The risk and development of work disability among individuals with gambling disorder: a longitudinal case-cohort study in Sweden

BACKGROUND

This longitudinal register study aimed to investigate the association between gambling disorder (GD) and work disability and to map work disability in subgroups of individuals with GD, three years before and three years after diagnosis.

METHODS

We included individuals aged 19-62 with GD between 2005 and 2018 (n = 2830; 71.1% men, mean age: 35.1) and a matched comparison cohort (n = 28 300). Work disability was operationalized as the aggregated net days of sickness absence and disability pension. Generalized estimating equation models were used to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the risk of long-term work disability (>90 days of work disability/year). Secondly, we conducted Group-based Trajectory Models on days of work disability.

RESULTS

Individuals with GD showed a four-year increased risk of long-term work disability compared to the matched cohort, peaking at the time of diagnosis (AOR = 1.89; CI 1.67-2.13). Four trajectory groups of work disability days were identified: constant low (60.3%, 5.6-11.2 days), low and increasing (11.4%, 11.8-152.5 days), medium-high and decreasing (11.1%, 65.1-110 days), and constant high (17.1%, 264-331 days). Individuals who were females, older, with prior psychiatric diagnosis, and had been dispensed a psychotropic medication, particularly antidepressants, were more likely to be assigned to groups other than the constant low.

CONCLUSION

Individuals with GD have an increased risk of work disability which may add financial and social pressure and is an additional incentive for earlier detection and prevention of GD.

From alcohol detoxification to treatment: A qualitative interview study on perceived barriers and assessed potential of mHealth among individuals postdetoxification

OBJECTIVE

Most individuals attending detoxification clinics do not pursue subsequent treatment. Earlier research has suggested that emerging technologies like mHealth interventions could address the postdetoxification treatment gap, yet it remains unclear whether patients themselves endorse such approaches. Our study aimed to qualitatively explore perceived treatment barriers and assessed potential of mHealth among individuals who have undergone alcohol detoxification.

METHOD

We conducted a single-interview-per-participant qualitative study, sampling participants (n = 23) that had visited the Stockholm substance use disorder emergency department for alcohol-related reasons, of whom n = 8 were purposively included due to having missed their scheduled follow-up outpatient appointment. Semistructured telephone interviews were conducted (2021-2022) and then systematically analyzed using reflexive thematic analysis.

RESULTS

Across both areas of analysis, we identified six themes in total. We clustered barriers to postdetoxification treatment into three themes (10 subthemes) that may offer a nuancing perspective on previous research: "Misalignment between the treatment system and the individual," "Practical hurdles" and "Between reaching out and retreating." We identified three themes in participants' perspectives on mHealth as aftercare support, revealing expectations that such an approach may promote "self-awareness on own terms," assist in "navigating from solitary substance use struggles to supportive connections," and "offer a lifeline when needed most," thereby potentially resolving several barriers to treatment.

CONCLUSIONS

This first qualitative study on barriers to alcohol treatment and mHealth potential postdetoxification offered various insights that may be translated into effective, real-world solutions to bridge the postdetoxification treatment gap. A natural next step for future research is to evaluate the impact of mHealth postdetoxification. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Internet-delivered transdiagnostic psychological treatments for individuals with depression, anxiety or both: a systematic review with meta-analysis of randomised controlled trials

OBJECTIVE

Depression and anxiety are major public health problems. This study evaluated the effects of internet-delivered transdiagnostic psychological treatments for individuals with depression, anxiety, or both.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Medline (Ovid), Cochrane Library (Wiley), the Web of Science Core Collection (Clarivate), and PsycInfo (EBSCO) were searched on 24 May 2021, with an update on 6 February 2023.

ELIGIBILITY CRITERIA

Randomised controlled trials of internet-delivered transdiagnostic psychological treatments, open to both participants with primary depression and participants with primary anxiety. This review concerned all treatment frameworks, both guided and unguided formats and all age groups.

DATA EXTRACTION AND SYNTHESIS

In random-effects meta-analysis, we estimated pooled effects on depression symptoms and anxiety in terms of Hedges' g with 95% CIs. Absolute and relative heterogeneity was quantified as the τ2 and I 2.

RESULTS

We included 57 trials with 21 795 participants. Nine trials (16%) recruited exclusively from routine care, and three (5%) delivered treatment via video. For adults, large within-group reductions were seen in depression (g=0.90; 95% CI 0.81 to 0.99) and anxiety (g=0.87; 95% CI 0.78 to 0.96). Compared with rudimentary passive controls, the added effects were moderate (depression: g=0.52; 95% CI 0.42 to 0.63; anxiety: g=0.45; 95% CI 0.34 to 0.56) and larger in trials that required all participants to meet full diagnostic criteria for depression or an anxiety disorder. Compared with attention/engagement controls, the added effects were small (depression: g=0.30; 95% CI 0.07 to 0.53; anxiety: g=0.21; 95% CI 0.01 to 0.42). Heterogeneity was substantial, and the certainty of the evidence was very low. Two trials concerned adolescents and reported mixed results. One trial concerned older adults and reported promising results.

CONCLUSION

Internet-delivered transdiagnostic treatments for depression and anxiety show small-to-moderate added effects, varying by control condition. Research is needed regarding routine care, the video format, children and adolescents and older adults.

PROSPERO REGISTRATION NUMBER

CRD42021243172.

Transdiagnostic and tailored internet intervention to improve mental health among university students: Research protocol for a randomized controlled trial

BACKGROUND

Emerging adulthood is often associated with mental health problems. About one in three university students report symptoms of depression and anxiety that can negatively affect their developmental trajectory concerning work, intimate relationships, and health. This can interfere with academic performance, as mood and anxiety disorders are key predictors of dropout from higher education. A treatment gap exists, where a considerable proportion of students do not seek help for mood and anxiety symptoms. Offering internet interventions to students with mental health problems could reduce the treatment gap, increase mental health, and improve academic performance. A meta-analysis on internet interventions for university students showed small effects for depression and none for anxiety. Larger trials are recommended to further explore effects of guidance, transdiagnostic approaches, and individual treatment components.

METHODS

This study will offer 1200 university students in Sweden participation in a three-armed randomized controlled trial (RCT) evaluating a guided or unguided transdiagnostic internet intervention for mild to moderate depression and anxiety, where the waitlist control group accesses the intervention at 6-month follow-up. Students reporting suicidal ideation/behaviors will be excluded and referred to treatment within the existing healthcare system. An embedded study within the trial (SWAT) will assess at week 3 of 8 whether participants in the guided and unguided groups are at higher risk of failing to benefit from treatment. Those at risk will be randomized to an adaptive treatment strategy, or to continue the treatment as originally randomized. Primary outcomes are symptoms of depression and anxiety. Follow-ups will occur at post-treatment and at 6-, 12-, and 24-month post-randomization. Between-group outcome analyses will be reported, and qualitative interviews about treatment experiences are planned.

DISCUSSION

This study investigates the effects of a transdiagnostic internet intervention among university students in Sweden, with an adaptive treatment strategy employed during the course of treatment to minimize the risk of treatment failure. The study will contribute knowledge about longitudinal trajectories of mental health and well-being following treatment, taking into account possible gender differences in responsiveness to treatment. With time, effective internet interventions could make treatment for mental health issues more widely accessible to the student group.

Assessing gambling disorder using frequency- and time-based response options: A Rasch analysis of the gambling disorder identification test

OBJECTIVES

The Gambling Disorder Identification Test (GDIT) is a recently developed self-report measure. The GDIT includes items with multiple response options that are either based on frequency or time, and item response theory evaluations of these could yield vital knowledge on its measurement performance.

METHODS

The GDIT was evaluated using Rasch analysis in a study involving 597 Swedish gamblers.

RESULTS

In a three-dimensional Rasch model, the item response difficulty range extended from -1.88 to 4.06 and increased with higher time- and frequency-based responses. Differential item functioning showed that some GDIT items displayed age and gender-related differences. Additionally, person-separation reliability indicated the GDIT could reliably be divided into three to four diagnostic levels.

CONCLUSIONS

The frequency- and time-based item response options of the GDIT offer excellent measurement, allowing for elaborate assessment across both lower and higher gambling severity. The GDIT can be used to detect DSM-5 Gambling Disorder, thereby holding significance from both epidemiological and clinical standpoints. Notably, the 3-item GDIT Gambling Behavior subscale also shows potential as a brief screening tool for identifying at-risk gambling behavior.

Assessing Gambling Disorder Using Semistructured Interviews or Self-Report? Evaluation of the Structured Clinical Interview for Gambling Disorder Among Swedish Gamblers

The Structured Clinical Interview for Gambling Disorder (SCI-GD) has the potential to bridge a diagnostic clinical gap, but psychometric evaluations have been scarce, in particular in relation to self-reported diagnostic criteria. This study analyzed existing data, including Swedish gamblers (N = 204) from treatment- and help-seeking contexts, self-help groups, and the general population, who were interviewed with the SCI-GD and completed self-report measures. The results indicated that fewer individuals fulfilled the diagnostic criteria for gambling disorder (GD) with the SCI-GD (n = 110, 54%), compared to a self-report Diagnostic and Statistical Manual of Mental Disorders:5th Edition (DSM-5) questionnaire on GD (n = 145, 71%; p < .001). Agreement between interviews and self-reported criteria was generally low (Fleiss kappa range: 0.31-0.52; r range: 0.35-0.55). A Rasch analysis showed that specific diagnostic criteria varied in difficulty, indicating a general pattern of higher item difficulty for the SCI-GD compared to self-reported DSM-5 criteria. Both the SCI-GD and the self-reported DSM-5 criteria performed well in terms of internal consistency, convergent, and discriminant validity. We conclude that the SCI-GD is a reliable and valid diagnostic tool to assess GD among individuals with various gambling behavior patterns. Further research-related and clinical implications are discussed.

Two novel prehabilitation apps to help patients stop smoking and risky drinking prior to hip and knee arthroplasty

PURPOSE

Daily smoking or risky drinking increases the risk of complications after surgery by ~50%. Intensive prehabilitation aimed at complete cessation reduces the complication rate but is time-consuming. The purpose of this study was to carry out preoperative pilot tests (randomized design) of the feasibility (1A) and validation (1B) of two novel prehabilitation apps, habeat® (Ha-app) or rehaviour® (Re-app).

METHODS

Patients scheduled for hip or knee arthroplasty with daily smoking, risky drinking, or both were randomised to one of the two apps. In part 1A, eight patients and their staff measured feasibility on a visual analog scale (VAS) and were interviewed about what worked well and the challenges requiring improvement. In part 1B, seven patients and their staff tested the improved apps for up to two weeks before validating the understanding, usability, coverage, and empowerment on a VAS and being interviewed.

RESULTS

In 1A, all patients and staff returned scores of ≥5 for understanding the apps and mostly suggested technical improvements. In 1B, the scores varied widely for both apps, with no consensus achieved. Two of four patients (Ha-app) and one-third of the patients (Re-app) found the apps helpful for reducing smoking, but without successful quitting. The staff experienced low app competencies among patients and high time consumption. Specifically, patients most often needed help for the Ha-app, and the staff most often for Re-app; however, the staff reported the Re-app dashboard was more user-friendly. Support and follow-up from an addiction specialist staff member were suggested to complement the apps, thereby increasing the time consumption for staff.

CONCLUSIONS

This pilot study to test prototype apps generated helpful feedback for the app developers. Based on the patient and staff comments, multiple improvements in functionality seem required before scaling up the evaluation for effect on prehabilitation and postoperative complications.

The meaning and feeling of the time and space between psychotherapy sessions and everyday life: Client experiences of transitions

OBJECTIVE

To explore how clients in psychodynamic or psychoanalytic psychotherapy, conducted in the traditional in-person setting, experience the transitions in time and space between psychotherapy sessions and everyday life.

METHOD

Twelve semi-structured interviews were analyzed with inductive experiential thematic analysis, focusing on how the participants experience and make sense of the phenomenon in focus.

RESULTS

The participants described therapy as a sheltered space where they could be open, vulnerable, receptive, and present. Approaching and leaving psychotherapy sessions, the participants established different behavioral patterns and routines dealing with their anxieties and resistances. In this in-between area, the participants could handle interconnections and differences between therapy and everyday life. Participants stressed the clinical impact of transitions: transitions affect both therapy and everyday life; disturbed transitions have an adverse impact; transitions are insufficiently addressed in therapy.

CONCLUSION

Transitions between therapy and life appear to be an essential but seldom recognized part of the therapy process beyond the borders of therapy sessions. Implications of these findings for psychotherapy training and practice are discussed, and a tentative transtheoretical framework for further research is proposed.

Problematic substance use among patients in a Swedish outpatient psychiatry setting: staff and manager perceptions of digital options for increased intervention access

BACKGROUND

Approximately 50% of the patients who globally seek help in psychiatry have been assessed with problematic substance use or been diagnosed with substance use disorder (SUD). Given the high treatment gap for mental health care, in particular SUD, these individuals risk poorer treatment outcomes in psychiatry. Integrated treatment for psychiatric and SUD disorders has been proposed to reduce the treatment gap for SUD, but access to integrated treatment is low. Digital interventions addressing SUD in psychiatry could potentially make treatment available to patients who otherwise would not have access. In this study "digital interventions" comprise an umbrella term covering all kinds of interventions from minimal motivational app-based interventions to internet-based interventions with and without human guidance, up to remote sessions in telepsychiatry. This study aims to explore healthcare staff perceptions of referring patients to digital interventions for reducing problematic substance use, whether or not diagnosed as SUD, in the psychiatric outpatient setting.

METHOD

The study was exploratory with a qualitative design. Data were collected in the Swedish outpatient psychiatry setting, via individual semi-structured interviews with managers, and focus groups with healthcare staff. An adapted form of phenomenological hermeneutical analysis was used to analyze the data.

RESULTS

Three themes emerged from the analysis. The first theme was Encountering obstacles on the path to future implementation of digital interventions, with sub-themes: Lacking resources and Feeling concerned about technical solutions. The second theme was Searching for ways forward to achieve increased access to care, with sub-themes: Blended care could facilitate integrated care and Addressing variations in patients' technical skills. The third theme was Taking steps towards the future, with sub-themes: Wanting to know more about digital interventions and Formulating a vision for the future.

CONCLUSIONS

The study reveals a concern that implementing digital interventions in psychiatry will create additional work or be technically challenging. The staff see significant advantages from the patient perspective, but they feel that they themselves need training in implementing digital interventions. In order to establish constructive implementation of digital interventions for SUD in psychiatry, staff attitudes and concerns need to be considered and addressed. This study was conducted within the Swedish healthcare system and the findings may not generalize to other countries with differing healthcare systems.

Healthy lifestyle promotion via digital self-help for mental health patients in primary care: a pilot study including an embedded randomized recruitment trial

AIM

This study piloted a digital self-help intervention facilitating healthy lifestyle for patients with mental health problems in primary care.

BACKGROUND

Patients with mental health problems show more unhealthy lifestyle behaviors than the general population and prior research indicates that healthy lifestyle behaviors can improve mental health.

METHODS

This pilot study assessed use of a self-help digital intervention for healthy lifestyle promotion and included an embedded randomized recruitment trial, where all patients were randomized to digital self-help plus treatment as usual (TAU) or to TAU only. Patients seeking help for mental health problems were recruited from two primary care clinics in Stockholm, Sweden, and offered participation in a healthy lifestyle promotion study via digital self-help. Outcome measures included use-related assessment of inclusion and follow-up rates at both clinics, participant characteristics, and intervention adherence. Secondary outcomes included depression (the Patient Health Questionnaire-9) and anxiety (the GAD-7) up to 10 weeks, and changes in alcohol and tobacco use, physical activity, and diet.

RESULTS

The study included 152 patients. The recruitment rate, initially low, increased after involving the clinicians more and maintaining more frequent contact with the patients. The 10-week missing data rate was 33/152 (22%). Participants were 70% (106/152) women, with a mean age of 42 years (SD = 14); fewer than half (38%, n = 58/152) had one or more high-risk unhealthy behaviors at inclusion. Psychiatric symptoms were moderate at baseline and declined in both groups after 10 weeks (d = 0.57-0.75). No between-group effects over time occurred on depression (b = 0.3 [95% CI -1.6, 2.2]; d = 0.06), anxiety (b = -0.7 [-2.5, 1.2]; d = 0.13), or lifestyle behaviors (b = 0.01 [-0.3, 0,3]; d = -0.01).

CONCLUSIONS

Recruitment routines seemed to be decisive for reaching as many patients as possible. The relatively low rate of unhealthy lifestyle behaviors and small effect sizes suggests that the intervention may only suit patients at risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03691116 (01/10/2018), focusing on the embedded trial. Retrospectively registered for the first clinic and prospectively for the second clinic.

Study environment and the incidence of mental health problems and activity-limiting musculoskeletal problems among university students: the SUN cohort study

OBJECTIVE

To determine the association between different aspects of study environment and the incidence of mental health problems and activity-limiting musculoskeletal problems.

DESIGN, SETTING AND PARTICIPANTS

We recruited a cohort of 4262 Swedish university students of whom 2503 (59%) were without moderate or worse mental health problems and 2871 (67%) without activity-limiting musculoskeletal problems at baseline. The participants were followed at five time points over 1 year using web surveys.

EXPOSURES

Self-rated discrimination, high study pace, low social cohesion and poor physical environment measured at baseline.

OUTCOMES

Self-rated mental health problems defined as scoring above cut-off on any of the subscales of the Depression, Anxiety and Stress Scale. Self-rated activity-limiting musculoskeletal problems in any body location assessed by the Nordic Musculoskeletal Questionnaire.

STATISTICAL ANALYSIS

Discrete survival-time analysis was used to estimate the hazard rate ratio (HR) of each exposure-outcome combination while adjusting for gender, age, living situation, education type, year of studies, place of birth and parental education as potential confounders.

RESULTS

For discrimination, adjusted HRs were 1.75 (95% CI 1.40 to 2.19) for mental health problems and 1.39 (95% CI 1.12 to 1.72) for activity-limiting musculoskeletal problems. For high study pace, adjusted HRs were 1.70 (95% CI 1.48 to 1.94) for mental health problems and 1.25 (95% CI 1.09 to 1.43) for activity-limiting musculoskeletal problems. For low social cohesion, adjusted HRs were 1.51 (95% CI 1.29 to 1.77) for mental health problems and 1.08 (95% CI 0.93 to 1.25) for activity-limiting musculoskeletal problems. For perceived poor physical study environment, adjusted HRs were 1.20 (95% CI 0.99 to 1.45) for mental health problems and 1.20 (95% CI 1.01 to 1.43) for activity-limiting musculoskeletal problems.

CONCLUSIONS

Several aspects of the study environment were associated with the incidence of mental health problems and activity-limiting musculoskeletal problems in this sample of Swedish university students.

High- versus low-intensity internet interventions for alcohol use disorders (AUD): A two-year follow-up of a single-blind randomized controlled trial

Alcohol Use Disorders (AUD) are widespread and have serious consequences, but are among the most undertreated mental disorders. Internet interventions have been found effective in treating AUD, but we know little about long-term outcomes, two years or more after treatment. This study explored 12- and 24-month outcomes in alcohol consumption following initial 6-month improvements after a therapist-guided high-intensity internet intervention and an unguided low-intensity internet intervention among individuals with alcohol use disorder. Between-group comparisons were analyzed, as well as within-group comparisons with (1) pre-treatment measurements (2) post-treatment measurements. Participants consisted of a general population sample of internet help-seekers in Sweden. A total of 143 adults (47% men) with a score of 14 (women)/16 (men) or more on the Alcohol Use Disorders Identification Test, alcohol consumption of 11 (women)/14 (men) or more standard drinks the preceding week and ≥ 2 DSM-5 alcohol use disorder (AUD) criteria based on a diagnostic interview were included. The high- and low-intensity internet interventions (n = 72 and n = 71 respectively) consisted of modules based on relapse prevention and cognitive-behavioral therapy. The primary outcome was self-reported alcohol consumption in the preceding week measured as (1) number of standard drinks and (2) number of heavy drinking days. Attrition from self-reported questionnaires was 36% at the 12-month follow-up and 53% at the 24-month follow-up. No significant between-group differences occurred in outcomes at either long-term follow-up. Regarding within-group differences, compared to pre-treatment, alcohol consumption was lower in both high- and low-intensity interventions at both long-term follow-ups [within-group standard drinks effect sizes varied between g = 0.38-1.04 and heavy drinking days effect sizes varied between g = 0.65-0.94]. Compared to post-treatment, within-group alcohol consumption in the high intensity intervention increased at both follow-ups; for the low-intensity intervention, within-group consumption decreased at 12-month follow-up, but did not differ compared to post-treatment at 24 months. Both high- and low-intensity internet interventions for AUD were thus associated with overall reductions in alcohol consumption at long term follow-ups, with no significant differences between the two. However, conclusions are hampered by differential and non-differential attrition.

Screening and treating problematic substance use among patients in psychiatry - obstacles and solutions

OBJECTIVE

In Sweden, national guidelines recommend that all staff in the healthcare system systematically screen patients for alcohol use and illicit substance use. Where hazardous use is identified, it should be addressed as soon as possible, preferably through brief interventions (BI). Results from a previous national survey showed that most clinic directors stated that they had clear guidelines for screening alcohol use and illicit substance use, but that fewer staff than expected used screening in their work. This study aims to identify obstacles and solutions to screening and brief intervention, based on survey respondents' free-text responses to open-ended questions.

RESULTS

A qualitative content analysis yielded four codes: guidelines, continuing education, cooperation and resources. The codes indicated that staff would need (a) clearer routines in order to optimize compliance with the national guidelines; (b) more knowledge about how to treat patients with problematic substance use; (c) better cooperation between addiction care and psychiatry; and (d) increased resources to improve routines at their own clinic. We conclude that increased resources could contribute to better routines and cooperation, and provide increased opportunities for continuing education. This could increase guideline compliance and increase healthy behavior changes among patients in psychiatry with problematic substance use.

What do we know about alcohol internet interventions aimed at employees?-A scoping review

Background

Internet interventions are a promising avenue for delivering alcohol prevention to employees. The objective of this scoping review was to map all research on alcohol internet interventions aimed at employees regardless of design, to gain an overview of current evidence and identify potential knowledge gaps.

Methods

We conducted a literature search in three data bases (PsycInfo, PubMed, and Web of Science). Eligibility criteria were that (1) the study targeted employees age ≥18 years; (2) the intervention was delivered predominantly online; (3) the study focused specifically or in part on alcohol use; and (4) the study was published in English in a peer-reviewed academic journal. Two reviewers independently screened, reviewed, and extracted data.

Results

Twenty studies were included, of which 10 were randomized controlled trials, five were secondary analyses, three were feasibility trials, one was a cohort study and one described the rationale and development of an intervention. No qualitative studies were found. Randomized trials tended to show effects when interventions were compared to waitlists but not when more intensive interventions were compared to less intensive ones. We identified two design-related aspects where studies differed; (1) whether all applicants were included regardless of alcohol use level and (2) whether the intervention was explicitly framed as alcohol-focused or not. Significant recruitment problems were noted in several studies.

Conclusions

Alcohol internet interventions hold promise in delivering alcohol prevention to employees, but heterogeneity in study design and difficulties in recruitment complicate interpretation of findings.

Systematic review registration

https://osf.io/25x7e/, Open Science Framework.

Feasibility of a video-delivered mental health course for primary care patients: a single-group prospective cohort study

BACKGROUND

In many health care systems, primary care is tasked with offering psychological treatment for common mental disorders. Resources are often limited, which complicates widespread dissemination of traditional psychological treatments. Stepped care models where the less resource-intensive interventions are delivered first, can be employed, but often do not eliminate the need for a thorough diagnostic assessment, which can be time-consuming, has the potential to bottleneck patient intake, and can add to waiting times. Novel low-threshold formats are needed to improve access to mental health care in the primary care setting.

METHODS

This was a single-group prospective cohort study (N = 91). We assessed the feasibility of a video-delivered course as a first-line intervention for patients seeking help for mental health problems at a primary care center. The course had a transdiagnostic approach, suitable for both depression and anxiety disorders, and was based on cognitive behavioral techniques. Patients in need of psychosocial assessment, which usually entailed a four- to six-week wait, were referred by physicians or triage nurses. Study participants could start within a week, without the need for conventional diagnostic assessment, and were informed that they would be offered assessment after the course if needed. Key feasibility outcomes included participant satisfaction, attendance rates, the proportion of participants in need of additional clinical intervention after the course, and the rate of clinically significant improvement in anxiety and depression symptoms.

RESULTS

Participants scored a mean of 21.8 (SD = 4.0, 9-32, n = 86) on the Client Satisfaction Questionnaire-8; just below our target of 22. The mean attendance rate was 5.0/6 lectures (SD = 1.6, range: 0-6, n = 91). Forty-six percent (37/81) reported experiencing no need of further clinical intervention after the course. The rate of clinically significant improvement was 59% (27/46) for anxiety and 48% (22/46) for depression. No serious adverse event was reported.

CONCLUSIONS

Delivering a low-threshold online video-delivered mental health course in primary care appears to be feasible. Adjustments to further improve patient satisfaction are warranted, such as offering the choice of participating online or face-to-face.

TRIAL REGISTRATION

(ClinicalTrials.gov NCT04522713) August 21, 2020.

"I see myself": Craving imagery among individuals with addictive disorders

Craving has been put forward as a core feature of addictive disorders.

The present qualitative study investigated the experience of craving among individuals with addictive disorders and recent experiences of cravings.

Eleven individuals with Gambling Disorder and ten with Alcohol Use Disorder (n = 21) were recruited. A semi-structured interview explored: (1) modes of thought during craving (mental imagery or verbal thoughts), (2) craving content, (3) coping strategies and (4) craving context.

The thematic analysis showed that cravings were initially dominated by imagery, with a subsequent conflict between imagery and verbal thoughts. Craving content included imagery of preparative rituals, anticipation, and sensory activation, imagery of the addictive behavior "me, there and then imagery" and anticipating that "something good will come out of it." Some participants related to craving as a symptom of sickness, and coping with craving were through distraction, reminding oneself of negative consequences, or via sensory control: avoiding stimuli associated with the addiction. Craving contexts included typical settings of drinking or gambling and engagement of both positive and negative emotions. Alcohol craving was described as an expected relief from internal stimuli, such as anxiety or stress, whereas gambling craving was more often described as an expectancy of financial reward.

Craving was experienced mainly through imagery containing the preparative routines and expected outcomes. Future research and clinical practice should incorporate mode of thought in cravings to better understand its role in the maintenance of the disorders and their treatment.

Supplemental data for this article is available online at https://doi.org/10.1080/10550887.2022.2058299 .

What Predicts Treatment Adherence and Low-Risk Drinking? An Exploratory Study of Internet Interventions for Alcohol Use Disorders

INTRODUCTION

Internet interventions for alcohol problems are effective, but not all participants are helped. Further, the importance of adherence has often been neglected in research on internet interventions for alcohol problems. Prediction analysis can help in prospectively assessing participants' probability of success, and ideally, this information could be used to tailor internet interventions to individual needs.

METHODS

Data were obtained from a randomized controlled trial on internet interventions for alcohol use disorders. Twenty-nine candidate predictors were run in univariate logistic regressions with two dichotomous dependent outcomes: adherence (defined as completing at least 60% of the treatment modules) and low-risk drinking (defined as drinking within national public health guidelines) at two time points - immediately post-treatment and at the 6-month follow-up. Significant predictors were entered hierarchically into domain-specific logistic regressions. In the final models, predictors still showing significant effects were run in multiple logistic regressions.

RESULTS

One predictor significantly predicted adherence: treatment credibility (as in how logical the treatment is and how successful one perceives the treatment to be) assessed during the third week of the intervention. Four predictors significantly predicted low-risk drinking at the post-treatment follow-up: pre-treatment abstinence (i.e., not drinking during the 7 days before treatment started), being of the male gender, and two personality factors - a low degree of antagonism and a high degree of alexithymia. At the 6-month follow-up, pre-treatment abstinence was the only significant predictor.

CONCLUSION

Adherence was not predictive of low-risk drinking. Personality variables may have predictive value and should be studied further. Those who abstain from alcohol during the week before treatment starts have a higher likelihood of achieving low-risk drinking than people who initially continue drinking.

The Gambling Disorders Identification Test (GDIT): Psychometric Evaluation of a New Comprehensive Measure for Gambling Disorder and Problem Gambling

The novel gambling disorder identification test (GDIT) was recently developed in an international Delphi and consensus process. In this first psychometric evaluation, gamblers (N = 603) were recruited from treatment- and support-seeking contexts (n = 79 and n = 185), self-help groups (n = 47), and a population sample (n = 292). Participants completed self-report measures, a GDIT retest (n = 499), as well as diagnostic semistructured interviews assessing gambling disorder (GD; n = 203). The GDIT showed excellent internal consistency reliability (α = .94) and test-retest reliability (6-16 days, intraclass correlation coefficient = 0.93). Confirmatory factor analysis yielded factor loadings supporting the three proposed GDIT domains of gambling behavior, gambling symptoms, and negative consequences. Receiver operator curves and clinical significance indicators were used to estimate GDIT cut-off scores in relation to recreational (<15) and problem gambling (15-19), any GD (≥20), mild GD (20-24), moderate GD (25-29), and severe GD (≥30). The GDIT can be considered a valid and reliable measure to identify and predict GD severity, as well as problem gambling. In addition, the GDIT improves content validity in relation to an international research agreement concerning features of gambling outcome measures, known as the Banff Consensus Agreement.

Academic self-efficacy: Associations with self-reported COVID-19 symptoms, mental health, and trust in universities' management of the pandemic-induced university lockdown

Objective: To investigate perceived changes in academic self-efficacy associated with self-reported symptoms of COVID-19, changes in mental health, and trust in universities' management of the pandemic and transition to remote education during lockdown of Swedish universities in the spring of 2020. Methods: 4495 participated and 3638 responded to self-efficacy questions. Associations were investigated using multinomial regression. Results: Most students reported self-experienced effects on self-efficacy. Lowered self-efficacy was associated with symptoms of contagion, perceived worsening of mental health and low trust in universities' capacity to successfully manage the lockdown and transition to emergency remote education. Increased self-efficacy was associated with better perceived mental health and high trust in universities. Conclusion: The initial phase of the pandemic was associated with a larger proportion of students reporting self-experienced negative effects on academic self-efficacy. Since self-efficacy is a predictor of academic performance, it is likely that students' academic performance will be adversely affected.

What to target in cognitive behavioral treatment for gambling disorder-A qualitative study of clinically relevant behaviors

BACKGROUND

From a clinical perspective, knowledge of the psychological processes involved in maintaining gambling disorder has been lacking. This qualitative study formulated hypotheses on how gambling disorder is maintained by identifying clinically relevant behaviors at an individual level, as a means to guide the development of new cognitive behavioral interventions.

METHODS

Six individuals from a treatment study, diagnosed with gambling disorder and with diverse symptom profiles of psychiatric comorbidity, were recruited. Participants were interviewed using an in-depth semi-structured functional interview and completed self-report measures assessing gambling behavior.

RESULTS

Functional analysis was used as a theoretical framework for a thematic analysis, which yielded the following categories: 1) antecedents that may increase or decrease gambling; 2) experiences accompanying gambling; 3) control strategies; 4) consequences of gambling behavior; and 5) events terminating gambling behavior. Few differences were identified in relation to symptom profiles of psychiatric comorbidity, although some gamblers did not report experiencing abstinence when not being able to gamble.

CONCLUSIONS

Gambling is a secluded activity mainly triggered by access to money. Positive and negative emotions could be both antecedents and functions of gambling behavior. Avoidance-based strategies used to control gambling might result in a failure to learn to control gambling behavior. Anticipation, selective attention, and chasing could be important reinforcers, which should be addressed in new developments in cognitive behavioral treatment for gambling disorder.

A Behavior-based Coding Tool for Assessing Supervisors' Adherence and Competence: Findings From a Motivational Interviewing Implementation Study

Supervision seems to be an essential part of therapist training, and thus also of implementing evidence-based practices. However, there is a shortage of valid and reliable instruments for objective assessment of supervision competence that include both global measures and frequency counts of behavior - two essential aspects of supervisory competence. This study tests the internal consistency and inter-rater reliability of an assessment tool that includes both these measures. Additionally, strategies and techniques used by ten supervisors in 35 Motivational interviewing supervision sessions are described. Codings were conducted after two separate coding training sessions. The internal consistency across the global measures was acceptable (α = 0.70; 0.71). After the second training, the inter-rater reliabilities for all frequency counts were in the moderate to good range, except for two that were in the poor range; inter-rater reliability for one of the four global measures was in the moderate range, and three were in the poor range. A prerequisite for identifying specific supervisor skills central to the development of therapist skills, teaching these skills to supervisors, and performing quality assurance of supervision, is to create instruments that can measure these behaviors. This study is a step in that direction.

Symptoms of COVID-19 contagion in different social contexts in association to self-reported symptoms, mental health and study capacity in Swedish university students

Objective

The present study investigates if symptoms of COVID-19 contagion in different social contexts (cohabitants, family, acquaintances, and others) are associated with university students' own self-reported symptoms of COVID-19 contagion, mental health, and study capacity. This was investigated by a cross-sectional survey administrated in Sweden during the first wave of the COVID-19 pandemic, at the time when universities were locked down to limit viral spread and contagion.

Results

Mild to moderate symptoms of COVID-19 in cohabitants and family members were associated with student’s self-reported symptoms of contagion, while no associations could be seen in relation to mental health and study capacity. Symptoms of COVID-19 contagion in acquaintances and others were not associated with students’ self-reported symptoms, nor with their mental health and study capacity.

To conclude, during the initial lockdown of universities students’ self-reported symptoms of contagion were mainly associated with cohabitants and family members, while symptoms of contagion in different social contexts were not associated with mental health and study capacity. Findings suggest that lockdown of universities may have contributed to limiting infection pathways, while still allowing students to focus on their studies despite significant contagion among others known to the student.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06009-z.

Effectiveness, Cost-effectiveness, and Cost-Utility of a Digital Alcohol Moderation Intervention for Cancer Survivors: Health Economic Evaluation and Outcomes of a Pragmatic Randomized Controlled Trial

Background

Alcohol moderation (AM) interventions may contribute to better treatment outcomes and the general well-being of cancer survivors.

Objective

This study evaluates the effectiveness, cost-effectiveness, and cost-utility of MyCourse, a digital AM intervention, compared with a noninteractive digital information brochure for cancer survivors.

Methods

A health economic evaluation alongside a pragmatic 2-arm parallel-group randomized controlled trial was conducted with follow-ups at 3, 6, and 12 months after randomization. The study was conducted on the web in the Netherlands from 2016 to 2019. Participants were adult 10-year cancer survivors drinking over the Dutch-recommended drinking guidelines (≤7 standard units [10 g of alcohol] per week) with the intention to moderate or quit drinking. Overall, 103 participants were randomized and analyzed: 53 (51.5%) in the MyCourse group and 50 (48.5%) in the control group. In the MyCourse group, participants had access to a newly developed, digital, minimally guided AM intervention, MyCourse–Moderate Drinking. The primary outcome was the self-reported number of standard drinks (10 g of ethanol) consumed in the past 7 days at the 6-month follow-up. The secondary outcome measures were alcohol-related problems as measured by the Alcohol Use Disorders Identification Test (AUDIT) and treatment satisfaction. For the health economic evaluation, health care costs, costs because of productivity losses, and intervention costs were assessed over a 12-month horizon.

Results

Alcohol use at the 6-month follow-up decreased by 38% in the MyCourse group and by 33% in the control group. No difference in 7-day alcohol use was found between the groups (B=2.1, 95% CI −7.6 to 3.1; P=.22) at any of the follow-ups. AUDIT scores for alcohol-related problems decreased over time in both groups, showing no significant difference between the groups (Cohen d=0.3, 95% CI −0.1 to 0.6; P=.21). Intervention costs per participant were estimated at US $279 for the MyCourse group and US $74 for the control group. The mean societal costs were US $18,092 (SD 25,662) and US $23,496 (SD 34,327), respectively. The MyCourse group led to fewer gained quality-adjusted life years at lower societal costs in the cost-utility analysis. In the cost-effectiveness analysis, the MyCourse group led to a larger reduction in drinking units over time at lower societal costs (incremental cost-effectiveness ratio per reduced drink: US $ −1158, 95% CI −1609 to −781).

Conclusions

At 6 months, alcohol use was reduced by approximately one-third in both groups, with no significant differences between the digital intervention MyCourse and a noninteractive web-based brochure. At 12 months, cost-effectiveness analyses showed that MyCourse led to a larger reduction in drinking units over time, at lower societal costs. The MyCourse group led to marginally fewer gained quality-adjusted life years, also at lower societal costs.

Trial Registration

Netherlands Trial Register NTR6010; https://www.trialregister.nl/trial/5433

International Registered Report Identifier (IRRID)

RR2-10.1186/s12885-018-4206-z

Emotion regulation-enhanced group treatment for gambling disorder: a non-randomized pilot trial

BACKGROUND

Despite the association of Gambling Disorder (GD) with poor mental health, treatment options generally lack components targeting emotional difficulties. This study investigated the feasibility and acceptability of adding strategies of emotion regulation to an eight-session weekly group treatment.

METHOD

This non-randomized pilot study recruited 21 treatment-seeking adults with GD, (mean age = 36.3, 19% females) from addiction care. In a mixed methods design, measures of within-group changes in self-reported symptoms of GD were complemented with thematic analysis of post-treatment interviews regarding the feasibility of the treatment.

RESULTS

Within-group scores on the Gambling Symptoms Assessment Scale (G-SAS) showed a 47% decrease (β: -0.1599, 95% CI: - 0.2526 to - 0.0500) from pre-treatment to 12-month follow-up, with Hedges' g = 1.07 (CI: 0.57-1.60). The number of GD-symptoms according to the Structured Clinical Interview for Gambling Disorder (SCI-GD) decreased from 7.0 (SD = 1.60) at pre-treatment to 2.1 (SD = 2.36) at 12-month follow-up. Participants completed an average of 6.3 sessions and rated the intervention high in satisfaction and acceptability. Feasibility interviews showed no noticeable negative effects or ethical issues. Furthermore, helpful components in the treatment were: increased awareness of emotional processes and strategies to deal with difficult emotions.

CONCLUSIONS

Adding emotion regulation strategies in the treatment of GD is feasible and acceptable and warrants further investigation in a controlled trial.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov (Identifier NCT03725735 ).

Treatment for problem gambling and counselors' perception of their clinical competence: a national web survey in Sweden

BACKGROUND

Despite their crucial role in bridging science and practice, not much is known about counselors offering treatment for Problem Gambling (PG). This study maps current treatment, the type of change techniques that are prioritized in treatment and how counselors perceive their clinical competence in their work with PG clients.

METHODS

A sample of PG counselors from the healthcare and social services (N = 188, mean age: 49 years, 67% women) completed an online survey. A principal component analysis was conducted to map prioritized types of change techniques, and a multiple regression analysis was carried out to analyze predictors of counselors' role adequacy in their clinical work.

RESULTS

There was a large variation in the type of treatments offered for PG (mean 3.6). Cognitive Behavioral Therapy (CBT) and Motivational Interviewing were the most common treatments offered and motivation was rated as the most important type of change technique prioritized in the treatment of PG. A principal component analysis identified four components reflecting different types of change techniques prioritized by the counselors: (1) standard CBT, e.g., gambling cognitions, craving management, and finding alternative activities, (2) assessment of PG, (3) family orientation, i.e., involvement of concerned significant others in treatment, and (4) focus on exposure strategies. Counseling more clients monthly was associated with higher levels of willingness, adequacy and legitimacy in their clinical work with clients with PG. Additionally, offering CBT was a predictor for higher role adequacy and providing counseling on the origins of and consequences of PG.

CONCLUSION

There was a large heterogeneity among the treatments offered and what change techniques that were prioritized among the PG counselors. Clinical experience is of importance for developing competence in treating clients with PG. This finding suggests there could be benefits to establishing specialized, more visible treatment units where PG counselors could gain adequate clinical experience, thus increasing clinical competence for treating PG.

Evaluation of a Brief Online Self-help Program for Concerned Gamblers

The purpose of this study was to evaluate the feasibility and module content of a brief online self-help program for concerned gamblers, i.e., gamblers who perceived a need to change their gambling habits, in the context of a gambling helpline. The program consisted of four modules based on Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT), covering motivation to change, logging gambling behaviors, planning and implementing gambling-free activities, and managing risk situations. Gambling expenditures were also logged in the program, and their development over time were analyzed as longitudinal data using marginalized two-part models. Out of 4655 gamblers recruited via the helpline's webpage, 92% completed content in at least one module, and 23% were active in all four modules. Attrition was in general high, with only 10% retention in the gambling log for longer than 14 days. Gambling expenditures decreased for those who logged them for a shorter time period, whereas it increased for those who logged expenditures for a longer time period. This study shows that it is relatively easy to recruit participants to an online program for concerned gamblers in the context of a gambling helpline. However, since few users logged in to the program more than once, we suggest future online programs to have open modules with all content accessible at once.

Does the management of personal integrity information lead to differing participation rates and response patterns in mental health surveys with young adults? A three-armed methodological experiment

OBJECTIVES

This study evaluates whether initiation rates, completion rates, response patterns and prevalence of psychiatric conditions differ by level of personal integrity information given to prospective participants in an online mental health self-report survey.

METHODS

A three-arm, parallel-group, single-blind experiment was conducted among students from two Swedish universities. Consenting participants following e-mail invitation answered the World Health Organization (WHO) World Mental Health-International College Student (WMH-ICS) mental health self-report survey, screening for eight psychiatric conditions. Random allocation meant consenting to respond (1) anonymously; (2) confidentially, or (3) confidentially, where the respondent also gave consent for collection of register data.

RESULTS

No evidence was found for overall between-group differences with respect to (1) pressing a hyperlink to the survey in the invitation email; and (2) abandoning the questionnaire before completion. However, participation consent and self-reported depression were in the direction of higher levels for the anonymous group compared to the two confidential groups.

CONCLUSIONS

Consent to participate is marginally affected by different levels of personal integrity information. Current standard participant information procedures may not engage participants to read the information thoroughly, and online self-report mental health surveys may reduce stigma and thus be less subject to social desirability bias.

Associations between compliance with covid-19 public health recommendations and perceived contagion in others: a self-report study in Swedish university students

Objective

During the COVID pandemic, government authorities worldwide have tried to limit the spread of the virus. Sweden’s distinctive feature was the use of voluntary public health recommendations. Few studies have evaluated the effectiveness of this strategy. Based on data collected in the spring of 2020, this study explored associations between compliance with recommendations and observed symptoms of contagion in others, using self-report data from university students.

Results

Compliance with recommendations ranged between 69.7 and 95.7 percent. Observations of moderate symptoms of contagion in “Someone else I have had contact with” and “Another person” were markedly associated with reported self-quarantine, which is the most restrictive recommendation, complied with by 81.2% of participants. Uncertainty regarding the incidence and severity of contagion in cohabitants was markedly associated with the recommendation to avoid public transportation, a recommendation being followed by 69.7%. It is concluded that students largely followed the voluntary recommendations implemented in Sweden, suggesting that coercive measures were not necessary. Compliance with recommendations were associated with the symptoms students saw in others, and with the perceived risk of contagion in the student’s immediate vicinity. It is recommended that voluntary recommendations should stress personal relevance, and that close relatives are at risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05848-6.

Effects of Internet-Based Cognitive Behavioral Therapy for Harmful Alcohol Use and Alcohol Dependence as Self-help or With Therapist Guidance: Three-Armed Randomized Trial

Background

Alcohol use is a major contributor to health loss. Many persons with harmful use or alcohol dependence do not obtain treatment because of limited availability or stigma. They may use internet-based interventions as an alternative way of obtaining support. Internet-based interventions have previously been shown to be effective in reducing alcohol consumption in studies that included hazardous use; however, few studies have been conducted with a specific focus on harmful use or alcohol dependence. The importance of therapist guidance in internet-based cognitive behavioral therapy (ICBT) programs is still unclear.

Objective

This trial aims to investigate the effects of a web-based alcohol program with or without therapist guidance among anonymous adult help-seekers.

Methods

A three-armed randomized controlled trial was conducted to compare therapist-guided ICBT and self-help ICBT with an information-only control condition. Swedish-speaking adult internet users with alcohol dependence (3 or more International Classification of Diseases, Tenth Revision criteria) or harmful alcohol use (alcohol use disorder identification test>15) were included in the study. Participants in the therapist-guided ICBT and self-help ICBT groups had 12-week access to a program consisting of 5 main modules, as well as a drinking calendar with automatic feedback. Guidance was given by experienced therapists trained in motivational interviewing. The primary outcome measure was weekly alcohol consumption in standard drinks (12 g of ethanol). Secondary outcomes were alcohol-related problems measured using the total alcohol use disorder identification test-score, diagnostic criteria for alcohol dependence and alcohol use disorder, depression, anxiety, health, readiness to change, and access to other treatments or support. Follow-up was conducted 3 (posttreatment) and 6 months after recruitment.

Results

During the recruitment period, from March 2015 to March 2017, 1169 participants were included. Participants had a mean age of 45 (SD 13) years, and 56.72% (663/1169) were women. At the 3-month follow-up, the therapist-guided ICBT and control groups differed significantly in weekly alcohol consumption (−3.84, 95% Cl −6.53 to −1.16; t₄₁₇=2.81; P=.005; Cohen d=0.27). No significant differences were found in weekly alcohol consumption between the self-help ICBT group and the therapist-guided ICBT at 3 months, between the self-help ICBT and the control group at 3 months, or between any of the groups at the 6-month follow-up. A limitation of the study was the large number of participants who were completely lost to follow-up (477/1169, 40.8%).

Conclusions

In this study, a therapist-guided ICBT program was not found to be more effective than the same program in a self-help ICBT version for reducing alcohol consumption or other alcohol-related outcomes. In the short run, therapist-guided ICBT was more effective than information. Only some internet help-seekers may need a multisession program and therapist guidance to change their drinking when they use internet-based interventions.

Trial Registration

ClinicalTrials.gov NCT02377726; https://clinicaltrials.gov/ct2/show/NCT02377726

A Longitudinal Study of Gambling Behaviors During the COVID-19 Pandemic in Sweden

This study aimed to investigate changes in gambling behaviors during the first and second waves of the COVID-19 pandemic in Sweden. Participants who had gambled within the past year were recruited from social media and the Swedish National Helpline (n = 325, mean age 39.8 years, 64.8% males, 31.3% with problem gambling) and completed an online survey measuring gambling behaviors, consequences of the pandemic in general and worries related to the pandemic. A sub-sample (n = 139) completed a follow-up survey, during the second wave. The results showed no significant associations between COVID-19 consequences (financial or increased isolation) and increased monthly gambling behavior. No major migrations were observed between game types. However, gambling on a high-risk game (OR = 7.44, p < 0.001) and worrying about mental health due to the pandemic (OR = 2.85, p < 0.001) were significantly associated with past year gambling problems and increased monthly gambling problems from the first to the second wave. More longitudinal research is needed in vulnerable populations, to fully understand the long-term consequences of the pandemic.

The "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) Core Outcome Set: International Consensus on Outcomes to Measure in Efficacy and Effectiveness Trials of Alcohol Brief Interventions

OBJECTIVE

The purpose of this study was to report the "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) recommended core outcome set (COS) to improve efficacy and effectiveness trials/evaluations for alcohol brief interventions (ABIs).

METHOD

A systematic review identified 2,641 outcomes in 401 ABI articles measured by 1,560 different approaches. These outcomes were classified into outcome categories, and 150 participants from 19 countries participated in a two-round e-Delphi outcome prioritization exercise. This process prioritized 15 of 93 outcome categories for discussion at a consensus meeting of key stakeholders to decide the COS. A psychometric evaluation determined how to measure the outcomes.

RESULTS

Ten outcomes were voted into the COS at the consensus meeting: (a) typical frequency, (b) typical quantity, (c) frequency of heavy episodic drinking, (d) combined consumption measure summarizing alcohol use, (e) hazardous or harmful drinking (average consumption), (f) standard drinks consumed in the past week (recent, current consumption), (g) alcohol-related consequences, (h) alcohol-related injury, (i) use of emergency health care services (impact of alcohol use), and (j) quality of life.

CONCLUSIONS

The ORBITAL COS is an international consensus standard for future ABI trials and evaluations. It can improve the synthesis of new findings, reduce redundant/selective reporting (i.e., reporting only some, usually significant outcomes), improve between-study comparisons, and enhance the relevance of trial and evaluation findings to decision makers. The COS is the recommended minimum and does not exclude other, additional outcomes.

The “Outcome Reporting in Brief Intervention Trials: Alcohol” (ORBITAL) Core Outcome Set: International Consensus on Outcomes to Measure in Efficacy and Effectiveness Trials of Alcohol Brief Interventions

Objective:

The purpose of this study was to report the “Outcome Reporting in Brief Intervention Trials: Alcohol” (ORBITAL) recommended core outcome set (COS) to improve efficacy and effectiveness trials/evaluations for alcohol brief interventions (ABIs).

Method:

A systematic review identified 2,641 outcomes in 401 ABI articles measured by 1,560 different approaches. These outcomes were classified into outcome categories, and 150 participants from 19 countries participated in a two-round e-Delphi outcome prioritization exercise. This process prioritized 15 of 93 outcome categories for discussion at a consensus meeting of key stakeholders to decide the COS. A psychometric evaluation determined how to measure the outcomes.

Results:

Ten outcomes were voted into the COS at the consensus meeting: (a) typical frequency, (b) typical quantity, (c) frequency of heavy episodic drinking, (d) combined consumption measure summarizing alcohol use, (e) hazardous or harmful drinking (average consumption), (f) standard drinks consumed in the past week (recent, current consumption), (g) alcohol-related consequences, (h) alcohol-related injury, (i) use of emergency health care services (impact of alcohol use), and (j) quality of life.

Conclusions:

The ORBITAL COS is an international consensus standard for future ABI trials and evaluations. It can improve the synthesis of new findings, reduce redundant/selective reporting (i.e., reporting only some, usually significant outcomes), improve between-study comparisons, and enhance the relevance of trial and evaluation findings to decision makers. The COS is the recommended minimum and does not exclude other, additional outcomes.

Compliance with recommendations limiting COVID-19 contagion among university students in Sweden: associations with self-reported symptoms, mental health and academic self-efficacy

AIMS

The COVID-19 containment strategy in Sweden uses public health recommendations relying on personal responsibility for compliance. Universities were one of few public institutions subject to strict closure, meaning that students had to adapt overnight to online teaching. This study investigates the prevalence of self-reported recommendation compliance and associations with self-reported symptoms of contagion, self-experienced effects on mental health and academic self-efficacy among university students in Sweden in May-June 2020.

METHODS

This was a cross-sectional 23 question online survey in which data were analysed by multinomial regression, taking a Bayesian analysis approach complemented by null hypothesis testing.

RESULTS

A total of 4495 students consented to respond. Recommendation compliance ranged between 70% and 96%. Women and older students reported higher compliance than did men and younger students. Mild to moderate COVID-19 symptoms were reported by 30%, severe symptoms by fewer than 2%; 15% reported being uncertain and half of the participants reported no symptoms. Mental health effects were reported by over 80%, and changes in academic self-efficacy were reported by over 85%; in both these areas negative effects predominated. Self-reported symptoms and uncertainty about contagion were associated with non-compliance, negative mental health effects, and impaired academic self-efficacy.

CONCLUSIONS

Students generally followed public health recommendations during strict closure of universities, but many reported considerable negative consequences related to mental health and academic self-efficacy. Digital interventions should be developed and evaluated to boost coping skills, build resilience and alleviate student suffering during the pandemic and future similar crises.

Definition and Characteristics of Behavioral Medicine, and Main Tasks and Goals of the International Society of Behavioral Medicine-an International Delphi Study

BACKGROUND

In the past decades, behavioral medicine has attained global recognition. Due to its global reach, a critical need has emerged to consider whether the original definition of behavioral medicine is still valid, comprehensive, and inclusive, and to reconsider the main tasks and goals of the International Society of Behavioral Medicine (ISBM), as the umbrella organization in the field. The purpose of the present study was to (i) update the definition and scope of behavioral medicine and its defining characteristics; and (ii) develop a proposal on ISBM's main tasks and goals.

METHOD

Our study used the Delphi method. A core group prepared a discussion paper. An international Delphi panel rated questions and provided comments. The panel intended to reach an a priori defined level of consensus (i.e., 70%).

RESULTS

The international panel reached consensus on an updated definition and scope of behavioral medicine as a field of research and practice that builds on collaboration among multiple disciplines. These disciplines are concerned with development and application of behavioral and biomedical evidence across the disease continuum in clinical and public health domains. Consensus was reached on a proposal for ISBM's main tasks and goals focused on supporting communication and collaboration across disciplines and participating organizations; stimulating research, education, and practice; and supporting individuals and organizations in the field.

CONCLUSION

The consensus on definition and scope of behavioral medicine and ISBM's tasks and goals provides a foundational step toward achieving these goals.

Development of the Gambling Disorder Identification Test: Results from an international Delphi and consensus process

OBJECTIVES

Diverse instruments are used to measure problem gambling and Gambling Disorder intervention outcomes. The 2004 Banff consensus agreement proposed necessary features for reporting gambling treatment efficacy. To address the challenge of including these features in a single instrument, a process was initiated to develop the Gambling Disorder Identification Test (GDIT), as an instrument analogous to the Alcohol Use Disorders Identification Test and the Drug Use Disorders Identification Test.

METHODS

Gambling experts from 10 countries participated in an international two-round Delphi (n = 61; n = 30), rating 30 items proposed for inclusion in the GDIT. Gambling researchers and clinicians from several countries participated in three consensus meetings (n = 10; n = 4; n = 3). User feedback was obtained from individuals with experience of problem gambling (n = 12) and from treatment-seekers with Gambling Disorder (n = 8).

RESULTS

Ten items fulfilled Delphi consensus criteria for inclusion in the GDIT (M ≥ 7 on a scale of 1-9 in the second round). Item-related issues were addressed, and four more items were added to conform to the Banff agreement recommendations, yielding a final draft version of the GDIT with 14 items in three domains: gambling behavior, gambling symptoms and negative consequences.

CONCLUSIONS

This study established preliminary construct and face validity for the GDIT.

Staff experiences of encountering and treating outpatients with substance use disorder in the psychiatric context: a qualitative study

Background

High comorbidity exists between mental illness and substance use disorders (SUD). Patients in psychiatry living with problematic alcohol or drug consumption can experience a sense of exclusion, where seeking help for SUD can be perceived as stigmatizing. The aim of this study is to illuminate staff experiences of encountering patients with SUD within the psychiatric outpatient context.

Methods

The study was exploratory, with a qualitative design. Interviews with outpatient psychiatry managers and focus groups with clinical staff focused on the experience of encountering patients with SUD. Data were evaluated using content analysis inspired by phenomenological-hermeneutic methodology.

Results

Three themes were identified and each illuminated by two sub-themes. Bridging the organizational gap included sub-themes of having an established collaboration and facing difficulties in the collaboration; Having beliefs about the patient you encounter included sub-themes of working with patients who are exposed to prejudicial thoughts and expressing prejudicial thoughts about the patient. Striving to achieve a therapeutic alliance included sub-themes of having a feeling of developing together and supporting the patient towards recovery.

Conclusion

A life-world perspective, used to interpret results, indicated that caring for patients with SUD in psychiatry was perceived as difficult, where collaboration between psychiatry and addiction care was often experienced as problematic. Based on these findings, we believe that the current gap between the psychiatry and addiction care could be reduced to some extent by offering patients digital treatment for SUD. In this way, patients could remain under the care of their regular psychiatric clinic without having to physically visit SUD services. Thus, a virtual bridge could be established to bring psychiatry and addiction care closer to each other for the patients’ benefit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00235-9.

Internet-based therapy versus face-to-face therapy for alcohol use disorder, a randomized controlled non-inferiority trial

BACKGROUND AND AIMS

Most people with alcohol use disorder (AUD) are never treated. Internet-based interventions are effective in reducing alcohol consumption and could help to overcome some of the barriers to people not seeking or receiving treatment. The aim of the current study was to compare internet-delivered and face-to-face treatment among adult users with AUD.

DESIGN

Randomized controlled non-inferiority trial with a parallel design, comparing internet-delivered cognitive-behavioural therapy (ICBT) (n = 150) with face-to-face CBT (n = 151), at 3- and 6-month follow-ups.

SETTING

A specialized clinic for people with AUD in Stockholm, Sweden. Participants were recruited between 8 December 2015 and 5 January 2018.

PARTICIPANTS

A total of 301 patients [mean age 50 years, standard deviation (SD) = 12.3] with AUD, of whom 115 (38%) were female and 186 (62%) were male.

INTERVENTION AND COMPARATOR

Participants were randomized in blocks of 20 at a ratio of 1 : 1 to five modules of therapist-guided ICBT or to five modules of face-to-face CBT, delivered over a 3-month period. The same treatment material and the same therapists were used in both groups.

MEASUREMENTS

The primary outcome was standard drinks of alcohol consumed during the previous week at 6-month follow-up, analysed according to intention-to-treat. The pre-specified non-inferiority limit was five standard drinks of alcohol and d = 0.32 for secondary outcomes.

RESULTS

The difference in alcohol consumption between the internet and the face-to-face group was non-inferior in the intention-to-treat analysis of data from the 6-month follow-up [internet = 12.33 and face-to-face = 11.43, difference = 0.89, 95% confidence interval (CI) = -1.10 to 2.88]. The secondary outcome, Alcohol Use Disorder Identification Test score, failed to show non-inferiority of internet compared with face-to-face in the intention-to-treat analysis at 6-month follow-up (internet = 12.26 and face-to-face = 11.57, d = 0.11, 95% CI = -0.11 to 0.34).

CONCLUSIONS

Internet-delivered treatment was non-inferior to face-to-face treatment in reducing alcohol consumption among help-seeking patients with alcohol use disorder but failed to show non-inferiority on some secondary outcomes.

Psychometric properties of the short version of the children of alcoholics screening test (CAST-6) among Swedish adolescents

AIMS

The Children of Alcoholics Screening Test (CAST-6) is a brief screening instrument developed to identify children with parents having problematic alcohol use. The aim of this study was to evaluate the psychometric properties of the CAST-6 among adolescents aged 15-18 years, and also to identify an optimal cut-off score for this age group.

METHODS

A total of 3000 15 to18 year-olds were randomly selected from a register of postal addresses in Sweden. An invitation letter, including access information to the electronic questionnaire, was sent out by regular mail and 1450 adolescents responded with baseline data. Test-retest reliability within a 2-3-week period was calculated based on the 111 respondents who answered the same questionnaire twice. To determine an optimal cut-off score, a small treatment-seeking sample (n = 22) was recruited from a support group agency to be used as a reference group.

RESULTS

The six items of the CAST-6 screening test loaded onto one latent factor with good internal consistency (alpha = 0.88), and excellent test-retest reliability (ICC = 0.93, 95% CI 0.90-0.95). The optimal cut-off score among adolescents was 2 points with a sensitivity of 55% and specificity of 79% (AUROC = 0.71, 95% CI 0.58-0.83).

CONCLUSIONS

The CAST-6 has good to excellent psychometric properties among adolescents. The identified optimal cut-off score of 2 points should be treated with caution due to study limitations. The CAST-6 can be used in various settings to identify a vulnerable at-risk group of children and adolescents that may be in need of support.

Transitioning Between Online Gambling Modalities and Decrease in Total Gambling Activity, but No Indication of Increase in Problematic Online Gambling Intensity During the First Phase of the COVID-19 Outbreak in Sweden: A Time Series Forecast Study

Introduction: The COVID-19 outbreak will likely have a public health impact beyond immediate disease transmission. Little is known about whether social distancing and other societal changes has provoked an increase in gambling, whether decreased betting opportunities due to paused sports events spurred gamblers to transition to online casino gambling, or whether any of these factors have had an impact on problem gambling.

Methods: Data on lookup queries against the Swedish Gambling Paus registry, logging all initiated gambling sessions by all licensed gambling providers, from 2019-01-01 (start of registry) to 2020-04-08 (well into the first phase of the outbreak) were analyzed using TBATS time series forecasting to estimate trends after the first domestic COVID-19 death. Obfuscated data on daily total wagered and deposited amounts, split by modality (casino or betting, and low and high intensity, respectively) for the equivalent period were supplied by a licensed online gambling provider.

Results: Total gambling activity decreased by 13.29% during the first phase of the outbreak compared to forecast. Analyses of online gambling data revealed that although betting decreased substantially in synchrony with a slight increase in online casino gambling, there was no increase in likely problematic, high-intensity gambling and neither did total online gambling increase.

Conclusions: This first, preliminary study revealed no increase in Swedish gambling activity, total or specifically online, in the first phase of the COVID-19 outbreak. Future research should examine whether pandemic-induced transitioning between gambling modalities and/or increased participation in gambling, leads to long-term effects on prevalence of problem gambling.

e-INEBRIA Special Interest Group Roadmap for Best Practices for Research on Brief Digital Interventions for Problematic Alcohol and Illicit Drug Use

There is great potential for scaling up the delivery of brief interventions for alcohol and illicit drug use, given the increasing coverage of mobile devices and technologies for digital interventions, including apps for smartphones and tablets. However, while the number of digital interventions is increasing rapidly, the involvement of brief-intervention researchers and the development of good practices has just begun. In 2018, the Special Interest Group on digital interventions of the International Network on Brief Interventions for Alcohol & Other Drugs (e-INEBRIA SIG) initiated a conversation regarding possible avenues of future research, which subsequently became a roadmap for digital interventions. This roadmap consists of points considered relevant for future research, ongoing technological developments, and their implementation across a continuum of prevention and care. Moreover, it outlines starting points for the diversification of brief digital interventions, as well as next steps for quality improvement and implementation in public health and clinical practice. The roadmap of the e-INEBRIA SIG on digital interventions is a starting point that indicates relevant next steps and provides orientation for researchers and interested practitioners with regard to the ambiguous literature and the complexity of current digital interventions.

Internet-based cognitive behavior therapy for problem gambling in routine care: protocol for a non-randomized pilot and feasibility trial

Background

Problem gambling and gambling disorder are major public health concerns worldwide, and awareness of associated negative consequences is rising. In parallel, treatment demand has increased, and Internet interventions offer a promising alternative for providing evidence-based treatment at scale to a low cost.

Method

We developed a novel Internet-delivered cognitive behavioral treatment for gambling, based on qualitative interviews with treatment-seeking gamblers, behavioral research on gambling behavior, and the pathway model for problem gambling. This research protocol describes a non-randomized pilot and feasibility trial conducted in routine addiction care with adult treatment-seeking patients (max N = 25) with problem gambling. The primary aim is to ensure acceptability and safety, measured by satisfaction, credibility, working alliance, and possible negative effects. Secondary aims are feasibility of study procedures in terms of recruitment and measurement procedures as well as potential effectiveness measured weekly by gambling symptoms as primary outcome and gambling behavior, quality of life, symptoms of depression and anxiety, alcohol, and drug use as secondary outcomes. Potential mediators measured weekly are loss of control, verbal rules, and well-being.

Discussion

This study is innovative in several respects, regarding both treatment development and implementation. The results of the study will guide a future randomized controlled trial, as well as the development of the intervention and intervention implementation within ordinary addiction care.

Trial registration

Clinical trials.gov, NCT ID: NCT03946098. Registered 10 May 2019

Internet-Delivered Cognitive Behavioral Therapy for Problematic Alcohol Use in a Workplace Setting: Protocol for Quantitative and Qualitative Evaluation of Feasibility and Outcomes

BACKGROUND

Internet-based cognitive behavioral therapy (ICBT) for mental health issues has been successfully implemented in routine health care settings, and research indicates that ICBT can also be applied to decrease problematic alcohol use in workplace settings. However, studies investigating the feasibility of implementing ICBT in a workplace setting have been lacking.

OBJECTIVE

The current study aims to investigate the feasibility of delivering ICBT for problematic alcohol use within an employee assistance program (EAP).

METHODS

The study has a quantitative naturalistic design, quantitively comparing ICBT and face-to-face treatment, and allowing for qualitative interviews with employees and employers. Recruitment of participants follows a five-session in-person psychological assessment at an EAP regarding an employee's presumed problematic alcohol consumption. All assessed employees referred to ICBT or face-to-face treatment will be offered participation in the study. Interviews will be held with employees and their employer representatives following ICBT to elucidate both stakeholders' experience and perception of ICBT and its context. Outcome comparisons between ICBT and face-to-face treatment will be assessed quantitatively using a Reliable Change Index and analysis of variance. Thematic analysis and Grounded Theory will be used to analyze the interview material.

RESULTS

The study is set to begin in April 2020 and to end in September 2021. The aim is to recruit up to 150 participants to the quantitative part of the study and 45 participants (15 employees and 30 employer representatives) to the qualitative part of the study.

CONCLUSIONS

The current study will provide knowledge that is lacking and urgently needed on how to implement ICBT for problematic alcohol use in a workplace setting.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/18693.

Gambler clusters and problem gambling severity: A cluster analysis of Swedish gamblers accessing an online problem gambling screener

It has been proposed that overall gambling involvement has a stronger association with problem gambling (PG) than any specific game type. However, few studies have used multiple analytic approaches on the same data set to assess these relationships. The aims of the current study were to identify patterns of gambling activity (PGAs) and to assess the relationships between different game types, PGAs, gambling involvement, and PG as measured by the Problem Gambling Severity Index (PGSI), using two different approaches. In a sample of Swedish gamblers who screened their gambling habits at the Swedish national gambling helpline website (N = 7,463, 79% males), seven different PGAs were identified. Increased gambling involvement was associated with PG severity, and the strength of the association varied by game type. Online casino games and electronic gambling machines had the weakest involvement effect and lotteries the strongest. Almost 50% of the gamblers belonged to the online casino PGA, characterized by online casino gambling. Gamblers in this PGA showed higher PGSI scores compared to three PGAs: online sports/online casino, horse/lottery, and online sports, and they had lower PGSI scores compared to the diverse PGA, characterized by engagement in all game types. No differences in PGSI scores were found between gamblers in three PGAs with high probability of online casino gambling but with varying engagement levels in other game types. In a Swedish context, the results from this study indicate that the focus of prevention and regulation should be on game types with the strongest associations with PG, namely, online casino games. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Effects of an automated digital brief prevention intervention targeting adolescents and young adults with risky alcohol and other substance use: study protocol for a randomised controlled trial

INTRODUCTION

Adolescence and young adulthood is a period in life when individuals may be especially vulnerable to harmful substance use. Several critical developmental processes are occurring in the brain, and substance use poses both short-term and long-term risks with regard to mental health and social development. From a public health perspective, it is important to prevent or delay substance use to reduce individual risk and societal costs. Given the scarcity of effective interventions targeting substance use among adolescents and young adults, cost-effective and easily disseminated interventions are warranted. The current study will test the effectiveness of a fully automated digital brief intervention aimed at reducing alcohol and other substance use in adolescents and young adults aged 15 to 25 years.

METHODS AND ANALYSIS

A two-arm, double-blind, randomised controlled trial design is applied to assess the effectiveness of the intervention. Baseline assessment, as well as 3-month and 6-month follow-up, will be carried out. The aim is to include 800 participants with risky substance use based on the screening tool CRAFFT (Car,Relax, Alone, Forget, Friends, Trouble). Recruitment, informed consent, randomisation, intervention and follow-up will be implemented online. The primary outcome is reduction in alcohol use, measured by Alcohol Use Disorders Identification Test total score. Secondary outcomes concern binge drinking, frequency of alcohol consumption, amount of alcohol consumed a typical day when alcohol is consumed, average daily drinks per typical week, other substance use, mental health, sexual risk behaviours and perceived peer pressure. Moreover, the study involves analyses of potential moderators including perfectionism, openness to parents, help-seeking and background variables.

ETHICS AND DISSEMINATION

The study was approved by the Swedish Ethical Review Authority (no. 2019-03249). The trial is expected to expand the knowledge on digital preventive interventions for substance using adolescents and young adults. Results will be disseminated in research journals, at conferences and via the media.

TRIAL REGISTRATION NUMBER

24 September 2019, ISRCTN91048246; Pre-results.

Using alcohol consumption diary data from an internet intervention for outcome and predictive modeling: a validation and machine learning study

BACKGROUND

Alcohol use disorder (AUD) is highly prevalent and presents a large treatment gap. Self-help internet interventions are an attractive approach to lowering thresholds for seeking help and disseminating evidence-based programs at scale. Internet interventions for AUD however suffer from high attrition and since continuous outcome measurements are uncommon, little is known about trajectories and processes. The current study investigates whether data from a non-mandatory alcohol consumption diary, common in internet interventions for AUD, approximates drinks reported at follow-up, and whether data from the first half of the intervention predict treatment success.

METHODS

N = 607 participants enrolled in a trial of online self-help for AUD, made an entry in the non-mandatory consumption diary (total of 9117 entries), and completed the follow-up assessment. Using multiple regression and a subset of calendar data overlapping with the follow-up, scaling factors were derived to account for missing entries per participant and week. Generalized estimating equations with an inverse time predictor were then used to calculate point-estimates of drinks per week at follow-up, the confidence intervals of which were compared to that from the measurement at follow-up. Next, calendar data form the first half of the intervention were retained and summary functions used to create 18 predictors for random forest machine learning models, the classification accuracies of which were ultimately estimated using nested cross-validation.

RESULTS

While the raw calendar data substantially underestimated drinks reported at follow-up, the confidence interval of the trajectory-derived point-estimate from the adjusted data overlapped with the confidence interval of drinks reported at follow-up. Machine learning models achieved prediction accuracies of 64% (predicting non-hazardous drinking) and 48% (predicting AUD severity decrease), in both cases with higher sensitivity than specificity.

CONCLUSIONS

Data from a non-mandatory alcohol consumption diary, adjusted for missing entries, approximates follow-up data at a group level, suggesting that such data can be used to reveal trajectories and processes during treatment and possibly be used to impute missing follow-up data. At an individual level, however, calendar data from the first half of the intervention did not have high predictive accuracy, presumable due to a high rate of missing data and unclear missing mechanisms.

High- versus low-intensity internet interventions for alcohol use disorders: results of a three-armed randomized controlled superiority trial

AIMS

To test the efficacy of a therapist-guided high-intensity internet intervention compared with an unguided low-intensity internet intervention among individuals with alcohol use disorder.

DESIGN

A three-group randomized controlled trial with follow-up assessments post-treatment (12 weeks) and 6 months post-randomization (primary end-point).

SETTINGS

General population sample in Sweden.

PARTICIPANTS

A total of 166 on-line self-referred adults (49% males) with a score of 14 (females)/16 (males) or more on the Alcohol Use Disorders Identification Test, a preceding week alcohol consumption of 11 (females)/14 (males) or more standard drinks and an alcohol use disorder according to a diagnostic interview.

INTERVENTIONS AND COMPARATORS

Both the high- (n = 72) and low-intensity internet interventions (n = 71) consisted of modules based on relapse prevention. Controls were on a waiting-list (n = 23), and were only followed until the post-treatment follow-up. Participants were randomized at a 7 : 7 : 2 ratio.

MEASUREMENTS

Primary outcome was self-reported alcohol consumption in the preceding week measured as (1) number of standard drinks and (2) number of heavy drinking days at the 6-month follow-up.

FINDINGS

Alcohol use disorders were largely in the severe category (74.7%), with the majority of participants having had alcohol problems for more than 5 years. Attrition was 13 and 22% at the post-treatment and 6-month follow-up, respectively. At the 6-month follow-up, an intent-to-treat analysis showed no significant differences in alcohol consumption between the high- and low-intensity interventions [standard drinks d = -0.17, 95% confidence interval (CI) = -0.50 to 0.16; heavy drinking days: d = -0.07, 95% CI = -0.40 to 0.26]. Prevalence of negative effects was somewhat low (8-14%) in both intervention groups, as was deterioration (3-5%).

CONCLUSIONS

At 6-month follow-up, there were no significant differences between a therapist-guided high-intensity internet intervention and an unguided low-intensity internet intervention in reducing alcohol consumption among individuals with an alcohol use disorder.