) and 27% (fathers' need of support from friends, T7). The proportion reporting need of support decreased over time (p < .001), no decrease occurred from three months after end of treatment/nine months after transplantation (T5) to one year after end of treatment/18 months after transplantation (T6). More mothers than fathers reported need of support from friends at T5 (p < .001) and T7 (p < .05) and from psychologists at T7 (p < .05). Opportunities for support from healthcare professionals varied, most reported opportunity for support from significant others. Almost all reported benefit from received support. CONCLUSION: A declining number reports a need of support over time, however subgroups report an unmet need and almost every parent perceive support from healthcare professionals as beneficial. More parents should get access to psychosocial support services after end of a child's cancer treatment/transplantation.

The interdependence of posttraumatic stress symptoms in parental dyads during and after their child's treatment for cancer.

BACKGROUND: Cancer in a child is highly distressing and some parents are at increased risk for developing posttraumatic stress symptoms (PTSS). However, the interdependence of PTSS in parental dyads has rarely been accounted for. The aim was to explore the dyadic relationship of PTSS in parents of children diagnosed with cancer. MATERIAL AND METHODS: The sample includes 150 parents (75 dyads) of 75 children diagnosed with cancer in Sweden during 2002-2004, with follow-up until one year after end of treatment. Data on PTSS from six assessments were included. The first three assessments were carried out during treatment and the remaining after end of treatment. Actor-partner interdependence models were estimated using a structural equation modeling approach to explore the dyadic relationship of PTSS. Actor effects refer to intra-individual dependency over time, and partner effects refer to inter-individual dependency over time, i.e., how much an individual's symptom levels are affected by their partner's symptom levels at the previous assessment. RESULTS: Results show both actor and partner effects during the child's treatment. Only an actor effect remained following end of treatment where level of PTSS at one assessment was associated with the level of PTSS at the subsequent assessment. The association between mothers' and fathers' PTSS did not remain after end of treatment. CONCLUSIONS: Parents appear to react as an interdependent emotional system during the child's treatment but this effect disappears after end of treatment. Results suggest psychological interventions for parents during the child's cancer treatment should also be sensitive to and address the influence that distress in one partner may have on the other.

Twelve-Month Follow-Up of a Randomized Controlled Trial of Internet-Based Guided Self-Help for Parents of Children on Cancer Treatment.

BACKGROUND: A substantial proportion of parents of children on cancer treatment report psychological distress such as symptoms of post-traumatic stress (PTSS), depression, and anxiety. During their child's treatment many parents also experience an economic burden. OBJECTIVE: The aim of this study was to evaluate the long-term efficacy of Internet-based guided self-help for parents of children on cancer treatment. METHODS: This study was a parallel randomized controlled trial comparing a 10-week Internet-based guided self-help program, including weekly support from a therapist via encrypted email, with a wait-list control condition. The intervention was based on cognitive behavior therapy (CBT) and focused on psychoeducation and skills to cope with difficult thoughts and feelings. Primary outcome was self-reported PTSS. Secondary outcomes were self-reported symptoms of depression, anxiety, health care consumption, and sick leave during the past month. Outcomes were assessed pre- and postintervention and at 12-month follow-up. Parents of children on cancer treatment were invited by health care personnel at pediatric oncology centers, and parents meeting the modified symptom criteria on the PCL-C were included in the study. Self-report assessments were provided on the Web. RESULTS: A total of 58 parents of children on cancer treatment (median months since diagnosis=3) were included in the study (intervention n=31 and control n=27). A total of 18 participants completed the intervention, and 16 participants in each group participated in the 12-month follow-up. Intention-to-treat analyses revealed significant effects in favor of the intervention on the primary outcome PTSS, with large between-group effect sizes at postassessment (d=0.89; 95% CI 0.35-1.43) and at 12-month follow-up (d=0.78; 95% CI 0.25-1.32). Significant effects in favor of the intervention on the secondary outcomes depression and anxiety were also observed. However, there was no evidence for intervention efficacy on health care consumption or sick leave. CONCLUSIONS: Using the Internet to provide psychological interventions shows promise as an effective mode of delivery for parents reporting an increased level of PTSS and who consider Internet-based interventions as a viable option. Future research should corroborate these findings and also develop and evaluate interventions and policies that may help ameliorate the economic burden that parents may face during their child's treatment for cancer.