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«Internet-based cognitive behavioural therapy A novel approach to treating depression in primary care patients — Ragnhild Sørensen Høifødt A ...»

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Faculty of Health Sciences

Department of Psychology

Internet-based cognitive behavioural therapy

A novel approach to treating depression in primary care patients

Ragnhild Sørensen Høifødt

A dissertation for the degree of Philosophiae Doctor – February 2015

INTERNET-BASED COGNITIVE BEHAVIOURAL THERAPY

A novel approach to treating depression in primary care patients

Ragnhild Sørensen Høifødt

Department of Psychology

Faculty of Health Sciences UiT The Arctic University of Norway Dissertation for the degree of Philosophiae Doctor February 2015 Table of Contents Acknowledgements

List of Papers

Summary in Norwegian

Summary in English

Abbreviations

Introduction

Overview

Depressive Disorders

Treatments for Depression

Cognitive Theory of and Therapy for Depression

Schemas

Negative automatic thoughts and cognitive distortions

Cognitive therapy for depression

The empirical status of cognitive theory and therapy

Treatment of Depression in Primary Health Care

Recognition and diagnosis

Treatment

Stepped Care Models

Self-help Approaches in Treatment

Internet-based Treatment for Depression

The importance of guidance

Treatments for specific subgroups

The role of the therapeutic alliance

Adherence and acceptability

For whom is internet-based treatment effective?

Aims of the thesis

Methods

Study Design

Phase 1: Randomised Controlled Trial (Paper II and III)

Sample

Recruitment

Intervention

Procedure

Measures

Primary and secondary outcome measures

Screening measures

Predictor variables

Analysing treatment effects (Paper II)

Mixed-effects models

Missing data

The size and significance of effects

Prediction of treatment response using Bayesian analysis (Paper III)

Phase 2: Qualitative Study of GPs’ Experiences with Implementation (Paper IV)

Objectives and research questions

Sample

Design, interviews and procedure

The influence of the researcher

Exploring the GPs’ experiences

Analysis

Existing theory

Summary of papers

Paper I

Paper II

Paper III

Paper IV

Discussion

Main Findings

The Effectiveness of Internet-based CBT with Face-to-Face Therapist Support

Program Design

Therapist Support

What, how much and by whom?

Limitations and Strengths of the RCT

For Whom is MoodGYM with Therapist Support Most Beneficial?

Is Web-based CBT Suitable for Implementation in General Practice?

General Practitioners’ Experiences with Implementing MoodGYM

How can the use of support be promoted?

Compatibility

Learning strategies and training

Organisational factors

Stepped Care

Conclusion and Future Directions

References

Paper I - IV

Appendix I - Measures Appendix II – Interview Guide

Acknowledgements

This project was a collaborative project between the Department of Psychology and the Department of Community Medicine at the Faculty of Health Sciences at the UiT The Arctic University of Norway. The studies were financially funded by the Research Council of Norway (196423/V50).

First of all, I would like to thank my supervisors Professor Knut Waterloo, Professor Martin Eisemann and Associate professor Nils Kolstrup for their supervision, endurance and optimism during the project. Without your management of the collaboration with the team at the Australian National University (ANU), this project could not have been carried out. Knut and Martin, you have always been supportive and available for a discussion. Nils, you have led the project steadily throughout these years and have always welcomed a good discussion and differing points of view. In addition to contributing to the research, all of you have contributed to the positive social environment in the research group, and the friendly and cooperative atmosphere has been of great importance to me.

I would like to give a special thanks to my fellow PhD-students: Kjersti Lillevoll, Maja Wilhelmsen and Hans Christian Vangberg. This dissertation had probably not been completed if it had not been for you fine colleagues. It has been a pleasure getting to know you, working with you and sharing both frustrations and successes. All the other colleagues at the Department of Psychology must also be thanked for making the Department such a nice place to work.

In writing of the papers, I have been lucky to receive invaluable help with statistical methods from Tom Wilsgaard, Matthias Mittner and Oddgeir Friborg. Your advice and help has been of great importance. Mette Bech Risør also deserves acknowledgement for her feedback and input on qualitative methods.

The participants in the trial deserve a special thanks for their contribution and perseverance in completing the questionnaires, as do the GPs who attended our course and shared their experiences with us.

MoodGYM was provided by the Australian National University (ANU). I would like to thank Professor Kathy Griffiths, director at the National Institute for Mental Health Research at ANU who has contributed to the project and as a co-author on one of my papers. In addition, the team at the e-mental health research and development group at the National Institute for Mental Health Research at ANU deserves acknowledgement for their support in administrating the trial. I would especially like to thank Anthony Bennett, IT manager, and Kylie Bennett, Collaborative Research and Development Manager, who provided technical expertise in administration of the trial; and Ada Tam, Web Developer, who provided technical support for users in the trial.





Last, but not least, I would like to thank my family and friends for all the support. Thank you, Magnus, my soon to be husband, for standing by me through ups and downs, and, Oskar, our wonderful son, for reminding me about what really matters!

Tromsø, 25.02.15 Ragnhild Sørensen Høifødt

–  –  –

Paper I Høifødt, R.S., Strøm, C., Kolstrup, N., Eisemann, M. & Waterloo, K. (2011). Effectiveness of cognitive behavioural therapy in primary health care: A review. Family Practice, 28, 489-504. doi: 10.1093/fampra/cmr017 Paper II Høifødt, R.S., Lillevoll, K.R., Griffiths, K.M., Wilsgaard, T., Eisemann, M., Waterloo, K., & Kolstrup, N. (2013). The clinical effectiveness of Web-based cognitive behavioral

therapy with face-to-face therapist support for depressed primary care patients:

Randomized controlled trial. Journal of Medical Internet Research, 15(8), e153. doi:

10.2196/jmir.2714 Paper III Høifødt, R.S., Mittner, M., Lillevoll, K.R., Katla, S.K., Kolstrup, N., Eisemann, M., Friborg, O., Waterloo, K. (2015). Predictors of response to Web-based cognitive behavioral therapy with face-to-face therapist support for depression: A Bayesian analysis.

Journal of Medical Internet Research (submitted). doi:10.2196/jmir.4351 Paper IV Wilhelmsen, M., Høifødt, R.S., Kolstrup, N., Waterloo, K., Eisemann, M., Chenhall, R., & Risør, M.B. (2014). Norwegian general practitioners' perspectives on implementation of a guided Web-based cognitive behavioral therapy for depression: A qualitative study. Journal of Medical Internet Research, 16(9), e208. doi: 10.2196/jmir.3556

Sammendrag

Målet med studiene i denne avhandlingen var å evaluere effekten av en behandling bestående av et internettbasert selvhjelpsprogram (MoodGYM) kombinert med korte samtaler med en terapeut. Vi ønsket også å undersøke om dette er en behandlingsmodell som pasienter opplever som nyttig og positiv.

Depresjon er en av de vanligst forekommende psykiske lidelsene, og for dem som rammes fører depresjon til både lidelse og vansker med å fungere i hverdagen. Mange av de som opplever milde til moderate depresjonsplager vil motta det meste eller all behandling i primærhelsetjenesten. Strukturert psykologisk behandling er mangelvare i allmennpraksis; til tross for at det finnes mange virksomme psykologiske behandlingsmetoder for depresjon og at pasienter ofte foretrekker slik behandling framfor medisiner. I tillegg anbefaler retningslinjer for depresjonsbehandling psykososiale intervensjoner som førstevalg av behandling for denne gruppen. De siste tiårene har det blitt utviklet en rekke internettbaserte intervensjoner som bygger på kognitiv atferdsterapi (CBT). Studier viser god effekt av slike intervensjoner i behandling av depresjon, særlig når selvhjelpsbehandlingen er veiledet av en terapeut.

Forskning antyder også at behandlingseffektene kan være positive ved bruk i primærhelsetjenesten.

En randomisert kontrollert studie ble gjennomført ved UiT Norges Arktiske Universitet for å sammenligne veiledet selvhjelp bestående av MoodGYM og korte samtaler med psykolog, med en kontrollgruppe som sto på venteliste til å motta samme behandling.

Deltakerne (n = 106) var pasienter med milde til moderate depresjonssymptomer rekruttert fra allmennpraksis. Resultatene viste at sammenlignet med kontrollgruppen reduserte behandlingen symptomer på depresjon, engstelse og bekymring, samt økte deltakernes livskvalitet. Oppfølging 6 måneder etter endt behandling tydet på at de positive effektene i stor grad hadde vedvart. Det var ingen forskjeller i behandlingseffekt mellom kvinner og menn eller for pasienter i ulike aldersgrupper. Behandlingseffekten var heller ikke påvirket av depresjonssymptomenes alvorlighetsgrad ved behandlingens oppstart, eller av hvorvidt deltakerne hadde komorbid angst. Frafallet fra intervensjonen var moderat og deltakernes vurdering av behandlingen var overveiende positiv.

Behandlingsmodellen ble introdusert til en gruppe allmennleger gjennom et 3-dagers kurs. Etter å ha gjennomført kurset anbefalte de fleste legene MoodGYM til pasientene sine.

Legene opplevde programmet som et nyttig verktøy for å gi pasienter tilgang til evidensbasert psykoedukasjon og selvhjelpsstrategier, samt for å aktivere dem i behandlingsprosessen.

Oppfølgingssamtaler ble imidlertid lite brukt på grunn av tidspress, konkurrerende oppgaver og for liten kunnskap om programmet, samt manglende praktisk trening i gjennomføringen av slike samtaler.

Samlet indikerer disse funnene at intervensjonen kan være en effektiv behandling for depresjon og at mange pasienter kan være positive til en slik behandlingsmodell. Kursing av leger i bruk av intervensjonen kan fremme endring av praksis i form av å anbefale MoodGYM til pasienter, men andre tilnærminger er nødvendig for å fremme bruk av oppfølgingssamtaler.

Dette kan trolig oppnås gjennom mer omfattende opplæringsprogrammer for leger med særlig interesse for feltet. Mer vidtrekkende implementering av behandlingsmodellen vil imidlertid kreve en mer sammensatt innsats med fokus på opplæring av både leger og pasienter, samt strukturelle endringer slik som endringer i finansieringsstrukturer. Andre lands erfaringer tyder på at opplæring av andre yrkesgrupper i primærhelsetjenesten til å gjennomføre veiledet internettbasert selvhjelp og lignende behandlingsmetoder også kan fremme effektiv implementering av slike helsetjenester.

Summary

The overall aim of this thesis was to explore the effectiveness and acceptability of a Webbased self-help program (MoodGYM) combined with brief face-to-face therapist support for adult primary care patients with mild to moderate depression.

Depression is a highly prevalent disorder causing substantial suffering and impairment of daily life. Many patients with mild to moderate depression will receive most or all of their mental health care from primary health care. Structured psychological interventions are infrequently delivered in general practice, despite the development of several effective psychological therapies for depression, patients’ preferences for such treatments, and last but not least, guideline recommendations. During the last decade several internet-based interventions based on cognitive behavioural therapy (CBT) have been developed. Studies indicate that guided internet-based treatments yield moderate to large treatment effects for depression and outperform unguided interventions concerning effect and adherence. In addition, previous research supports the effectiveness of internet-based CBT when delivered in primary health care.

A randomised controlled trial was conducted at UiT The Arctic University of Norway to compare the guided internet-based intervention comprising MoodGYM and face-to-face therapist support with a waitlist control group. Participants (n = 106) were primary care patients with mild to moderate depressive symptoms. Results indicated that the intervention was effective in reducing symptoms of depression and anxious worry and in increasing life satisfaction. Treatment gains were largely maintained at 6-month follow-up. Treatment effects appeared to be comparable for men and women, for patients of various ages, and for patients with varying levels of pre-treatment depressive severity. In addition, comparable effects were found for patients with and without comorbid anxiety. Moderate levels of non-adherence and predominately positive ratings of treatment satisfaction indicated that the intervention was acceptable to patients.

The intervention was introduced to general practitioners (GPs) through a 3-day educational course focusing on CBT and MoodGYM in general practice. Following the course most GPs recommended MoodGYM to their patients. They valued that the program provided patients with evidence-based psychoeducation and self-help strategies and empowered them to take active part in their recovery process. However, follow-ups were not successfully implemented due to limiting factors such as time constraints, competing tasks and inadequate module knowledge and practical training.



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