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Ruehr L, Blomé S, Kastrati G, Lagerbäck T, Jonsjö M, Möller H, Skorpil M, Lasselin J, Lalouni M, Gerdhem P, Jensen K. Back morphology and walking patterns mean 13.8 years after surgery for lumbar disk herniation in adolescents. Pain Rep 2024; 9:e1148. [PMID: 38500565 PMCID: PMC10948132 DOI: 10.1097/pr9.0000000000001148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/17/2024] [Accepted: 01/20/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction In many pain conditions, there is lingering pain despite healed tissue damage. Our previous study shows that individuals who underwent surgery for lumbar disk herniation (LDH) during adolescence have worse health, more pain, and increased disk degeneration mean 13 years after surgery compared with controls. It is unclear if walking patterns segregate surgically treated LDH adolescents and controls at mean 13-year follow-up. Objectives Here, we analyzed the relationship between gait, back morphology and other health outcomes in a cohort of individuals treated surgically because of lumbar disk herniation compared with controls. Methods We analyzed gait during a walking paradigm, back morphology at the site of surgery, and standardized health outcomes, among individuals who received surgery for LDH as adolescents, "cases" (n = 23), compared with "controls" (n = 23). Results There were gait differences in head (P = 0.021) and trunk angle (P = 0.021) between cases and controls in a direction where cases exhibited a posture associated with sickness. The gait variance was explained by subjective pain and exercise habits rather than objective disk degeneration. Conclusion Over a decade after surgery for LDH during adolescence, health among cases is worse compared with controls. The head and trunk angles differ between cases and controls, indicating that the residual pain lingers and may cause changes in movement patterns long after a painful episode in early life. Gait may be a useful target for understanding maintenance of pain and disability among individuals treated surgically for LDH during adolescence.
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Affiliation(s)
- Livia Ruehr
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
- Max Planck School of Cognition, Leipzig, Germany
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Blomé
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gránit Kastrati
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Lagerbäck
- Department of Clinical Science, Intervention and Technology, Division of Orthopedics and Biotechnology, Karolinska Institutet, Stockholm, Sweden
| | - Martin Jonsjö
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hans Möller
- Department of Clinical Science, Intervention and Technology, Division of Orthopedics and Biotechnology, Karolinska Institutet, Stockholm, Sweden
- Center for Spine Surgery in Stockholm, Stockholm, Sweden
| | - Mikael Skorpil
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Julie Lasselin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Psychology, Stockholm University, Stockholm, Sweden
- Osher Center for Integrative Health, Karolinska Institutet, Stockholm, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Paul Gerdhem
- Department of Clinical Science, Intervention and Technology, Division of Orthopedics and Biotechnology, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopedics and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Karin Jensen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Axelsson E, Kern D, Hedman-Lagerlöf E, Lindfors P, Palmgren J, Hesser H, Andersson E, Johansson R, Olén O, Bonnert M, Lalouni M, Ljótsson B. Psychological treatments for irritable bowel syndrome: a comprehensive systematic review and meta-analysis. Cogn Behav Ther 2023; 52:565-584. [PMID: 37341454 DOI: 10.1080/16506073.2023.2225745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 06/05/2023] [Indexed: 06/22/2023]
Abstract
A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a.
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Affiliation(s)
- Erland Axelsson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Liljeholmen Primary Health Care Center, Region Stockholm, Stockholm, Sweden
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
| | - Dorian Kern
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Erik Hedman-Lagerlöf
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Perjohan Lindfors
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Josefin Palmgren
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hugo Hesser
- Center for Health and Medical Psychology, School of Behavioural, Social and Legal Sciences, Örebro University, Örebro, Sweden
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Erik Andersson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Robert Johansson
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Ola Olén
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Gastroenterology and Nutrition, Sachs' Children's Hospital, Stockholm, Sweden
| | - Marianne Bonnert
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Maria Lalouni
- Division of Neuro, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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van Leuven L, Enebrink P, Ghaderi A, Sorjonen K, Lalouni M, Forster M. A randomized controlled trial of Safer Kids - A program for parents reported for child abuse: Short-term effects on further reports of child abuse and related risk factors. Child Abuse Negl 2023; 143:106329. [PMID: 37384960 DOI: 10.1016/j.chiabu.2023.106329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Millions of children are victims of child abuse world-wide. Consequences include long-term health impacts and large societal costs. Parent training is promising to prevent abuse, but challenges with motivation and attrition must be overcome to reach parents in need. OBJECTIVE To assess the effectiveness and acceptability of Safer Kids, a cognitive behavioral therapy-based parenting program delivered immediately after a report of child abuse. Safer Kids is used within the Child Welfare Services (CWS) in Sweden but has never been evaluated in an RCT. PARTICIPANTS AND SETTING In total, 112 families with children 2-12 years referred to the Swedish CWS for physical or emotional child abuse participated. METHODS Families were randomized to Safer Kids or intervention as usual (IAU). Data from parents, children and CWS were analyzed with multilevel and survival analyses. Primary outcomes were parent-rated child abuse potential and re-reports of abuse. Secondary outcomes were child abuse risk factors and treatment satisfaction. RESULTS Data 4 and 7 months from baseline were available for 96 % of the families. All except one family (98 %) who started Safer Kids completed the program. Both groups improved from baseline to follow-ups on most effectiveness outcomes. The changes were not statistically different between groups. Parents and social workers were more satisfied with Safer Kids than IAU. CONCLUSIONS Short manualized parenting programs can be a way to reach parents reported for child abuse with support. Safer Kids is a viable option to the CWS's standard interventions, as it was equally effective and slightly better accepted than IAU.
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Affiliation(s)
- Livia van Leuven
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden.
| | - Pia Enebrink
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Ata Ghaderi
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Kimmo Sorjonen
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Division of Neuro, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Martin Forster
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
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Gedin F, Blomé S, Pontén M, Lalouni M, Fust J, Raquette A, Vadenmark Lundquist V, Thompson WH, Jensen K. Placebo Response and Media Attention in Randomized Clinical Trials Assessing Cannabis-Based Therapies for Pain: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2243848. [PMID: 36441553 PMCID: PMC9706362 DOI: 10.1001/jamanetworkopen.2022.43848] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Persistent pain is a common and disabling health problem that is often difficult to treat. There is an increasing interest in medicinal cannabis for treatment of persistent pain; however, the limited superiority of cannabinoids over placebo in clinical trials suggests that positive expectations may contribute to the improvements. OBJECTIVE To evaluate the size of placebo responses in randomized clinical trials in which cannabinoids were compared with placebo in the treatment of pain and to correlate these responses to objective estimates of media attention. DATA SOURCES A systematic literature search was conducted within the MEDLINE and Embase databases. Studies published until September 2021 were considered. STUDY SELECTION Cannabinoid studies with a double-blind, placebo-controlled design with participants 18 years or older with clinical pain of any duration were included. Studies were excluded if they treated individuals with HIV/AIDS or severe skin disorders. DATA EXTRACTION AND SYNTHESIS The study followed the Preferred Reporting Items for Systematic Review and Meta-analyses reporting guideline. Data were extracted by independent reviewers. Quality assessment was performed using the Risk of Bias 2 tool. Attention and dissemination metrics for each trial were extracted from Altmetric and Crossref. Data were pooled and analyzed using a random-effects statistical model. MAIN OUTCOMES AND MEASURES Change in pain intensity from before to after treatment, measured as bias-corrected standardized mean difference (Hedges g). RESULTS Twenty studies, including 1459 individuals (mean [SD] age, 51 [7] years; age range, 33-62 years; 815 female [56%]), were included. Pain intensity was associated with a significant reduction in response to placebo, with a moderate to large effect size (mean [SE] Hedges g, 0.64 [0.13]; P < .001). Trials with low risk of bias had greater placebo responses (q1 = 5.47; I2 = 87.08; P = .02). The amount of media attention and dissemination linked to each trial was proportionally high, with a strong positive bias, but was not associated with the clinical outcomes. CONCLUSIONS AND RELEVANCE Placebo contributes significantly to pain reduction seen in cannabinoid clinical trials. The positive media attention and wide dissemination may uphold high expectations and shape placebo responses in future trials, which has the potential to affect the outcome of clinical trials, regulatory decisions, clinical practice, and ultimately patient access to cannabinoids for pain relief.
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Affiliation(s)
- Filip Gedin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Blomé
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Moa Pontén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jens Fust
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Andreé Raquette
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - William H. Thompson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Applied Information Technology, University of Gothenburg, Gothenburg, Sweden
| | - Karin Jensen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Kłosowska J, Bajcar EA, Bieniek H, Brączyk J, Joshanloo M, Mattarozzi K, Bagnis A, Pontén M, Lalouni M, Geers AL, Clemens KS, Park J, Choi G, Choi YK, Jung W, Son E, Yoon HY, Bąbel P. Development and cross-national investigation of a model explaining participation in WHO-recommended and placebo behaviours to prevent COVID-19 infection. Sci Rep 2022; 12:17704. [PMID: 36271008 PMCID: PMC9586969 DOI: 10.1038/s41598-022-17303-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/22/2022] [Indexed: 01/18/2023] Open
Abstract
To protect themselves from COVID-19, people follow the recommendations of the authorities, but they also resort to placebos. To stop the virus, it is important to understand the factors underlying both types of preventive behaviour. This study examined whether our model (developed based on the Health Belief Model and the Transactional Model of Stress) can explain participation in WHO-recommended and placebo actions during the pandemic. Model was tested on a sample of 3346 participants from Italy, Japan, Poland, Korea, Sweden, and the US. It was broadly supported: objective risk and cues to action showed both direct and indirect (through perceived threat) associations with preventive behaviours. Moreover, locus of control, decision balance, health anxiety and preventive coping moderated these relationships. Numerous differences were also found between countries. We conclude that beliefs about control over health and perceived benefits of actions are critical to the development of interventions to improve adherence to recommendations.
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Affiliation(s)
- Joanna Kłosowska
- grid.5522.00000 0001 2162 9631Institute of Psychology, Jagiellonian University, ul. Ingardena 6, 30-060 Kraków, Poland
| | - Elżbieta A. Bajcar
- grid.5522.00000 0001 2162 9631Institute of Psychology, Jagiellonian University, ul. Ingardena 6, 30-060 Kraków, Poland
| | - Helena Bieniek
- grid.5522.00000 0001 2162 9631Institute of Psychology, Jagiellonian University, ul. Ingardena 6, 30-060 Kraków, Poland
| | - Justyna Brączyk
- grid.5522.00000 0001 2162 9631Institute of Psychology, Jagiellonian University, ul. Ingardena 6, 30-060 Kraków, Poland
| | - Mohsen Joshanloo
- grid.412091.f0000 0001 0669 3109Department of Psychology, Keimyung University, Daegu, Republic of Korea
| | - Katia Mattarozzi
- grid.6292.f0000 0004 1757 1758Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Arianna Bagnis
- grid.6292.f0000 0004 1757 1758Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Moa Pontén
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Maria Lalouni
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Andrew L. Geers
- grid.267337.40000 0001 2184 944XDepartment of Psychology, University of Toledo, Toledo, USA
| | - Kelly S. Clemens
- grid.267337.40000 0001 2184 944XDepartment of Psychology, University of Toledo, Toledo, USA
| | | | - Gahee Choi
- grid.412091.f0000 0001 0669 3109Department of Psychology, Keimyung University, Daegu, Republic of Korea
| | - Yun-Kyeung Choi
- grid.412091.f0000 0001 0669 3109Department of Psychology, Keimyung University, Daegu, Republic of Korea
| | - Wookyoung Jung
- grid.412091.f0000 0001 0669 3109Department of Psychology, Keimyung University, Daegu, Republic of Korea
| | - Eunjung Son
- grid.412091.f0000 0001 0669 3109Department of Psychology, Keimyung University, Daegu, Republic of Korea
| | - Hyae Young Yoon
- grid.412091.f0000 0001 0669 3109Department of Psychology, Keimyung University, Daegu, Republic of Korea
| | - Przemysław Bąbel
- grid.5522.00000 0001 2162 9631Institute of Psychology, Jagiellonian University, ul. Ingardena 6, 30-060 Kraków, Poland
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Lalouni M, Bujacz A, Bonnert M, Jensen KB, Rosengren A, Hedman-Lagerlöf E, Serlachius E, Olén O, Ljótsson B. Parental responses and catastrophizing in online cognitive behavioral therapy for pediatric functional abdominal pain: A mediation analysis of a randomized controlled trial. Front Pain Res (Lausanne) 2022; 3:962037. [PMID: 36262179 PMCID: PMC9574038 DOI: 10.3389/fpain.2022.962037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To test if decreased parental protective behaviors, monitoring behaviors, and parental catastrophizing mediate relief of gastrointestinal symptoms in children 8-12 years with functional abdominal pain disorders (FAPDs). The study uses secondary data analyses of a randomized controlled trial in which exposure-based online cognitive behavioral therapy (ICBT) was found superior to treatment as usual in decreasing gastrointestinal symptoms. Methods The ICBT included 10 weekly modules for children and 10 weekly modules for parents. Treatment as usual consisted of any medication, dietary adjustments, and healthcare visits that the participants engaged in during 10 weeks. All measures were self-assessed online by parents. Biweekly assessments of the Adult Responses to Children's Symptoms (ARCS), Protect and Monitor subscales, and the Pain Catastrophizing Scale, parental version (PCS-P) were included in univariate and multivariate growth models to test their mediating effect on the child's gastrointestinal symptoms assessed with the Pediatric Quality of Life Gastrointestinal Symptoms Scale (PedsQL). Results A total of 90 dyads of children with FAPDs and their parents were included in the study, of which 46 were randomized to ICBT and 44 to treatment as usual. The PCS-P was found to mediate change in the PedsQL ab = 0.639 (95% CI 0.020-2.331), while the ARCS Monitor ab = 0.472 (95% CI -1.002 to 2.547), and Protect ab = -0.151 (95% CI -1.455 to 0.674) were not mediators of change. Conclusions To target parental catastrophizing in ICBT for pediatric FAPDs is potentially important to reduce abdominal symptoms in children.
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Affiliation(s)
- Maria Lalouni
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden,Correspondence: Maria Lalouni
| | - Aleksandra Bujacz
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden,Department of Leadership and Command / Control, The Swedish Defense University, Stockholm, Sweden
| | - Marianne Bonnert
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet / Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Karin B. Jensen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Rosengren
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Erik Hedman-Lagerlöf
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet / Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden,Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Ola Olén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden,Department of Paediatric Gastroenterology and Nutrition, Sachs’ Children’s Hospital, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden,Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet / Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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van Leuven L, Lalouni M, Forster M. "Will it Work as Well on Zoom?" A Natural Experiment During the Covid-19 Pandemic of Delivering Parenting Groups Via Video Conferencing or in Person. J Child Fam Stud 2022; 32:67-80. [PMID: 35965634 PMCID: PMC9358366 DOI: 10.1007/s10826-022-02398-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 06/15/2023]
Abstract
While rates of child maltreatment increased during the Covid-19-pandemic, face-to-face interventions to support families got difficult to carry out due to restrictions. Meanwhile, many services do not have access to parenting programs designed for digital or remote delivery. A solution employed by some services was to use video conferencing (VC) to deliver their regular parenting programs. This study examined the effectiveness of the universal group-based parenting program ABC offered through VC instead of on-site meetings during the pandemic. Pre and post measurements were collected from 469 parents participating in either 1) ABC with VC meetings only, 2) on-site meetings only, or 3) blended - a combination of VC and on-site sessions. In addition, 74 group leaders completed a survey about their experiences of VC groups. Analyses showed general improvements in parent practices and child conduct over time, but no differences in effectiveness depending on the format of the parent group (VC, blended, or on-site). Qualitative analyses of group leaders' experiences revealed four key-themes pertaining to both challenges (e.g., concerns about parents' ability to benefit and learn parenting skills) and benefits (e.g., reaching parents who would not have been able to attend physical meetings) of VC groups. Overall, this study showed no significant differences in outcomes between the VC, blended, or on-site format of delivery. There are however limitations of this trial, and results should be considered preliminary. Effectiveness and potential negative consequences of replacing interventions intended to be delivered on-site with VC alternatives need to be further investigated in future trials.
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Affiliation(s)
- Livia van Leuven
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Division of Neuro, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Martin Forster
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
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Mortazavi R, Lalouni M, Grudin R, Serlachius E, Sundberg CJ, Norrbom J, Larsson I, Haglund E, Ivarsson A, Lenhard F, Cronqvist T, Ingemarsson K, Mårsell Å, Rask O, Jarbin H. Moderate-to-vigorous group aerobic exercise versus group leisure activities for mild-to-moderate depression in adolescents: study protocol for a multicentre randomised controlled trial. BMJ Open 2022; 12:e060159. [PMID: 35820753 PMCID: PMC9274524 DOI: 10.1136/bmjopen-2021-060159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/21/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Depression is common, increasing among adolescents and carries risk of disability, lower educational achievements, cardiovascular disease, substance abuse, self-harm and suicide. The effects of evidence-based treatments with medication or psychotherapy are modest. Aerobic exercise is a promising intervention for adolescents with depression, but available studies are hampered by methodological shortcomings. This study aims to evaluate aerobic group exercise versus an active comparator of leisure group activities in adolescents from clinical services with mild-to-moderate depression. METHODS AND ANALYSIS This study is a multicentre randomised controlled trial at four psychiatric clinics in Sweden. Participants (n=122) will be randomised 1:1 to group exercise delivered by exercise professionals and supported by mental health (MH) workers or leisure activities lead by the same MH workers for 1 hour three times a week for 12 weeks. Participants will be assessed at baseline, single blind after 13 weeks and 26 weeks and openly after 1 year. Participants randomised to the leisure group will be offered exercise in the open phase. The primary outcome is clinician-rated Children's Depression Rating Scale-Revised. Secondary outcomes are self-rated Quick Inventory of Depressive Symptomatology, self-rated functioning; clinician-rated improvement and functioning; objectively measured aerobic capacity, muscular strength, muscular endurance, body composition and presence or activity of selected biological markers of neuroprotection and neuroinflammation in blood samples. Further outcomes are cost-effectiveness and adolescents', parents' and coaches' experiences of the interventions and an exploration of how the adolescents' health and lifestyle are influenced by the interventions through qualitative interviews. ETHICS AND DISSEMINATION The study is approved by the Swedish Ethical Review Authority (Ref. 2021-05307-01). Informed consent in writing will be provided from patients and parents of participants below 15 years of age. The results of this study will be communicated to the included participants and healthcare providers and also submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05076214.
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Affiliation(s)
- Rebecca Mortazavi
- Department of Clinical Sciences, Child and Adolescent Psychiatry, Lund University, Lund, Sweden
- Child and Adolescent Psychiatry, Region Halland, Halmstad, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Region Stockholm, Sweden
| | - Rebecca Grudin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Region Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Sciences, Child and Adolescent Psychiatry, Lund University, Lund, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Region Stockholm, Sweden
| | - Carl Johan Sundberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Learning, Informatics, Karolinska Institutet, Stockholm, Sweden
| | - Jessica Norrbom
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Larsson
- Department of Health and Nursing, School of Health and Welfare, Halmstad University, Halmstad, Sweden
- Spenshult Research and Development Centre, Halmstad, Halland, Sweden
| | - Emma Haglund
- The Rydberg Laboratory for Applied Sciences, Halmstad, Sweden
- Department of Health and Sport, School of Health and Sport, Halmstad University, Halmstad, Sweden
| | - Andreas Ivarsson
- Department of Health and Nursing, School of Health and Welfare, Halmstad University, Halmstad, Sweden
- Department of Sport Science and Physical Education, University of Agder, Kristiansand, Norway
| | - Fabian Lenhard
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Åsa Mårsell
- PRIMA Barn- och Vuxenpsykiatri AB, Stockholm, Sweden
| | - Olof Rask
- Department of Clinical Sciences, Child and Adolescent Psychiatry, Lund University, Lund, Sweden
| | - Håkan Jarbin
- Department of Clinical Sciences, Child and Adolescent Psychiatry, Lund University, Lund, Sweden
- Child and Adolescent Psychiatry, Region Halland, Halmstad, Sweden
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Lalouni M, Olén O, Bjureberg J, Bonnert M, Chalder T, Hedman‐Lagerlöf E, Reme SE, Serlachius E, Ljótsson B. Validation of child-adapted short scales for measuring gastrointestinal-specific avoidance and anxiety. Acta Paediatr 2022; 111:1621-1627. [PMID: 35545865 PMCID: PMC9545055 DOI: 10.1111/apa.16403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/13/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022]
Abstract
Aim To validate child‐adapted shortened versions of the Irritable Bowel Syndrome‐Behavioural Responses Questionnaire (IBS‐BRQ; short scale denoted BRQ‐C) and the Visceral Sensitivity Index (VSI; short scale denoted VSI‐C) for children with functional abdominal pain disorders (FAPDs). Methods A child psychologist supervised by a child gastroenterologist was responsible for shortening the scales (BRQ‐C, 11 items; and VSI‐C, 7 items). Then, a sample of 89 children aged 8–12 years with FAPDs was used in the validation. Construct validity was assessed with correlations. Measures included gastrointestinal symptoms, quality of life, pain intensity and anxiety. Also, internal consistency, test–retest reliability, administration time and factor structure were assessed. Results Internal consistency for the BRQ‐C and the VSI‐C was α = 0.84 and α = 0.80, respectively. Correlations with related scales were similar between child‐adapted scales and original scales, indicating construct validity equivalence. Correlations between short scales and original scales were high. Mean administration time was reduced by 47% (BRQ‐C) and 42% (VSI‐C), compared with original scales. Test–retest reliability was r = 0.72 for BRQ‐C and r = 0.83 for VSI‐C. BRQ‐C had two factors (Avoidance and Bowel control). VSI‐C had a unifactorial structure. Conclusion The BRQ‐C and the VSI‐C were found to be time‐saving, reliable and valid for children with FAPDs.
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Affiliation(s)
- Maria Lalouni
- Department of Medicine, Solna Karolinska Institutet Stockholm Sweden
- Stockholm Health Care Services Region Stockholm Stockholm Sweden
- Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
| | - Ola Olén
- Department of Medicine, Solna Karolinska Institutet Stockholm Sweden
- Department of Paediatric Gastroenterology and Nutrition Sachs' Children's Hospital Stockholm Sweden
| | - Johan Bjureberg
- Stockholm Health Care Services Region Stockholm Stockholm Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research Karolinska Institutet Stockholm Sweden
| | - Marianne Bonnert
- Stockholm Health Care Services Region Stockholm Stockholm Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research Karolinska Institutet Stockholm Sweden
- Department of Medical Epidemiology and Biostatistics Karolinska Institutet Stockholm Sweden
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | | | | | - Eva Serlachius
- Stockholm Health Care Services Region Stockholm Stockholm Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research Karolinska Institutet Stockholm Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research Karolinska Institutet Stockholm Sweden
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10
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van Leuven L, Lalouni M, Enebrink P, Sorjonen K, Forster M. Feasibility and implementation of Safer Kids - A parenting program to reduce child abuse. Child Abuse Negl 2022; 123:105434. [PMID: 34894587 DOI: 10.1016/j.chiabu.2021.105434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/19/2021] [Accepted: 12/02/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Child abuse is a world-wide problem causing long-term suffering for children and large costs to society. Parent-training programs have been shown to reduce harsh parenting but more research on parenting programs specifically addressing child abuse is needed. OBJECTIVE This study aimed at assessing the feasibility, implementation, and preliminary effectiveness of Safer Kids (SK); a structured parent-training program delivered immediately after parents are reported for child abuse. PARTICIPANTS AND SETTING Caregivers were eligible if they had been reported for child abuse to the Swedish social services and their child was 3-12 years old. METHODS Families were allocated to SK or intervention as usual (IAU) through a quasi-experimental design. Multilevel analyses and a Cox Proportional Hazard Model were used to assess between-group differences in risk factors for abuse and further child welfare reports. RESULTS In total, 67 families participated. SK was successfully implemented as an early-start intervention and most families completed the intervention. All agencies continued working with SK two years after the study, indicating sustainability of implementation. SK was more effective than IAU in reducing further child welfare reports up to 18 months from baseline. However, analyses of parent and child rated risk factors of re-abuse (abuse potential, wellbeing, and parent-child relationships) indicate none to small differences between conditions. CONCLUSIONS SK can be successfully implemented within the social services and may be effective in reducing occurrence of further child welfare reports. The effects of SK need to be further evaluated in a randomized controlled trial.
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Affiliation(s)
- Livia van Leuven
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden.
| | - Maria Lalouni
- Department of Clinical Neuroscience, Division of Neuro, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden, Sweden
| | - Pia Enebrink
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Kimmo Sorjonen
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
| | - Martin Forster
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Nobels väg 9, 171 65 Solna, Sweden
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11
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Lalouni M, Fust J, Bjureberg J, Kastrati G, Fondberg R, Fransson P, Jayaram-Lindström N, Kosek E, Hellner C, Jensen KB. Augmented pain inhibition and higher integration of pain modulatory brain networks in women with self-injury behavior. Mol Psychiatry 2022; 27:3452-3459. [PMID: 35691963 PMCID: PMC9708552 DOI: 10.1038/s41380-022-01639-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/09/2022] [Accepted: 05/18/2022] [Indexed: 11/09/2022]
Abstract
Individuals who engage in nonsuicidal self-injury (NSSI) have demonstrated insensitivity to pain compared with individuals without NSSI. Yet, the neural mechanisms behind this difference are unknown. The objective of the present study was to determine which aspects of the pain regulatory system that account for this decreased sensitivity to pain. In a case-control design, 81 women, aged 18-35 (mean [SD] age, 23.4 [3.9]), were included (41 with NSSI and 40 healthy controls). A quantitative sensory testing protocol, including heat pain thresholds, heat pain tolerance, pressure pain thresholds, conditioned pain modulation (assessing central down-regulation of pain), and temporal summation (assessing facilitation of pain signals) was used. Pain-evoked brain responses were assessed by means of fMRI scanning during thermal pain. NSSI participants showed a more effective central down-regulation of pain, compared to controls, assessed with conditioned pain modulation. The neural responses to painful stimulation revealed a stronger relation between nociceptive and pain modulatory brain regions in NSSI compared to controls. In line with previous studies, pressure and heat pain thresholds were higher in participants with NSSI, however, there were no correlations between pain outcomes and NSSI clinical characteristics. The augmented pain inhibition and higher involvement of pain modulatory brain networks in NSSI may represent a pain insensitive endophenotype associated with a greater risk for developing self-injurious behavior.
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Affiliation(s)
- Maria Lalouni
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jens Fust
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Johan Bjureberg
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden ,grid.168010.e0000000419368956Department of Psychology, Stanford University, Stanford, CA USA
| | - Gránit Kastrati
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Robin Fondberg
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Peter Fransson
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Nitya Jayaram-Lindström
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Eva Kosek
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Clara Hellner
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Karin B. Jensen
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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12
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Nordh M, Wahlund T, Jolstedt M, Sahlin H, Bjureberg J, Ahlen J, Lalouni M, Salomonsson S, Vigerland S, Lavner M, Öst LG, Lenhard F, Hesser H, Mataix-Cols D, Högström J, Serlachius E. Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2021; 78:705-713. [PMID: 33978699 PMCID: PMC8117054 DOI: 10.1001/jamapsychiatry.2021.0469] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
IMPORTANCE Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited. OBJECTIVE To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT). DESIGN, SETTING, AND PARTICIPANTS This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study. INTERVENTIONS ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist. MAIN OUTCOMES AND MEASURES The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs. RESULTS Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03247075.
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Affiliation(s)
- Martina Nordh
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Tove Wahlund
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Maral Jolstedt
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Hanna Sahlin
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Johan Bjureberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Johan Ahlen
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maria Lalouni
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden,Division of Neuro, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sigrid Salomonsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Sarah Vigerland
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Malin Lavner
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Lars-Göran Öst
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Fabian Lenhard
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Hugo Hesser
- Center for Health and Medical Psychology, Örebro University, Örebro, Sweden,Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Jens Högström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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13
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Bonnert M, Särnholm J, Andersson E, Bergström SE, Lalouni M, Lundholm C, Serlachius E, Almqvist C. Targeting excessive avoidance behavior to reduce anxiety related to asthma: A feasibility study of an exposure-based treatment delivered online. Internet Interv 2021; 25:100415. [PMID: 34401374 PMCID: PMC8350602 DOI: 10.1016/j.invent.2021.100415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/13/2021] [Accepted: 06/11/2021] [Indexed: 12/11/2022] Open
Abstract
There is an established relationship between anxiety and asthma, which is associated with poor health outcomes. Most previous cognitive behavior therapies (CBT) have focused on comorbid panic disorder whereas anxiety related to asthma may rather be illness-specific. The feasibility of an online CBT targeting avoidance behavior in anxiety related to asthma was evaluated, using a pretest-posttest design. Thirty participants with self-reported anxiety related to asthma were offered an eight-week treatment with therapist support. Mean adherence was good (80% of content), and most participants (89%) reported adequate relief after treatment. Catastrophizing about asthma (CAS), assessed at 2 months after treatment, improved significantly with a large effect size (Cohen's d = 1.52). All secondary outcomes, including asthma control, avoidance behavior, fear of asthma symptoms and quality of life, improved significantly with moderate to large effect sizes (d: 0.40-1.44). All improvements were stable at 4 months follow up. Weekly ratings showed that a decrease in avoidance behavior predicted a decrease in CAS the following week throughout the treatment period. We conclude that CBT targeting avoidance behavior is a feasible treatment for anxiety related to asthma. The results justify investigation of efficacy and mechanisms of change in a randomized controlled trial. ClinicalTrials.gov, ID: NCT03486756.
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Affiliation(s)
- Marianne Bonnert
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 77 Stockholm, Sweden,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden, Norra Stationsgatan 69, 113 64 Stockholm, Sweden,Corresponding author at: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 65 Stockholm, Sweden.
| | - Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden, Nobels väg 9, 171 65 Stockholm, Sweden
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden, Nobels väg 9, 171 65 Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Gävlegatan 22, SE-113 30 Stockholm, Sweden
| | - Sten-Erik Bergström
- Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Division of Neuro, Karolinska Institutet, Sweden, Nobels väg 9, 171 65 Stockholm, Sweden
| | - Cecilia Lundholm
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 77 Stockholm, Sweden
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden, Norra Stationsgatan 69, 113 64 Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Gävlegatan 22, SE-113 30 Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 77 Stockholm, Sweden,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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14
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Hedman-Lagerlöf E, Fust J, Axelsson E, Bonnert M, Lalouni M, Molander O, Agrell P, Bergman A, Lindefors N, Bradley M. Internet-Delivered Cognitive Behavior Therapy for Atopic Dermatitis: A Randomized Clinical Trial. JAMA Dermatol 2021; 157:796-804. [PMID: 34009282 DOI: 10.1001/jamadermatol.2021.1450] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Atopic dermatitis is a common and debilitating skin condition characterized by intense itching and chronic inflammation. Research on behavioral treatments with high accessibility is needed. Objective To investigate the efficacy of a highly scalable internet-delivered cognitive behavior therapy (CBT) for adults with atopic dermatitis. Design, Setting, and Participants This randomized clinical trial from a medical university in Stockholm, Sweden, included 102 adults with atopic dermatitis, recruited from across Sweden, who received 12 weeks of internet-delivered CBT (March 29, 2017, to February 16, 2018). The first participant provided screening data on November 27, 2016, and the last 1-year follow-up assessment was conducted on June 28, 2019. Interventions Participants were randomized in a 1:1 ratio to 12 weeks of therapist-guided internet-delivered CBT (n = 51) or a control condition (n = 51) that gave instructions about standard care. Main Outcomes and Measures The primary outcome was the between-group difference in mean reduction of atopic dermatitis symptoms as measured by the Patient-Oriented Eczema Measure and modeled intention to treat during the 12-week treatment period. Results A total of 102 participants (mean [SD] age, 37 [11] years; 83 [81%] female) were recruited and randomized. The primary analysis indicated that participants receiving internet-delivered CBT, relative to the controls, had a significantly larger mean weekly reduction in symptoms of atopic dermatitis as measured with the Patient-Oriented Eczema Measure (B = 0.32; 95% CI, 0.14-0.49; P < .001), with a moderate to large, controlled effect size after treatment (d = 0.75; 95% CI, 0.32-1.16). Secondary analyses indicated that internet-delivered CBT also produced significantly larger reductions in itch intensity, perceived stress, sleep problems, and depression. Gains were sustained at 12 months of follow-up. Treatment satisfaction was high, and therapists spent a mean (SD) of 39.7 (34.7) minutes per treated patient providing internet-delivered CBT. Conclusions and Relevance Internet-delivered CBT appears to be efficacious for reducing symptoms of atopic dermatitis, despite requiring minimal therapist resources. Thus, internet-delivered CBT has the potential to increase access to effective adjunct behavioral treatment for patients with this common skin condition. Trial Registration ClinicalTrials.gov Identifier: NCT03051958.
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Affiliation(s)
| | - Jens Fust
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erland Axelsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Bonnert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Olof Molander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Petter Agrell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Bergman
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Nils Lindefors
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Maria Bradley
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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15
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Lalouni M, Hesser H, Bonnert M, Hedman-Lagerlöf E, Serlachius E, Olén O, Ljótsson B. Breaking the vicious circle of fear and avoidance in children with abdominal pain: A mediation analysis. J Psychosom Res 2021; 140:110287. [PMID: 33227558 DOI: 10.1016/j.jpsychores.2020.110287] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Exposure-based cognitive behavioral therapy via internet (Internet-CBT) has been shown to reduce symptoms and increase quality of life for children with functional abdominal pain disorders (FAPDs), but the mechanisms of change are unknown. The objective was to examine whether a change in symptom-specific fear and avoidance, i.e., gastrointestinal-specific anxiety (GI-anxiety) and gastrointestinal-specific avoidance (GI-avoidance), mediated changes in parent-reported abdominal symptoms for children receiving Internet-CBT compared with children receiving treatment as usual. A further aim was to assess if baseline levels of the proposed mediators moderated the mediation. METHODS Weekly assessments of child-reported mediators and parent-reported outcome from 90 children aged 8-12 who were included in a randomized controlled trial were used in univariate and multivariate growth models to test the direct effect of treatment on outcome and the indirect effects via mediators and moderated mediation. RESULTS Treatment condition significantly predicted the slope of the mediators (a-path), in favor of Internet-CBT, and mediators were correlated with the outcome (b-path). The indirect effects of the mediators on the outcome (cross-product of the a and b-paths) were significantly different from zero for both GI-avoidance, ab = 1.43, 95%CI [0.42, 3.23]; and GI-anxiety ab = 1.58, 95%CI [0.43, 3.62]. Baseline levels of the proposed mediators moderated the size of the mediation. CONCLUSIONS GI-anxiety and GI-avoidance were mediators of change in Internet-CBT and high levels of the mediators at baseline were associated with larger mediated effects. Healthcare professionals should be aware of, and inform families about, the potential benefits of reducing symptom-specific fear and avoidance.
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Affiliation(s)
- Maria Lalouni
- Department of Medicine, Karolinska Institutet, Solna, Sweden; Stockholm Health Care Services, Stockholm County Council, Sweden; Department of Clinical Neuroscience, Neuro, Karolinska Institutet, Stockholm, Sweden.
| | - Hugo Hesser
- Department of Behavioral Sciences and Learning, Linköping University, Sweden; Center for Health and Medical Psychology, Örebro University, Sweden
| | - Marianne Bonnert
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hedman-Lagerlöf
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Sweden
| | - Eva Serlachius
- Stockholm Health Care Services, Stockholm County Council, Sweden; Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Ola Olén
- Department of Medicine, Karolinska Institutet, Solna, Sweden; Department of Paediatric Gastroenterology and Nutrition, Sachs' Children's Hospital, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden
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16
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Lalouni M, Ljótsson B, Bonnert M, Ssegonja R, Benninga M, Bjureberg J, Högström J, Sahlin H, Simrén M, Feldman I, Hedman-Lagerlöf E, Serlachius E, Olén O. Clinical and Cost Effectiveness of Online Cognitive Behavioral Therapy in Children With Functional Abdominal Pain Disorders. Clin Gastroenterol Hepatol 2019; 17:2236-2244.e11. [PMID: 30502501 DOI: 10.1016/j.cgh.2018.11.043] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Scalable and effective treatments are needed for children with functional abdominal pain disorders (FAPDs). We performed a randomized controlled trial of the efficacy and cost effectiveness of cognitive behavioral therapy delivered online (Internet-CBT) compared with usual therapy. METHODS We studied children (age, 8-12 y) diagnosed with FAPDs, based on the Rome IV criteria, in Sweden from September 2016 through April 2017. The patients were assigned randomly to groups that received 10 weeks of therapist-guided, internet-delivered cognitive behavioral therapy (Internet-CBT, n = 46) or treatment as usual (treatments within the health care and school systems, including medications and visits to doctors and other health care professionals; n = 44). The primary outcome was global child-rated gastrointestinal symptom severity assessed using the Pediatric Quality of Life Gastrointestinal Symptom scale. All outcomes were collected from September 2016 through January 2018. Secondary outcomes included quality of life, gastrointestinal-specific anxiety, avoidance behaviors, and parental responses to children's symptoms. Societal costs and costs for health care consumption were collected during the treatment. RESULTS Children who received Internet-CBT had a significantly larger improvement in gastrointestinal symptom severity with a medium effect size (Cohen's d = 0.46; 95% CI, 0.05-0.88; number needed to treat, 3.8) compared with children who received the treatment as usual. The children's quality of life, gastrointestinal-specific anxiety, avoidance behaviors, and parental responses to children's symptoms also improved significantly in the Internet-CBT group compared with the treatment as usual group. The effects of Internet-CBT persisted through 36 weeks of follow-up evaluation. Children who received Internet-CBT had significantly less health care use than children who received treatment as usual, with an average cost difference of US $137 (P = .011). We calculated a cost savings of US $1050 for every child treated with Internet-CBT compared with treatment as usual. CONCLUSIONS In a randomized trial of pediatric patients with FAPDs, we found Internet-CBT to be clinically cost effective compared with treatment as usual. Internet-CBT has the potential to increase the availability of treatment for a number of patients and reduce health care costs. ClinicalTrials.gov: NCT02873078.
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Affiliation(s)
- Maria Lalouni
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.
| | - Brjánn Ljótsson
- Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Bonnert
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Richard Ssegonja
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Marc Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Johan Bjureberg
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jens Högström
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Sahlin
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
| | - Inna Feldman
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Erik Hedman-Lagerlöf
- Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Eva Serlachius
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ola Olén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Department of Pediatric Gastroenterology and Nutrition, Sachs' Children's Hospital, Stockholm, Sweden
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Sampaio F, Bonnert M, Olén O, Hedman E, Lalouni M, Lenhard F, Ljótsson B, Ssegonja R, Serlachius E, Feldman I. Cost-effectiveness of internet-delivered cognitive-behavioural therapy for adolescents with irritable bowel syndrome. BMJ Open 2019; 9:e023881. [PMID: 30679293 PMCID: PMC6347900 DOI: 10.1136/bmjopen-2018-023881] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To assess whether exposure-based internet-delivered cognitive-behavioural therapy (internet-CBT) is a cost-effective treatment for adolescents with irritable bowel syndrome (IBS) compared with a waitlist control, from a societal perspective, based on data from a randomised trial. DESIGN Within-trial cost-effectiveness analysis. SETTING Participants were recruited from the whole of Sweden via primary, secondary and tertiary care clinics reached through news media and advertising. PARTICIPANTS Adolescents (aged 13-17) with a diagnosis of IBS. INTERVENTIONS Participants were randomised to either an exposure-based internet-CBT, including 10 weekly modules for adolescents and five modules for parents, or a waitlist. OUTCOME MEASURES The main health outcome was the quality-adjusted life-year (QALY) estimated by mapping Pediatric Quality-of-Life Inventory (PedsQL) scores onto EQ-5D-3L utilities. The secondary outcome was the point improvement on the PedsQL scale. Data on health outcomes and resource use were collected at baseline and 10 weeks post-treatment. Resource use was measured using the Trimbos and Institute of Medical Technology Assessment Cost Questionnaire for Psychiatry (TIC-P) . Incremental cost-effectiveness ratios (ICER) were calculated as the difference in average costs by the difference in average outcomes between groups. RESULTS The base-case results showed that internet-CBT costs were on average US$170.24 (95% CI 63.14 to 315.04) more per participant than the waitlist. Adolescents in the internet-CBT group showed small QALY gains (0.0031; 95% CI 0.0003 to 0.0061), and an average improvement of 5.647 points (95% CI 1.82 to 9.46) on the PedsQL compared with the waitlist. Internet-CBT yielded an ICER of $54 916/QALY gained and a probability of cost-effectiveness of 74% given the Swedish willingness-to-pay threshold. The ICER for the outcome PedsQL was US$85.29/point improvement. CONCLUSIONS Offering internet-CBT to adolescents with IBS improves health-related quality of life and generates small QALY gains at a higher cost than a waitlist control. Internet-CBT is thus likely to be cost-effective given the strong efficacy evidence, small QALY gains and low cost. TRIAL REGISTRATION NUMBER NCT02306369; Results.
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Affiliation(s)
- Filipa Sampaio
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Marianne Bonnert
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholms Lans Landsting, Stockholm, Sweden
| | - Ola Olén
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Gastroenterology and Nutrition, Sachs’ Children’s Hospital, Stockholm, Sweden
| | - Erik Hedman
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Osher Centre for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Maria Lalouni
- Stockholm Health Care Services, Stockholms Lans Landsting, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Fabian Lenhard
- Stockholm Health Care Services, Stockholms Lans Landsting, Stockholm, Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Richard Ssegonja
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Eva Serlachius
- Stockholm Health Care Services, Stockholms Lans Landsting, Stockholm, Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Inna Feldman
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
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18
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Bonnert M, Olén O, Lalouni M, Hedman-Lagerlöf E, Särnholm J, Serlachius E, Ljótsson B. Internet-Delivered Exposure-Based Cognitive-Behavioral Therapy for Adolescents With Functional Abdominal Pain or Functional Dyspepsia: A Feasibility Study. Behav Ther 2019; 50:177-188. [PMID: 30661558 DOI: 10.1016/j.beth.2018.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 05/06/2018] [Accepted: 05/12/2018] [Indexed: 12/18/2022]
Abstract
Functional abdominal pain (FAP) and functional dyspepsia (FD) are common in adolescents and associated with low quality of life. Exposure-based cognitive-behavioral therapy (CBT) is efficient for adult and adolescent irritable bowel syndrome (IBS), but has never been evaluated for adolescent FAP/FD. The aim of this study was to evaluate the feasibility and potential efficacy of a novel disorder-specific Internet-delivered CBT (Internet-CBT) for adolescents with FAP or FD, using an uncontrolled open pilot including 31 adolescents. The Internet-CBT consisted of 10 weekly online modules, which focused mainly on exposure to abdominal symptoms. Parents received modules to help them reduce unhelpful parental behaviors. Participants reported the treatment to be credible, and an overall satisfaction with the treatment. Data attrition rate was low (7%) and adherence to treatment was acceptable. We saw a significant and large effect on the primary outcome, pain intensity, at posttreatment (d = 1.20, p < .001) that was further improved after 6 months (d = 1.69, p < .001). Participants also made significant and large improvements on gastrointestinal symptoms (d = 0.84, p < .001) and quality of life (d = 0.84, p < .001) that were sustained or further improved at follow-up 6 months after treatment. This study demonstrated that exposure-based Internet-CBT, tailored for adolescents with FAP or FD, is a feasible treatment that potentially improves pain intensity, gastrointestinal symptoms, and quality of life.
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Affiliation(s)
- Marianne Bonnert
- Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council.
| | - Ola Olén
- Karolinska Institutet; Karolinska University Hospital; Sachs' Children's Hospital
| | - Maria Lalouni
- Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council
| | | | | | - Eva Serlachius
- Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council
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Bonnert M, Olén O, Bjureberg J, Lalouni M, Hedman-Lagerlöf E, Serlachius E, Ljótsson B. The role of avoidance behavior in the treatment of adolescents with irritable bowel syndrome: A mediation analysis. Behav Res Ther 2018; 105:27-35. [PMID: 29614378 DOI: 10.1016/j.brat.2018.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 02/09/2018] [Accepted: 03/26/2018] [Indexed: 12/18/2022]
Abstract
Irritable bowel syndrome (IBS) is common in adolescents with a pronounced negative impact on quality of life. A pattern of avoidance behavior is commonly seen in the IBS population, which is associated with more gastrointestinal (GI) symptoms. Exposure-based cognitive behavior therapy (CBT) targets the avoidance behavior to reduce symptoms, but it is unknown whether reduced avoidance is a mediator of symptom improvement in adolescent IBS. Stress has been suggested to play a key role in worsening GI symptoms and is also a potential mediator of the treatment effect in IBS. This study was based on data from a randomized controlled trial (N = 101) that evaluated exposure-based internet-delivered CBT (Internet-CBT) compared with a wait-list for adolescents with IBS. We investigated whether avoidance behavior and perceived stress mediated the improvement in global GI symptoms due to treatment. We found that a change in avoidance behavior, but not perceived stress, mediated the effect of exposure-based Internet-CBT on GI symptoms. The decrease in avoidance behavior explained a large portion (67%) of the total treatment effect. Moreover, a unidirectional relationship over time was observed between avoidance behavior and GI symptoms. Our conclusion is that exposure-based CBT in adolescent IBS reduces avoidance and, consequently, reduces GI symptoms.
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Affiliation(s)
- Marianne Bonnert
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, SE-171 77, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Box 45436, SE-10431, Stockholm, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Ola Olén
- Department of Medicine Solna, Karolinska Institutet, SE-171 77, Stockholm, Sweden; Department of Pediatric Gastroenterology and Nutrition, Sachs' Children's Hospital, Södersjukhuset (KI SÖS), S1, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden.
| | - Johan Bjureberg
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, SE-171 77, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Norra Stationsgatan 69, SE-171 77, Stockholm, Sweden.
| | - Maria Lalouni
- Stockholm Health Care Services, Stockholm County Council, Box 45436, SE-10431, Stockholm, Sweden; Department of Medicine Solna, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Erik Hedman-Lagerlöf
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, SE-171 77, Stockholm, Sweden; Department of Clinical Neuroscience, Osher Centre for Integrative Medicine, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Eva Serlachius
- Stockholm Health Care Services, Stockholm County Council, Box 45436, SE-10431, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Norra Stationsgatan 69, SE-171 77, Stockholm, Sweden.
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, SE-171 77, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Norra Stationsgatan 69, SE-171 77, Stockholm, Sweden.
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20
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Lalouni M, Ljótsson B, Bonnert M, Hedman-Lagerlöf E, Högström J, Serlachius E, Olén O. Internet-Delivered Cognitive Behavioral Therapy for Children With Pain-Related Functional Gastrointestinal Disorders: Feasibility Study. JMIR Ment Health 2017; 4:e32. [PMID: 28798012 PMCID: PMC5571236 DOI: 10.2196/mental.7985] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 06/26/2017] [Accepted: 06/27/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pain-related functional gastrointestinal disorders (P-FGIDs; eg, irritable bowel syndrome) are highly prevalent in children and associated with low quality of life, anxiety, and school absence. Treatment options are scarce, and there is a need for effective and accessible treatments. Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure exercises is effective for adult and adolescent irritable bowel syndrome, but it has not been evaluated for younger children. OBJECTIVE The objective of this study was to assess acceptability, feasibility, and potential clinical efficacy of Internet-CBT for children with P-FGIDs. METHODS This was a feasibility study with a within-group design. We included 31 children aged 8-12 years and diagnosed with P-FGID, according to the ROME III criteria. Mean duration of abdominal symptoms at baseline was 3.8 years (standard deviation [SD] 2.6). The treatment was therapist-guided and consisted of 10 weekly modules of exposure-based Internet-CBT. The children were instructed to provoke abdominal symptoms in a graded manner and to engage in previously avoided activities. The parents were taught to decrease their attention to their children's pain behaviors and to reinforce and support their work with the exposures. Assessments included treatment satisfaction, subjective treatment effect, gastrointestinal symptoms, quality of life, pain intensity, anxiety, depression, and school absence. Data were collected at pretreatment, posttreatment, and 6-month follow-up. Means, standard errors (SEs), and Cohen d effect sizes were estimated based on multi-level linear mixed models. RESULTS Most children 25/31 (81%) completed 9 or 10 of the 10 treatment modules. Almost all children, 28/31 (90%), reported that the treatment had helped them to deal more effectively with their symptoms, and 27/31 (87%) children declared that their symptoms had improved during the treatment. Assessments from the parents were in accordance with the children's reports. No child or parent reported that the symptoms had worsened. We observed a large within-group effect size on the primary outcome measure, child-rated gastrointestinal symptoms from pretreatment to posttreatment (Cohen d=1.14, P<.001, 95% CI 0.69-1.61), and this effect size was maintained at 6-month follow-up (Cohen d=1.40, P<.001, 95% CI 1.04-1.81). We also observed significant improvements from pretreatment to posttreatment on a wide range of child- and parent-rated measures including quality of life, pain intensity, anxiety, depression, and school absence. All results remained stable or were further improved at 6-month follow-up. CONCLUSIONS This study shows that children with longstanding P-FGIDs, and their parents, perceive exposure-based Internet-CBT as a helpful and feasible treatment. The included children improved significantly despite a long duration of abdominal symptoms before the intervention. The treatment shows potential to be highly effective for P-FGIDs. The results need to be confirmed in a randomized controlled trial (RCT).
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Affiliation(s)
- Maria Lalouni
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Bonnert
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.,Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hedman-Lagerlöf
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jens Högström
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eva Serlachius
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ola Olén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of pediatric gastroenterology and nutrition, Sachs' Children's hospital, Stockholm, Sweden
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Vigerland S, Lenhard F, Bonnert M, Lalouni M, Hedman E, Ahlen J, Olén O, Serlachius E, Ljótsson B. Internet-delivered cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis. Clin Psychol Rev 2016; 50:1-10. [DOI: 10.1016/j.cpr.2016.09.005] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/16/2016] [Accepted: 09/18/2016] [Indexed: 11/29/2022]
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Lalouni M, Olén O, Bonnert M, Hedman E, Serlachius E, Ljótsson B. Exposure-Based Cognitive Behavior Therapy for Children with Abdominal Pain: A Pilot Trial. PLoS One 2016; 11:e0164647. [PMID: 27736943 PMCID: PMC5063361 DOI: 10.1371/journal.pone.0164647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/22/2016] [Indexed: 12/13/2022] Open
Abstract
Background Children with pain-related functional gastrointestinal disorders (P-FGIDs) have an increased risk for school absenteeism, depression, anxiety and low quality of life. Exposure-based cognitive behavior therapy (CBT) has shown large treatment effects in adults with irritable bowel syndrome, but has not been tested for children 8–12 years with P-FGIDs. Aim The aim of this trial was to test the feasibility, acceptability and potential efficacy of a newly developed exposure-based CBT for children with P-FGIDs. Method The children (n = 20) with a P-FGID, were referred by their treating physicians. The participants received 10 weekly sessions of exposure-based CBT and were assessed at pre-treatment, post-treatment and 6-month follow-up. Results Children improved significantly on the primary outcome measure pain intensity at post (Cohen’s d = 0.40, p = 0.049) and at 6-month follow-up (Cohen’s d = 0.85, p = 0.004). Improvements were also seen in pain frequency, gastrointestinal symptoms, quality of life, depression, anxiety, school absenteeism and somatic symptoms. Improvements were maintained or further increased at 6-month follow-up. The children engaged in the exposures and were satisfied with the treatment. Conclusions Exposure-based CBT for children with P-FGIDs is feasible, acceptable and potentially efficacious.
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Affiliation(s)
- Maria Lalouni
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Sweden
- * E-mail:
| | - Ola Olén
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
- Department of pediatric gastroenterology and nutrition, Sachs’ Children’s hospital, Stockholm, Sweden
| | - Marianne Bonnert
- Stockholm Health Care Services, Stockholm County Council, Sweden
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hedman
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Eva Serlachius
- Stockholm Health Care Services, Stockholm County Council, Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
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Lindberg L, Ulfsdotter M, Jalling C, Skärstrand E, Lalouni M, Lönn Rhodin K, Månsdotter A, Enebrink P. The effects and costs of the universal parent group program - all children in focus: a study protocol for a randomized wait-list controlled trial. BMC Public Health 2013; 13:688. [PMID: 23890316 PMCID: PMC3729493 DOI: 10.1186/1471-2458-13-688] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/26/2013] [Indexed: 12/04/2022] Open
Abstract
Background In recent decades, parents have been involved in programs that aim to improve parenting style and reduce child behavior problems. Research of preventive parenting programs has shown that these interventions generally have a positive influence on both parents and children. However, to our knowledge there is a gap in the scientific literature when it comes to randomized controlled trials of brief, manual-based structured programs which address general parenting among the population, and focus on promoting health. A four-session universal health promotion parent group program named All Children in Focus was developed. It aims at promoting parental competence and children’s positive development with the parent–child relationship as the target. There is currently no randomized controlled trial existing of the program. Methods/Design A prospective multicenter randomized wait-list controlled trial is being conducted. Approximately 600 parents with children ranging in age from 3–12 years have been recruited in eleven municipalities and city districts in the County of Stockholm, Sweden. Parents are randomized at baseline to an intervention group, which receives the program directly, or to a waiting-list control group, which participates in the program six months later. Changes in parenting and child health and development are assessed with measures immediately post-intervention and six months after the baseline. Observations of a minor group of parents and children are conducted to explore possible relations between parental reports and observed behaviors, as well as changes in the interaction between parent and child. Further, data collected within the evaluation will also be applied to evaluate the possible cost-effectiveness of the program. Discussion This paper describes a study protocol of a randomized controlled trial. Except for the quantitative outcome measures to evaluate the effectiveness of All Children in Focus, this protocol also describes health economic and qualitative analyses to deepen the knowledge of the program. We further discuss some issues regarding the implementation of the program in municipalities and city districts. Trial registration Current Controlled Trials ISRCTN70202532
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Affiliation(s)
- Lene Lindberg
- Department of public health sciences, Karolinska institutet, Stockholm, Sweden.
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