Psychometric properties and factor structure of the Swedish version of the Perceived Stress Scale

MediYoga compared to physiotherapy treatment as usual for patients with stress-related symptoms in primary care rehabilitation: A randomized controlled trial

OBJECTIVE

The purpose of this study was to compare the effect of MediYoga as a group treatment to conventional treatment provided by a physiotherapist for people with perceived stress-related symptoms.

DESIGN

Randomized controlled trial.

SETTINGS

Primary care rehabilitation, Gothenburg Sweden.

SUBJECTS

Fifty-five patients with stress-related symptoms were invited to participate. Nine patients declined, and a total of 46 patients aged 26-70 years (mean 47), 44 women and two men were randomized, 23 to the MediYoga group and 23 to the physiotherapy treatment as usual group.

INTERVENTIONS

The MediYoga group performed MediYoga for one hour a week during an 8-week period. The control group received physiotherapy treatment as usual.

MAIN MEASURES

Data were mainly collected by self-reported questionnaires. For primary outcome the Swedish version of the Perceived Stress Scale (PSS) was used. Secondary outcomes were the Hospital Anxiety and Depression Scale (HADS), EuroQol-5D (EQ-5D) and EuroQol-Visual Analog Scale (EQ-VAS). Thoracic excursion was the only physical measurement. Mixed effect model was used for analyse.

RESULTS

For the primary outcome PSS, there was a close to statistically significant group effect over time advantaging MediYoga over physiotherapy (P = 0.06). For secondary outcomes, the group effect over time was statistically significant in HADS anxiety (P = 0.01) and EQ-VAS (P = 0.03). There was a group trend over time advantaging MediYoga in HADS depression (P = 0.08).

CONCLUSION

Despite a large dropout in both groups, MediYoga can be recommended as a treatment option for people suffering from stress-related symptoms.

TRIAL REGISTRATION

Registered in: ClinicalTrials.gov NCT02907138.

Heterogeneous trajectories of perceived stress and their associations with active leisure: a longitudinal study during the first year of COVID-19

Introduction

There is a plethora of literature on the dynamics of mental health indicators throughout the COVID-19 pandemic, yet research is scarce on the potential heterogeneity in the development of perceived stress. Furthermore, there is a paucity of longitudinal research on whether active leisure engagement, which typically is beneficial in reducing stress, might have similar benefits during times of major disruption. Here we aimed to extend previous work by exploring the dynamics of change in stress and coping, and the associations with active leisure engagement over the first year of COVID-19.

Methods

Data from 439 adults (Mage = 45, SD = 13) in Estonia who participated in a longitudinal online study were analyzed. The participants were assessed at three timepoints: April-May 2020; November-December 2020; and April-May 2021.

Results

Mean stress and coping levels were stable over time. However, latent profile analysis identified four distinct trajectories of change in stress and coping, involving resilient, stressed, recovering, and deteriorating trends. Participants belonging to the positively developing stress trajectories reported higher active leisure engagement than those belonging to the negatively developing stress trajectories.

Discussion

These findings highlight the importance of adopting person-centered approaches to understand the diverse experiences of stress, as well as suggest the promotion of active leisure as a potentially beneficial coping resource, in future crises.

Factors associated with the Single Leg Squat test in female soccer players: a cross-sectional study

BACKGROUND

The Single Leg Squat (SLS) test is widely used in the clinical setting to examine and evaluate rehabilitation goals. It is simple to perform and is proposed to have biomechanical and neuromuscular similarities to athletic movements. The aim of the present study was to investigate whether demographics, previous injuries, and biomechanical and psychosocial factors are associated with the outcome of the SLS, assessed as a total score for all segments and as a separate knee segment in elite and sub-elite female soccer players.

METHODS

We conducted a cross-sectional study involving 254 female soccer players (22 yrs; SD ± 4, height 1.69 m; SD ± 0.1, weight 64 kg; SD ± 6) from divisions 1-3 of the Swedish Soccer League. During the preseason, we assessed the participants using the SLS and tested their hip strength and ankle mobility. Demographics, previous injury, sleep quality, fear of movement, anxiety, and perceived stress were assessed with questionnaires. Logistic regression models were built to analyse the association between the outcome of the SLS and the independent variables for the dominant and non-dominant leg.

RESULTS

Significantly more participants failed the SLS on the dominant leg compared with the non-dominant leg (p < 0.001). The outcome of the SLS associated with various biopsychosocial factors depending on if the dominant or non-dominant leg was tested. The total score associated with hip strength for the dominant (OR 0.99, 95% CI 0.98-0.99, p = 0.04) and the non-dominant leg (OR 0.99, 95% CI 0.97-0.99, p = 0.03). The knee segment associated with division level for the dominant (div 2; OR 2.34, 95% CI 1.01-5.12, p = 0.033. div 3; OR 3.07, 95% CI 1.61-5.85, p = 0.001) and non-dominant leg (div 2; OR 3.30, 95% CI 1.33-8.00, p = 0.01. div 3; OR 3.05, 95% CI 1.44-6.43, p = 0.003).

CONCLUSIONS

This study identified that leg dominance, division level, hip strength, and psychosocial factors were associated with the outcome of the SLS when assessed as a total score and as a separate knee segment. This indicates that clinicians need to understand that movement control is associated with factors from several domains. Whether these factors and, the results of the SLS are related to injury need to be studied prospectively.

TRIAL REGISTRATION

Clinical Trials Gov, date of registration 2022-03-01.

CLINICAL TRIALS IDENTIFIER

NCT05289284A.

Perceived stress, coping strategies, symptoms severity and function status among carpal tunnel syndrome patients: a nurse-led correlational Study

BACKGROUND

Carpal tunnel syndrome (CTS) is a prevalent condition characterized by hand pain, tingling, and numbness. The severity of symptoms and functional status in CTS patients may be influenced by perceived stress and how individuals cope with it. However, scarce knowledge exists about the role of coping strategies as moderators in this relationship. Unfolding the role of perceived stress and coping strategies for CTS management will help the nurse to provide comprehensive and tailored nursing care. This will ultimately improve patient comfort, functionality, and quality of life.

PURPOSES

This study aimed to examine the role of coping strategies (adaptive and maladaptive) in the relationship between perceived stress and both symptoms severity and function status among those patients.

METHOD

We employed a multisite, correlational study design with moderation analysis. The study included 215 patients with CTS from neurosurgery outpatient clinics at three hospitals in Egypt. After obtaining their consent to participate, eligible participants completed anonymous, self-reported measures of perceived stress, the brief COPE inventory, and the Boston Carpal Tunnel Questionnaire. Demographic and biomedical data were also collected. The questionnaire took about 20 min to be completed. The data was collected over six months, starting in February 2023.

RESULTS

The results showed that perceived stress, adaptive coping, and maladaptive coping were significant predictors of symptoms severity and functional status. Adaptive coping moderated the relationships between perceived stress and both symptoms severity and function status, while maladaptive coping did not. The interaction between perceived stress and adaptive coping explained a moderate effect on symptoms severity and function status after controlling for the main effects and the covariates.

CONCLUSION

This study explored the relationship between perceived stress, coping strategies, and outcomes in patients with CTS. The results indicate that nurses play a vital role in assessing and assisting patients to adopt effective coping strategies to manage perceived stress and alleviate symptoms and functional impairment. Moreover, the findings support the need for psychological interventions that address both perceived stress and coping strategies as a way to enhance the functioning status and quality of life of patients with CTS.

Tailored internet-delivered cognitive behavioral therapy for individuals experiencing psychological distress associated with climate change: A pilot randomized controlled trial

Even among people who are not directly impacted by the consequences of climate change, perceptions about the ongoing crisis can have a negative effect on mental health and well-being. However, empirical evidence on interventions aiming to provide support is currently scarce. In order to address this issue, a pilot-RCT was carried out to investigate the effects of a novel ICBT treatment program. Sixty participants (23-73 years) were recruited and randomly allocated to eight weeks of therapist-supported ICBT (n = 30) or a wait-list control condition (n = 30). Measures of depressive symptoms, stress, and quality of life were used as primary outcomes, while measures of anxiety, insomnia, climate change-related distress, pro-environmental behaviour, and alcohol use were used as secondary outcomes. The treatment group had moderate to large between-group effects compared to the waitlist group on measures of depression (d = 0.87), stress (d = 0.76), quality of life (d = 0.79) and climate change-related distress (d = 0.79). There were no significant between-group differences on the other outcome measures. The results from this pilot-RCT indicate that individually tailored ICBT can be an effective way to reduce psychological distress associated with climate change without reducing pro-environmental behaviour.

Psychometric validation of the Perceived Stress Scale (PSS-10) among family caregivers of people with schizophrenia in China

BACKGROUND

The 10-item Perceived Stress Scale (PSS-10) is a widely used measure of perceived stress that has been validated in various populations, yet with inconsistent results on its factor structure. The present study examines the reliability and validity of the PSS-10 in a population not previously examined: Chinese family caregivers of persons with schizophrenia, with a focus on factor analysis.

METHODS

A sample of 449 family caregivers of persons with schizophrenia was recruited for psychometric testing of the scale. The factor structure of PSS-10 was tested by randomly dividing the sample into two groups for both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The scale was further tested for internal consistency, test-retest reliability, convergent validity, discriminant validity and concurrent validity.

RESULTS

EFA extracted two factors: perceived helplessness with six negative phrasing items and perceived efficacy with four positive phrasing items. CFA confirmed the structure of two factors with satisfactory model fit indices. Convergent validity was supported by high standard regression weight (0.78-0.92), average variance extracted (AVE=0.79-0.81) and composite reliability (0.88-0.94), while discriminant validity was confirmed by higher AVE estimates than the squared interconstruct correlations. The PSS-10 showed good internal consistency and test-retest reliability, with Cronbach's alpha of 0.79 and intraclass correlation coefficient of 0.91, respectively. Concurrent validity was demonstrated by its significant positive correlations with stigma, depression and anxiety, as well as significant negative correlations with social support, family functioning and positive caregiving experiences.

CONCLUSION

The two-factor PSS-10 has good psychometric characteristics assessing the perceived stress of family caregivers of people with schizophrenia. The findings indicate that the PSS-10 can be used to measure perceived stress in future research and practice among caregivers of people with schizophrenia, and potentially, other caregiving samples.

A psychometric evaluation of the Swedish translation of the Perceived Stress Scale: a Rasch analysis

BACKGROUND

Stress reflects physical and psychological reactions to imposing demands and is often measured using self-reports. A widely-used instrument is the Perceived Stress Scale (PSS), intended to capture more general aspects of stress. A Swedish translation of the PSS is available but has not previously been examined using modern test theory approaches. The aim of the current study is to apply Rasch analysis to further the understanding of the PSS' measurement properties, and, in turn, improve its utility in different settings.

METHODS

Data from 793 university students was used to investigate the dimensionality of different version of the PSS (14, 10, and 4 items) as well as potential response patterns among the participants.

RESULTS

The current study demonstrates that the PSS-14 has two separate factors, divided between negatively worded items (perceived stress) and positively worded items (perceived [lack of] control), although with only the negative subscale exhibiting good reliability. Response patterns were analyzed using Differential Item Functioning, which did not find an influence of gender on any of the items, but for age regarding the positive subscale (items 6 and 9). The PSS-10 also demonstrated adequate reliability for the negative subscale, but the PSS-4 was not deemed suitable as a unidimensional scale.

CONCLUSIONS

Based on the results, none of the versions of the PSS should be used by sum-scoring all of the items. Only the negative items from the PSS-14 or PSS-10 can be used as unidimensional scales to measure general aspects of stress. As for different response patterns, gender may nevertheless be important to consider, as prior research has found differences on several items. Meanwhile, content validity is discussed, questioning the relevance of anger and being upset when measuring more general aspects of stress. Finally, a table to convert the PSS-7 (i.e., negative items) ordinal sum scores to interval level scores is provided.

Autonomic function and inflammation in pregnant women participating in a randomized controlled study of Mindfulness Based Childbirth and Parenting

BACKGROUND

Pregnancy and childbirth are significant events in many women's lives, and the prevalence of depressive symptoms increases during this vulnerable period. Apart from well documented cognitive, affective, and somatic symptoms, stress and depression are associated with physiological changes, such as reduced heart-rate variability (HRV) and activation of the inflammatory response system. Mindfulness Based Interventions may potentially have an effect on both HRV, inflammatory biomarkers, and self-assessed mental health. Therefore, the aim of this study was to assess the effects of a Mindfulness Childbirth and Parenting (MBCP) intervention on HRV, serum inflammatory marker levels, through an RCT study design with an active control group.

METHODS

This study is a sub-study of a larger RCT, where significant intervention effects were found on perinatal depression (PND) and perceived stress. Participants were recruited through eight maternity health clinics in Stockholm, Sweden. In this sub-study, we included altogether 80 women with increased risk for PND, and blood samples and HRV measures were available from 60 of the participants (26 in the intervention and 34 in the control group).

RESULTS

Participants who received MBCP reported a significantly larger reduction in perceived stress and a significantly larger increase in mindfulness, compared to participants who received the active control treatment. However, in this sub-study, the intervention had no significant effect on PND, inflammatory serum markers or measures of HRV.

CONCLUSIONS

No significant differences were found regarding changes in HRV measures and biomarkers of inflammation, larger studies may be needed in the future.

TRIAL REGISTRATION

ClinicalTrials.gov ID:  NCT02441595 . Registered 12 May 2015 - Retrospectively registered.

Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting

LAY ABSTRACT

Autistic adults are often stressed and feel depressed or anxious. However, mental health programs that are suited for autistic adults are few. Acceptance and commitment therapy is a psychotherapy method that seems to help people feel better, although not thoroughly evaluated in autistic individuals. In this study, 20 autistic adults had 14 weeks of acceptance and commitment therapy group treatment suited for autism (NeuroACT), while 19 autistic adults had ordinary care. The acceptance and commitment therapy group treatment program seemed logical and reasonable to the participants. Also, when comparing the participants in the NeuroACT group with those in the ordinary care group, the NeuroACT participants reported less stress and higher quality of life. Compared to the ordinary care group, they could also manage distressing thoughts better, perceived themselves as more flexible, and did not avoid stressful situations as much as before. However, there was no significant difference between the groups in depression, anxiety, sleep problems, social aspects of autism, everyday functioning, or executive challenges. Slightly more NeuroACT participants did not finish the treatment than ordinary care participants. In conclusion, the NeuroACT program may be a treatment for autistic adults who feel stressed and have reduced quality of life. More studies are needed to see how helpful the NeuroACT program is for autistic adults.

The e-mental health treatment in Stockholm myocardial infarction with non-obstructive coronaries or Takotsubo syndrome study (E-SMINC): a study protocol for a randomised controlled trial

BACKGROUND

In the aftermath of a myocardial infarction with non-obstructive coronary arteries (MINOCA) or Takotsubo syndrome (TS), patients commonly express high levels of stress and anxiety. Current treatment alternatives rarely address these issues.

METHODS

The study is a randomised controlled trial, where 90 patients with a discharge diagnosis of MINOCA or TS who also report symptoms of stress or anxiety will be randomised 2-6 weeks after their cardiac event. The treatment consists of 10 weeks of Internet-based cognitive behaviour therapy (CBT) and starts immediately after randomisation for the treatment group. The control group receives usual care. Main outcomes are symptoms of anxiety measured with the Hospital Anxiety and Depression scale, anxiety subscale, and perceived stress measured with the Perceived Stress Scale, 14-item version, 10 weeks after randomisation. Secondary measures include cardiac specific anxiety, symptoms of post-traumatic stress, quality of life, cortisol measured in hair and physiological stress responses (heart rate variability, blood pressure and saliva cortisol) during a stress procedure. Ten weeks after randomisation, the control group will also receive treatment. Long-term follow-up in the self-report measures mentioned above will be conducted 20 and 50 weeks after randomisation where the total group's development over time is followed, and the groups receiving intervention early versus late compared.

DISCUSSION

At present, there are no randomised studies evaluating psychological treatment for patients with MINOCA or TS. There is an urgent need for treatment alternatives aiming at relieving stress and anxiety considering the high mental stress and anxiety levels observed in MINOCA and TS, leading to decreased quality of life. CBT aiming at reducing mental stress has been shown to be effective regarding prognosis in patients with coronary artery disease. The current protocol describes a randomised open-label controlled trial evaluating an Internet-based CBT program for reduction of stress and anxiety in patients with increased mental stress and/or anxiety with a discharge diagnosis of either MINOCA or TS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04178434 . Registered on 26 November 2019.

In-home online music-based intervention for stress, coping, and depression among family caregivers of persons with dementia: A pilot study

Little is known about how music affects family caregivers who provide care to persons with dementia at home. We examined the effects of an 8-week online music-based intervention on self-reported stress, coping, and depression among dementia family caregivers. Mann-Whitney U test and Wilcoxon signed-ranked tests were performed to examine between- and within-group differences between intervention (n = 24) and comparison (n = 11) groups from baseline to post-test. The coping subscale yielded a significant difference between the groups at post-test (U=76.50, Z=-1.978, p=0.048), indicating the intervention group had better coping than the comparison group at post-test. Significant within-group differences in overall stress (Z=-2.200, p=0.028) and coping subscale (Z=-1.997, p=0.046) in the comparison group at post-test suggest that overall stress and coping were maintained throughout the study in the intervention group, whereas the comparison group had higher overall stress and lower coping at post-test. Our in-home music-based intervention showed potential benefits for dementia family caregivers.

Predicting perinatal health outcomes using smartphone-based digital phenotyping and machine learning in a prospective Swedish cohort (Mom2B): study protocol

INTRODUCTION

Perinatal complications, such as perinatal depression and preterm birth, are major causes of morbidity and mortality for the mother and the child. Prediction of high risk can allow for early delivery of existing interventions for prevention. This ongoing study aims to use digital phenotyping data from the Mom2B smartphone application to develop models to predict women at high risk for mental and somatic complications.

METHODS AND ANALYSIS

All Swedish-speaking women over 18 years, who are either pregnant or within 3 months postpartum are eligible to participate by downloading the Mom2B smartphone app. We aim to recruit at least 5000 participants with completed outcome measures. Throughout the pregnancy and within the first year postpartum, both active and passive data are collected via the app in an effort to establish a participant's digital phenotype. Active data collection consists of surveys related to participant background information, mental and physical health, lifestyle, and social circumstances, as well as voice recordings. Participants' general smartphone activity, geographical movement patterns, social media activity and cognitive patterns can be estimated through passive data collection from smartphone sensors and activity logs. The outcomes will be measured using surveys, such as the Edinburgh Postnatal Depression Scale, and through linkage to national registers, from where information on registered clinical diagnoses and received care, including prescribed medication, can be obtained. Advanced machine learning and deep learning techniques will be applied to these multimodal data in order to develop accurate algorithms for the prediction of perinatal depression and preterm birth. In this way, earlier intervention may be possible.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Swedish Ethical Review Authority (dnr: 2019/01170, with amendments), and the project fully fulfils the General Data Protection Regulation (GDPR) requirements. All participants provide consent to participate and can withdraw their participation at any time. Results from this project will be disseminated in international peer-reviewed journals and presented in relevant conferences.

Distinct Roles of Distress and Coping Capacity in the Effects of Psychological Stress on Energy Intake and Percentage of Energy from Macronutrients

The aim of this study was to explore the association of perceived stress on energy intake and percentage of energy from macronutrients. We examined cross-sectional data from the China Health and Nutrition Survey among Chinese adults. Perceived stress scale was used to assess psychological stress, and confirmatory factor analysis was used to calculate the two latent variable scores: distress factor and coping factor of perceived stress. Combined two-level random effect model and structural equation modeling were used to explore the association between distress, coping, and energy intake. The study involved 6865 adults with an average age of 46.9 years. The intake of energy was 2047.9 ± 666.6 kcal/d, 51.1% from carbohydrate and 35.2% from fat. Neither distress nor coping capacity had an association with energy intake. The coping factor score was positively associated with the sum of percentage of energy intake from carbohydrate and fat (%C&F) in females (β = 0.149, p = 0.015) but not in males. Compared to the lowest tertile, %C&F of females with a coping factor score in the medium and top tertiles were 0.44 and 0.81 significantly higher, respectively (pmedium = 0.0013, ptop < 0.0001). Psychological stress was positively associated with %C&F in females. It was insufficient capacity to cope with stress that led to unhealthy eating behavior.

Psychosocial health in pregnancy and postpartum among women living with - and without HIV and non-pregnant women living with HIV living in the Nordic countries - Results from a longitudinal survey study

BACKGROUND

The success of antiretroviral therapy has normalized pregnancy among women living with HIV (WWH) with a very low risk of perinatal transmission of HIV. Despite these advances, WWH still face complex medical and psychosocial issues during pregnancy and postpartum. The aim of this study was to assess differences in psychosocial health outcomes between pregnant WWH, non-pregnant WWH, and pregnant women without HIV, and further identify factors associated with probable depression in the third trimester and postpartum.

METHODS

In a longitudinal survey study, participants were included from sites in Denmark, Finland, and Sweden during 2019-2020. Data was collected in the 3rd trimester, 3 and 6 months postpartum using standardized questionnaires assessing depression, perceived stress, loneliness, and social support. Mixed regression models were used to assess changes over time within and between groups. Logistic regression models were used to identify factors associated with depression in pregnancy and postpartum.

RESULTS

A total of 47 pregnant WWH, 75 non-pregnant WWH, and 147 pregnant women without HIV were included. The prevalence of depression was high among both pregnant and non-pregnant WWH. There was no significant difference between pregnant and non-pregnant WWH in depression scores, perceived stress scores, or social support scores at any time point. Compared to pregnant women without HIV, pregnant WWH reported worse outcomes on all psychosocial scales. Social support and loneliness were associated with an increased odds of depressive symptoms in the adjusted analysis.

CONCLUSIONS

A high burden of adverse psychosocial outcomes was observed in both pregnant and non-pregnant women living with HIV compared to pregnant women without HIV. Loneliness and inadequate social support were associated with increased odds of depression in pregnancy and should be a focus in future support interventions.

Telephone nurses' perceived stress, self-efficacy and empathy in their work with frequent callers

Aim

To examine telephone nurses' perceived stress, self‐efficacy and empathy in their work with answering calls from frequent callers.

Design

The study is a quantitative questionnaire survey study with a comparative design.

Methods

Telephone nurses (N = 199) answered a survey containing three instruments: Perceived Stress Scale, General Self‐Efficacy Scale and Jefferson's Scale of Empathy. Correlation analysis, multiple regression analysis and analysis of variance were performed to test the research questions.

Results

Significant negative correlations were found between stress involving calls from FCs and self‐efficacy (r = −.238), and significant negative correlations between stress involving calls from frequent callers and empathy (r = −.185). It was further revealed that telephone nurses who had worked less than 30 years scored higher on Jefferson's Scale of empathy than those who had worked more than 30 years, F(1, 183) = 4.98, η² = 0.027.

An exploration of group-based compassion-focused therapy for adolescents and their parents

Background

The long-term negative consequences of mental health problems during adolescence highlight the need for effective treatments. Compassion-focused therapy (CFT) aims to help individuals to enhance their ability to support and care for themselves and to alleviate shame and self-stigmatization.

Objective

This non-randomized controlled trial examined the effectiveness of group-based CFT on perceived stress and the extent of self-compassion in a clinical sample of adolescents receiving psychiatric care for complex mental health difficulties and their parents.

Method

The participants were 43 adolescents (ages 14-17; 83.7 % female) under treatment at a child and adolescent psychiatric outpatient clinic in Sweden and their parents (n = 77; 61 % female). The adolescents volunteered for group-based CFT (n = 19); if they did not want to participate, they were asked to join the control group receiving treatment as usual (TAU, n = 24). The CFT parents were given the same treatment as their children in parallel parent groups. The participants completed questionnaires measuring self-compassion and perceived stress before and after treatment. Paired samples t-tests and independent samples t-tests assessed the within-group and between-group differences via change scores.

Results

The fathers scored highest on self-compassion and had less perceived stress at both times than the adolescents or mothers. There were no significant differences between the CFT and TAU groups in self-compassion or perceived stress at either time, and the effect sizes were small (g ≤ 0.25). The TAU mother group was the only group with a significantly changed mean self-compassion score post-treatment.

Conclusions

Some patients seem to benefit from group-based CFT in ways similar to the benefits of specialized therapeutic approaches. Further research into the utility of CFT for adolescents with MH problems and their parents, as well as the long-term clinical effects of CFT for this group is needed.

The mediating role of insomnia severity in internet-based cognitive behavioral therapy for chronic stress: Secondary analysis of a randomized controlled trial

The aim of this study was to investigate insomnia symptom severity as a putative mediator of treatment response in therapist-guided internet-based cognitive behavioral therapy (ICBT) for chronic stress, using data from a randomized controlled trial. Participants (N = 100) were randomized to 12 weeks of ICBT or to a waitlist control condition (WLC). Insomnia severity was assessed weekly with the Insomnia Severity Index (ISI), as were the stress-related outcomes the Perceived Stress Scale (PSS) and the Shirom-Melamed Burnout Questionnaire (SMBQ). Latent growth models indicated that ICBT (vs. WLC) predicted a decrease in insomnia severity (α-path), and that growth in insomnia severity was predictive of growth in perceived stress and exhaustion (β-paths). Most importantly, there were also significant indirect effects (αβ products) such that the beneficial effects of ICBT on perceived stress and exhaustion were mediated by a reduction in insomnia symptom severity (PSS: αβ = -0.44, 95% CI [-0.92, -0.14]; SMBQ: αβ = -0.08, 95% CI [-0.15, -0.04]). Explorative analysis of moderated mediation showed that more severe insomnia symptoms at baseline were associated with larger mediated effects. We conclude that reducing insomnia severity could be of importance for achieving successful treatment outcomes in ICBT for chronic stress.

Self-rated stress and experience in patients with Takotsubo syndrome: a mixed methods study

BACKGROUND

A relation to stress and stressful triggers is often, but not always, described in patients with Takotsubo syndrome. Few studies have focused on patients' self-rated stress in combination with qualitative experiences of stress in Takotsubo syndrome.

AIMS

The aim of this study was to describe stress before and after the onset of Takotsubo syndrome.

METHODS

Twenty patients were recruited from five major hospitals in Stockholm, Sweden between December 2014 and November 2018. A mixed methods design was used containing the validated questionnaire, perceived stress scale (PSS-14) filled in at baseline and at a 6 and 12-month follow-up, respectively. Qualitative interviews were made at the 6-month follow-up.

RESULTS

Self-rated stress, measured by the perceived stress scale, showed stress levels above the cut-off value of 25, at the onset of Takotsubo syndrome (median 30.5). Stress had decreased significantly at the 12-month follow-up (median 20.5, P = 0.039) but remained high in one third of the patients. Qualitative interviews confirmed a high long-term stress and half of the patients had an acute stress trigger before the onset of Takotsubo syndrome. The qualitative interviews showed that the patients had reflected on and tried to find ways to deal with stress, but for many this was not successful.

CONCLUSION

Patients with Takotsubo syndrome reported long-term stress sometimes with an acute stress trigger before the onset of Takotsubo syndrome. Stress decreased over time but remained high for a considerable number of patients. Despite reflection over stress and attempts to deal with stress many were still affected after 6 months. New treatment options are needed for patients with Takotsubo syndrome.

Psychometric evaluation of the Swedish Quality of Dyadic Relationships scale - homogeneity and construct validity

RATIONALE AND AIMS

The Quality of Dyadic Relationships is a self-assessment scale used to evaluate various aspects of relationship quality. Psychometric evaluation by the developers of the instrument has led to a nontested amended version. Further psychometric testing is thus warranted, and the aim of this study was to evaluate homogeneity, construct validity (in terms of concurrent, discriminant and known-groups validity) and any floor and ceiling effects of the Quality of Dyadic Relationships.

METHODS

Forty-seven cohabitant couples (47 women with a mean age of 30.0 years and 47 men with a mean age of 31.5 years) answered the Quality of Dyadic Relationships, the Relationship Assessment Scale (to test concurrent validity) and the Perceived Stress Scale (to test discriminant validity). Homogeneity (internal consistency) was calculated by Cronbach's alpha. Concurrent and discriminant validity were estimated as correlations between Quality of Dyadic Relationships and the other instruments. Assessment of known-groups validity was based on the variables of parental status and gender. Floor and ceiling effects were evaluated according to frequency distribution.

RESULTS

The overall homogeneity was good with acceptable Cronbach's alpha values (α > 0.70) for all subscales but dyadic sexuality. Concurrent validity and discriminant validity were found. Known-groups validity was indicated by significant differences between individuals with different parental status on the total QDR index, where the ones without children scored higher. No difference between the genders was found. No significant floor effects were found, but a significant ceiling effect was found in the subscale dyadic sensuality, with 27.7% of respondents scoring maximum.

CONCLUSION

In all, the QDR showed promising psychometric properties and may be used for screening and follow-up purposes. However, it can benefit from further development, as suggested by the ceiling effect in the subscale dyadic sensuality and the low internal consistency in the subscale dyadic sexuality.

Psychometric properties of the perceived stress scale in a community sample of Chinese

BACKGROUND

The Perceived Stress Scale (PSS) is a globally used and self-report scale measuring perceived stress. Three versions of PSS (PSS-14, PSS-10 and PSS-4) are available which comprise 14, 10 and 4 items respectively. However, the Chinese version of the PSS has not yet been validated in a large community-based general population. The aims of this study were to evaluate the psychometric properties of the Chinese PSS in a large community-based general population and to compare the appropriateness of the three versions of PSS.

METHODS

A total of 9507 adults with at least a junior high school education and completed PSS-14 from the China Health and Nutrition Survey were involved in this study. The internal consistency reliability of PSS was assessed using Cronbach's alpha coefficient and confirmatory factor analysis was employed to test the construct validity. Modification index was used for model extension and the critical ratio was used for model restriction.

RESULTS

The internal consistency coefficients were satisfactory for PSS-14 and PSS-10, but not for PSS-4. The corresponding Cronbach's alpha were 0.830, 0.754 and 0.473 respectively. A 2-factor structure was confirmed for the PSS-14 and PSS-10, and all items' standardized factor loadings exceeded 0.4 for either negative or positive factors. Given that item 12 loaded on both negative and positive factors for PSS-14 and the goodness of fit for PSS-14 was not acceptable, PSS-13 (PSS-14 excluding item 12) was studied. The construct validities of PSS-13 and PSS-10 were satisfactory, but the goodness of fit for PSS-10 were better than that for PSS-13.

CONCLUSIONS

PSS-13 (PSS-14 excluding item 12) and PSS-10 have satisfactory psychometric properties. PSS-10 are more applicable to measure the perceived stress than PSS-13 in a large community-based general population in China.

Effects of a mindfulness based childbirth and parenting program on pregnant women's perceived stress and risk of perinatal depression-Results from a randomized controlled trial

OBJECTIVES

The aim of this study was to test the efficacy of a Mindfulness-Based Childbirth and Parenting Program (MBCP) in reducing pregnant women's perceived stress and preventing perinatal depression compared to an active control condition.

METHOD

First time pregnant women (n = 197) at risk of perinatal depression were randomized to MBCP or an active control treatment, which consisted of a Lamaze childbirth class. At baseline and post-intervention, participants filled out questionnaires on perceived stress, depressive symptoms, positive states of mind, and five facets of mindfulness.

RESULTS

Compared to the active control treatment, MBCP significantly reduced perceived stress (p = 0.038, d = 0.30) and depressive symptoms (p = 0.004, d = 0.42), and increased positive states of mind (p = 0.005, d = 0.41) and self-reported mindfulness (p = 0.039, d = 0.30). Moreover, change in mindfulness possibly mediated the treatment effects of MBCP on stress, depression symptoms, and positive states of mind. The subscales "non-reactivity to inner experience" and "non-judging of experience" seemed to have the strongest mediating effects.

LIMITATIONS

The outcomes were self-report questionnaires, the participants were not blinded to treatment condition and the condition was confounded by number of sessions.

CONCLUSIONS

Our results suggest that MBCP is more effective in decreasing perceived stress and risk of perinatal depression compared to a Lamaze childbirth class. The results also contribute to our understanding of the underlying psychological mechanisms through which the reduction of stress and depression symptoms may operate. Thus, this study increases our knowledge about efficient intervention strategies to prevent perinatal depression and promote mental wellbeing among pregnant women.

Study protocol: becoming and being a mother living with HIV - a multicentre longitudinal mixed methods study among pregnant women living with HIV, non-pregnant women living with HIV and pregnant women not living with HIV in a high-income setting (the 2B MOM study)

INTRODUCTION

The success of combination antiretroviral therapy has decreased the risk of perinatal HIV transmission and normalised pregnancy in women living with HIV (WLWH). Despite these advances, WLWH still face complex medical and psychosocial issues during pregnancy and postpartum, and there is a gap of knowledge on the experiences of becoming and being a mother living with HIV in today's context. The overall aim of this study is to investigate psychosocial outcomes and experiences of WLWH in Scandinavia during pregnancy and early motherhood.

METHODS AND ANALYSIS

This is a multicentre longitudinal convergent mixed methods study consisting of a quantitative survey study, a qualitative interview study and a mixed methods analysis. The survey study aims to examine psychosocial outcomes of WLWH across the pregnancy - postpartum trajectory. Participants are pregnant WLWH living in Scandinavia. Two control groups of HIV-negative pregnant women and non-pregnant WLWH are also included. Data is collected in the third trimester, 3 and 6 months postpartum using standardised questionnaires. Statistical analysis will assess changes over time and identify predictors of adverse outcomes. The interview study seeks to understand experiences of pregnancy and becoming a mother while living with HIV. Pregnant WLWH who are enrolled in the survey study will be asked to participate in individual interviews in the third trimester and 6 months postpartum. Data will be analysed using narrative analysis. The survey and interview results will be merged in a mixed methods analysis to assess confirmation, expansion or discordance between the data sets.

ETHICS AND DISSEMINATION

Approval from the Danish Data Protection Agency (VD-2018-253), and the Finnish and Swedish Ethics Committees have been obtained (HUS/1330/2019 and Dnr: 2019-04451, respectively). Study results will be disseminated to patient organisations, through publications in peer-reviewed journals and at scientific conferences.

Cost-Effectiveness of Therapist-Guided Internet-Based Cognitive Behavioral Therapy for Stress-Related Disorders: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Stress-related disorders are associated with significant suffering, functional impairment, and high societal costs. Internet-based cognitive behavioral therapy (ICBT) is a promising treatment for stress-related disorders but has so far not been subjected to health economic evaluation.

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness and cost-utility of ICBT for patients with stress-related disorders in the form of adjustment disorder (AD) or exhaustion disorder (ED). We hypothesized that ICBT, compared with a waitlist control (WLC) group, would generate improvements at low net costs, thereby making it cost-effective.

METHODS

Health economic data were obtained in tandem with a randomized controlled trial of a 12-week ICBT in which patients (N=100) were randomized to an ICBT (n=50) or a WLC (n=50) group. Health outcomes and costs were surveyed pre- and posttreatment. We calculated incremental cost-effectiveness ratios (ICERs) based on remission rates and incremental cost-utility ratios (ICURs) based on health-related quality of life. Bootstrap sampling was used to assess the uncertainty of our results.

RESULTS

The ICER indicated that the most likely scenario was that ICBT led to higher remission rates compared with the WLC and was associated with slightly larger reductions in costs from pre- to posttreatment. ICBT had a 60% probability of being cost-effective at a willingness to pay (WTP) of US $0 and a 96% probability of being cost-effective at a WTP of US $1000. The ICUR indicated that ICBT also led to improvements in quality of life at no net societal cost. Sensitivity analyses supported the robustness of our results.

CONCLUSIONS

The results suggest that ICBT is a cost-effective treatment for patients suffering from AD or ED. Compared with no treatment, ICBT for these patients yields large effects at no or minimal societal net costs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02540317; https://clinicaltrials.gov/ct2/show/NCT02540317.

Can the Attention Training Technique Reduce Stress in Students? A Controlled Study of Stress Appraisals and Meta-Worry

The present study tested the impact of attention training on cognition; secondary appraisal of perceived stress, and on metacognition; meta-worry in stressed students. Theoretically derived from the Self-Regulatory Executive Function model (S-REF model; Wells and Matthews, 1994a, 1996), the attention training technique (ATT; Wells, 1990) is intended to promote flexible, voluntary external attention and has been shown to reduce symptoms of psychological distress. The present experimental study explored the effects of ATT on cognitive and metacognitive levels of appraisal, namely perceived stress (primary outcome) and meta-worry (secondary outcome). Stressed students were randomized to an experimental ATT group (n = 23) or a control group (n = 23). The ATT group attended an initial training session followed by 4 weeks of individual (12 min) daily ATT practice. The control group waited for 4 weeks before receiving the intervention. The outcomes were scores on the Perceived Stress Scale 14 (PSS-14) and the Meta-Worry Questionnaire (MWQ) frequency and belief subscales at post study. Both measures decreased significantly following ATT with large pre- to post- effect sizes but there were minimal changes in the control group. The between-group differences were statistically significant. The results add to the literature on the potential effects of ATT by demonstrating effects on the content of cognitive stress appraisals and on meta-worry in an academic setting in a stressed student sample.

Correlates of health in adolescent elite athletes and adolescents: A cross-sectional study of 1016 adolescents

The primary aim of this cross-sectional study was to compare subjective correlates of health, such as nutrition, self-esteem, sleep and stress, between adolescent elite athletes (n = 625) and a reference group of adolescents (n = 391) not involved in elite sports. A secondary aim was to study predictors for self-perceived stress. A questionnaire was e-mailed to all participants containing valid questions about competence-based self-esteem, nutrition, self-perceived stress and sleep. Our results show that adolescent elite athletes reported significantly (p < .001) lower self-perceived stress, competence-based self-esteem, a more varied diet and more time of sleep, compared to adolescents not involved in elite sports (Hedges'g 0.31-0.82). Female adolescent elite athletes and female adolescents, compared to their male peer group, reported poorer values for competence-based self-esteem (elite, Hedges'g 0.29; adolescents, Hedges'g 0.30) and self-perceived stress (elite, Hedges'g 0.63; adolescents, Hedges'g 0.60). The linear mixed effect model revealed several significant (p < .05) predictors (sex, general well-being, competence-based self-esteem, sleep during weekdays, BMI, training volume) associated with self-perceived stress in adolescent elite athletes. In conclusion, differences in correlates of health with a moderate to strong effect sizes were found between the two groups, where elite athletes surprisingly reported less stress, competence-based self-esteem, a more varied diet and more time of sleep. Even if injury risk is high in adolescent elite athletes and pressure from multiple stakeholders is evident, it appears that the athletes still have better conditions for a good subjective health, based on self-reported measures, compared to adolescents not involved in elite sports.

Preventing lower extremity injury in elite orienteerers: study protocol for a randomised controlled trial

Background

The high physical load associated with running through uneven terrain contributes toorienteerers being exposed to high injury risk, where the majority of injuries are located in the lower extremities. Specific training programmes have been effective at reducing injury risk in sports. Yet no trial has been conducted in elite orienteering. The aim of this study is to investigate the effectiveness of a specific training programme in preventing lower extremity injury in adult elite orienteerers.

Study design

Randomised controlled trial (RCT).

Methods

Seventy-two Swedish elite orienteerers, aged 18–40 years, are allocated to an intervention or control group. The intervention group performs four specific exercises, with three difficult levels intensified every second week over the first 4 weeks, targeting strength, flexibility and coordination of the lower extremity. The exercises are completed four times a week (10 min per session) in conjunction with normal training over 14 weeks. Injury data are collected every second week using a valid injury questionnaire distributed by text messages over 14 weeks. The primary outcome is number of substantial injuries in the lower extremity. The secondary outcomes are incidence of ankle sprains and the average substantial injury prevalence across 14 weeks.

Discussion

Due to high injury risk and lack of injury prevention trials in orienteering, an RCT investigating the effect of a specific exercise programme in preventing lower extremity injury is warranted. The results of this trial will be beneficial to orienteerers, clubs and federations, and increase our understanding on how lower extremity injuries can be prevented in a physically challenging sport.

Trial registration number

NCT03408925.

Psychometric properties of the Perceived Stress Scale in a sample of German dementia patients and their caregivers

BACKGROUND

The aim of the present study was to investigate the psychometric characteristics of the Perceived Stress Scale (PSS) in a sample of dementia patients and their spousal caregivers.

METHODS

We investigated the reliability and validity of the 14-item PSS in a sample of 80 couples, each including one spouse who had been diagnosed with mild to moderate dementia (mean age 75.55, SD = 5.85, 38.7% female) and one spousal caregiver (mean age 73.06, SD = 6.75, 61.3% female). We also examined the factor structure and sensitivity of the scale with regard to gender differences.

RESULTS

Exploratory factor analysis of the PSS revealed a two-factor solution for the scale; the first factor reflected general stress while the second factor consisted of items reflecting the perceived ability to cope with stressors. A confirmatory factor analysis verified that the data were a better fit for the two-factor model than a one-factor model. The two factors of the PSS showed good reliability for patients as well as for caregivers ranging between α = 0.73 and α = 0.82. Perceived stress was significantly positively correlated with depressive symptomatology in both caregivers and patients. Mean PSS scores did not significantly differ between male and female patients nor did they differ between male and female caregivers.

CONCLUSION

The present data indicate that the PSS provides a reliable and valid measure of perceived stress in dementia patients and their caregivers.

The 12-item Self-Report World Health Organization Disability Assessment Schedule (WHODAS) 2.0 Administered Via the Internet to Individuals With Anxiety and Stress Disorders: A Psychometric Investigation Based on Data From Two Clinical Trials

BACKGROUND

The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a widespread measure of disability and functional impairment, which is bundled with the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) for use in psychiatry. Administering psychometric scales via the Internet is an effective way to reach respondents and allow for convenient handling of data.

OBJECTIVE

The aim was to study the psychometric properties of the 12-item self-report WHODAS 2.0 when administered online to individuals with anxiety and stress disorders. The WHODAS 2.0 was hypothesized to exhibit high internal consistency and be unidimensional. We also expected the WHODAS 2.0 to show high 2-week test-retest reliability, convergent validity (correlations approximately .50 to .90 with other self-report measures of functional impairment), that it would differentiate between patients with and without exhaustion disorder, and that it would respond to change in primary symptom domain.

METHODS

We administered the 12-item self-report WHODAS 2.0 online to patients with anxiety and stress disorders (N=160) enrolled in clinical trials of cognitive behavior therapy, and analyzed psychometric properties within a classical test theory framework. Scores were compared with well-established symptom and disability measures, and sensitivity to change was studied from pretreatment to posttreatment assessment.

RESULTS

The 12-item self-report WHODAS 2.0 showed high internal consistency (Cronbach alpha=.83-.92), high 2-week test-retest reliability (intraclass correlation coefficient=.83), adequate construct validity, and was sensitive to change. We found preliminary evidence for a three-factorial structure, but one strong factor accounted for a clear majority of the variance.

CONCLUSIONS

We conclude that the 12-item self-report WHODAS 2.0 is a psychometrically sound instrument when administered online to individuals with anxiety and stress disorders, but that it is probably fruitful to also report the three subfactors to facilitate comparisons between studies.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02540317; https://clinicaltrials.gov/ct2/show/NCT02540317 (Archived by WebCite at http://www.webcitation.org/6vQEdYAem); Clinicaltrials.gov NCT02314065; https://clinicaltrials.gov/ct2/show/NCT02314065 (Archived by WebCite at http://www.webcitation.org/6vQEjlUU8).

Nursing Staff Stress and Individual Characteristics in Relation to the Ward Atmosphere in Psychiatric In-Patient Wards

This study investigated the interplay between nursing staff stress, Mastery, Moral Sensitivity, individual characteristics and the ward atmosphere in psychiatric in-patient care. Data were collected through five questionnaires from 93 nursing staff. Multivariate analysis showed that Moral Strength, Moral Burden, Internal Demands, Perceived Stress and age were related to several factors of the ward atmosphere. We conclude that efforts to reduce stress levels and create a supporting ethical climate on psychiatric wards would be beneficial for both psychiatric nursing staff and their nursing practice.

The construct validity of the Perceived Stress Scale

OBJECTIVE

Stress impacts the quality of life and is associated with increased risk of mental and physical disorders. The Perceived Stress Scale (PSS) is widely used for measuring psychological distress. Although the instrument was originally defined as a single construct, several studies based on classical test theory suggest that a two-dimensional structure is more dominant. We aimed to explore the construct validity and dimensionality of the PSS-10 using modern test theory to determine if the scale is predominantly for a one- or a two-dimensional model.

METHODS

The study population consisted of 32,374 citizens who completed the PSS-10 as part of the Danish National Health Survey in 2010. We investigated the construct validity of the PSS-10 by CFA. We examined the scalability by investigating the fit of the data distribution in a unidimensional Rasch model and performing modification of response categories, persons and items. The scale dimensionality was additionally assessed by Mokken and Rasch analysis.

RESULTS

The PSS-10 did not fit the Rasch model. Item four indicated the largest misfit, and items four and seven displayed disordered thresholds. Unidimensionality could not be established although the data showed improved fit to the Rasch model for the two dimensions respectively with the positive and negative items. Mokken analysis revealed fit to the unidimensional model, but disordered thresholds were shown for item four.

CONCLUSION

Our large population-based study indicated scalability problems in the current version of the PSS-10. The conducted analysis overall revealed better statistical fit for a two-dimensional than a unidimensional model.

Internet-based cognitive behaviour therapy and physical exercise - Effects studied by automated telephone assessments in mental ill-health patients; a randomized controlled trial

OBJECTIVES

Mental ill-health has become a large health problem and it is important for caregivers to provide effective treatment alternatives. REGASSA is a randomized controlled study performed in primary care to study the effects of 12 weeks of Internet-based cognitive behaviour therapy (ICBT) and physical exercise (PE) compared with treatment as usual (TAU) in patients with mild-to-moderate mental ill-health. The present study aimed to examine the results of these treatment alternatives on psychological functioning, stress, and sleep disturbances.

METHODS

The study comprised 879 patients with mental ill-health taking part in the REGASSA study. Data were collected by Interactive Voice Response (IVR), a computerized, automated telephone technique. The treatments were compared at baseline, twice during treatment, at the end of treatment and at three follow-ups after treatment. Measures used were the Outcome Questionnaire-45, the short versions of the Perceived Stress Scale, and the Karolinska Sleep Questionnaire.

RESULTS

Linear mixed models showed that the patients in ICBT and PE had better results than in TAU on psychological functioning and sleep disturbances, p < .001, with weak-to-moderate effect sizes. On stress there were no differences; all groups made improvements. Women had stronger effects than men. More patients recovered on psychological functioning (OQ-45) in ICBT and PE than in TAU.

CONCLUSIONS

Internet-based cognitive behaviour therapy and PE proved to be effective treatment alternatives for patients with mild-to-moderate mental ill-health in improving psychological functioning, stress, and sleep disturbances and could be useful alternatives in primary care.

PRACTITIONER POINTS

Internet-based cognitive behaviour therapy and physical exercise proved to be effective treatment alternatives for mental ill-health patients in primary care. Automated techniques (Interactive Voice Response) could be useful for following treatment course in large groups of patients in the health care. It is important to use measures that capture different aspects of patients' health problems. The recruitment of participants was based on patients' interest and inclusion criteria which may have affect the generalizability.