Clinical psychology: treatment and assessment of anxiety
Anxiety disorders, depression and stress disorders are highly prevalent, lead to severe suffering for the affected, and are associated with substantial societal costs. The research in Erik Hedman’s group is focused on treatment and assessment of these disorders, with emphasis on health anxiety, i.e. a chronic and debilitating fear of acquiring somatic disease. Central aims of the research are also to investigate how psychological treatment works when provided in regular clinical settings and how well treatments work when delivered as via the Internet. Erik Hedman is a co-founder of the Internet Psychiatry (www.internetpsykiatri.se) which is one of the leading clinics in the field of Internet-based treatment.
Research program I
Health anxiety: exposure-based treatment, mechanisms and diagnostics
From time to time everyone experiences elevated health concerns, which is a functional reaction. Health anxiety refers to when the worry becomes chronic and leads to functional impairment. This condition is highly prevalent in medical settings and constitutes a challenge for primary care and psychiatry. The research group has developed a treatment based on a learning model assuming that persons with health anxiety have learnt to associate external stimuli (e.g. hospitals) and internal stimuli (e.g. normal bodily sensations) with danger and anxiety. The treatment’s main component is gradual exposure to situations and events that the individual fears. In one open trial and two randomized controlled trials, the treatment has been shown to be effective with up to 80% of participants in remission at 6-month follow-up. An important aspect from an accessibility perspective is that the randomized trials have tested the treatment delivered via the Internet. This type of treatment confers several advantages, such as that each psychologist can treat four times as many patients compared to face-to-face treatment and that the treatment is independent of geographic distance. The research group has shown that that exposure-based Internet treatment can be long-term effective and cost-effective from a societal perspective. There are however a number of limitations in the current body of knowledge, which the present research program aims to target.
Research questions of the program
- I. Is therapist-guidance necessary in Internet-delivered exposure-based treatment for health anxiety?
- II. Is Internet-based treatment non-inferior to face-to-face treatment?
- III. What are the mechanisms of the treatment effect?
- IV. Is health anxiety, defined as somatic symptom disorder, comprised of different clinically meaningful subgroups?
Clinical studies
Three large-scale randomized trials are conducted in this program. The trials test the effect of exposure-based treatment for health anxiety. Erland Axelsson conducts his phd-project within the scope of this program.
Internet-delivered exposure-based treatment compared to behavioural stress management
In this recently completed study, two Internet-based treatments (n=158) were compared - exposure treatment and behavioural stress management. Both treatments were effective, but exposure treatment produced significantly larger reductions of health anxiety. The study is published in the British Journal of Psychiatry; PMID 25104835.
Internet-delivered treatment for health anxiety: the effect of therapist guidance and comparison to bibliotherapy
This study investigates if a) therapist guidance is necessary to achieve improvements in the treatment of health anxiety, b) If biblitherapy can yield similar effects as Internet-delivered treatment. In this randomized controlled trial 132 participants are included and the study will be completed in 2016.
Internet-delivered treatment compared to face-to-face treatment
In this randomized controlled non-inferiority trial (ClinicalTrials.gov: NCT02314065) the effect of Internet-delivered cognitive behaviour therapy (n=102) is compared to cognitive behaviour therapy in a conventional face-to-face format (n=102).
Study protocol with appendices: Download
Research program II
Cognitive behaviour therapy for primary care patients with common mental illness
Anxiety disorders, depression and stress, the form of common mental illness that should be treated in primary care, is highly prevalent and the main cause of sick-leave in the western world. Cognitive behaviour therapy (CBT) has been shown to be effective in reducing psychiatric symptoms for these disorders, but the available evidence on how CBT works when delivered in primary care is limited. It is also unclear if reduced symptom burden leads to reduced sick-leave. The research group has developed a psychological intervention aimed at facilitating return to work for sick-listed primary care patients. This treatment is testet in this research program. Another central aim is to investigate psychological and biological mechanisms of improvement.
Research questions of the program
- I. Is CBT effective for primary care patients with anxiety disorders, depression and stress?
- II. Can a new return-to-work (RTW) intervention reduce sick-leave for this patient group?
- III. Is therapist-guided bibliotherapy effective and can further improvements be made if patients who do not achieve remission after bibliotherapy receive face-to-face CBT?
- IV. Is improvement mediated by reduced avoidance and change in cognitive processes?
- V. Is change in proinflammatory cytokines associated with improvement?
Clinical studies
Within this program, two randomized clinical trials (n=600) are conducted. These trials are the basis for Sigrid Salomonsson’s and Fredrik Santoft’s phd-studies. The studies are conducted at Gustavsberg’s Academic Primary Care Clinic in Stockholm.
CBT for sick-listed patients with common mental illness
In this study, the effect of therapist-guided bibliotherapy is tested. The study also investigates if face-to-face CBT can be helpful for patients who do not respond to bibliotherapy. In a first step all patients receive biblitherapy (n=400). Of those who are not in remission after nine weeks, half are randomized to face-to-tace CBT (n=100) and half to continued bibliotherapy (n=100) for 11 additional weeks. The study is expected to be completed in 2017.
Stepped-care for primary care patients with common mental illness
In this study, the effect of therapist-guided bibliotherapy is tested. The study also investigates if face-to-face CBT can be helpful for patients who do not respond to bibliotherapy. In a first step all patients receive biblitherapy (n=400). Of those who are not in remission after nine weeks, half are randomized to face-to-tace CBT (n=100) and half to continued bibliotherapy (n=100) for 11 additional weeks. The study is expected to be completed in 2017.
Research program III
Stress: how can it be treated and what characterizes the stressed patient?
Psychological stress can be defined as a perceived imbalance between an individual’s resources and the demands placed upon her. From an evolutionary perspective psychological stress fills an important function as it activates behavioral systems that aid in handling demands and threats. However, when stress is persistent and these behavioral systems continue to be activated without subsequent recuperation, negative physiological and psychological health-consequences can result, such as cardiovascular disease, cognitive dysfunction and depression. In the recent decades, the prevalence of clinically significant stress has increased. This research program’s aim is to increase the knowledge about stress as a clinical phenomenon and to investigate the effect of a new cognitive behavioral treatment.
Research questions of the program
- I. Do persons with adjustment disorder and burnout syndrome differ in terms of psychiatric symptom burden, functioning, and sick-leave?
- II. Do persons with stress-related ill-health in form of adjustment disorder and burnout syndrome differ from persons with other common psychiatric disorders, such as anxiety syndromes, depression and insomnia in terms of psychiatric symptom burden, functioning, and sick-leave?
- III. How effective is a novel cognitive behavioural treatment when delivered face-to-face, as therapist-guided bibliotherapy, and as Internet-based treatment?
Clinical studies
To answer the research questions of the program data from three clinical trials will be used, of which two are described in Research program II. Ca 400 participants with stress-related ill-health will be included in the studies. A unique part of this program is that a new Internet-based treatment will be tested. Elin Lindsäter conducts her phd-studies within this program.
Internet-delivered CBT for stress-related disorders
In this randomized controlled trial (n=100), the effect of Internet-delivered CBT for stress-related disorders in form of adjustment disorder and burnout syndrome will be investigated. The study is expected to be completed in 2017.
Collaborators
Brjánn Ljótsson, Ass. professor (lic. psycholist)
Erik Andersson, Medicine doktor (lic. psychologist)
Mats Lekander, Professor (lic. psychologist)
Torbjörn Åkerstedt, Professor (lic. psychologist)
Lars-Göran Öst, Professor (lic. psychologist)
Kersti Ejeby, Physician
Martin Ingvar, Professor (lic. physician)