A selection from Stockholm University publication database

• Beyond the Blank Screen: Internet-Delivered Psychodynamic Therapy for Adolescent Depression: Evaluating Non-Inferiority, the Role of Emotion Regulation, and Sudden Gains

  2023. Jakob Mechler.

  Thesis (Doc)

  Adolescent major depressive disorder (MDD) is a common and debilitating disorder, associated with clinically significant distress and impairment in functioning. A vast array of negative consequences of adolescent MDD have also been found to extend into adulthood. Still, the majority of affected youths do not receive adequate treatment. Internet-delivered interventions address many barriers to treatment, for instance stigma and lack of qualified psychiatric care. However, the most studied internet-delivered treatment, internet-delivered cognitive behavioural therapy (ICBT), leads to clinically meaningful change in somewhat less than 50% of participants. These results indicate the need for treatment alternatives. This thesis consists of three empirical studies examining a newly developed such alternative, internet-delivered psychodynamic treatment (IPDT). Study 1 (n = 272) was a randomised controlled trial, testing whether IPDT was non-inferior to ICBT for depressed adolescents (15–19 years). Results indicated that both treatments were effective, with large within-group effects, and that IPDT was non-inferior to ICBT. No significant differences were noted on primary or secondary outcomes in the intent-to-treat analyses. Study 2 (n = 67) tested emotion regulation as a baseline predictor of rate of change, and whether intra-individual change in emotion regulation was a mechanism of change in IPDT. Results indicated that patients with relatively more severe deficits in emotion regulation had a steeper trajectory towards improvement. Intra-individual changes in emotion regulation also predicted improvements in the subsequent week, indicating that emotion regulation acted as a mechanism of change in IPDT. Study 3 (n = 66) tested whether sudden gains (SGs) and large intersession improvements (LIIs; defined as SGs without demanding symptom stability pre- and post-gain) were associated with superior outcome. LIIs were associated with improved outcome at post-treatment and at follow-up, whilst SGs were not. Overall, the above findings suggest that IPDT is a viable alternative to ICBT for depressed adolescents, that IPDT partly works through increases in emotion regulation and that patients who improve suddenly, between consecutive weeks in IPDT, are more likely to benefit from treatment.

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• Comparing Transdiagnostic Treatments: Unified Protocol vs. Affect Phobia Therapy and the Role of Negative Effects

  2023. Per Carlbring (et al.). Abstracts and Program Parallel Sessions, 32-32

  Conference

  Aim: The aim of the TRAbee study was to compare the effectiveness of two transdiagnostic treatment modalities, Unified Protocol (Cognitive Behavior Therapy) and Affect Phobia Therapy (Psychodynamic Psychotherapy), in alleviating psychological distress and to examine the relative differences in the incidence of negative effects as assessed by the Negative Effects Questionnaire.

  Methods: This study is a randomized controlled trial with 2,400 participants divided into 12 subgroups based on treatment modality (CBT vs. PDT vs. waitlist), duration (8 or 16 weeks of treatment), and discussion forum access (yes/no). Participants were randomly assigned and measured weekly during treatment, and then at 6, 12, and 24 months. Inclusion criteria were: age 18 years or older, ability to read/write Swedish, access to a smartphone/computer, GAD-7 score ≥5, and/or PHQ-9 score ≥10. Exclusion criteria included: current psychological treatment, recent medication change, severe depression/suicidality. Outcome measures included the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire 9-item scale (PHQ-9), the Personality Inventory for DSM-5 (PID-5), the Reflective Functioning Questionnaire 8-item scale (RFQ- 8), the Negative Effects Questionnaire (NEQ), and the Brunnsviken Brief Quality of Life scale (BBQ).

  Results: Follow-up data is still being collected, but preliminary results, including 12-month follow-up, will be available at the ISRII conference. The results will report on the relative differences in the incidence of negative effects between the treatments as assessed by the NEQ scale.

  Conclusions: The study will provide insights into the comparative effectiveness of Unified Protocol and Affect Phobia Therapy in addressing psychological disorders in a transdiagnostic manner, as well as shedding light on the differences in negative effects experienced by patients undergoing these treatments. This information may inform future treatment approaches and help to optimize patient outcomes.

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• Therapeutic alliance is calming and curing - The interplay between alliance and emotion regulation as predictors of outcome in Internet-based treatments for adolescent depression

  2023. Karin Lindqvist (et al.). Journal of Consulting and Clinical Psychology 91 (7), 426-437

  Article

  Objective: Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance–outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance–outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation.

  Method: Two hundred and seventy-two participants aged 15–19 years and diagnosed with depression were randomized to 10 weeks of internet-based psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling.

  Results: Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships.

  Conclusion: Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance.

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• Transdiagnostic Internet interventions: A breakthrough in psychological disorders?

  2023. Per Carlbring (et al.). Abstracts from the 12th Swedish Congress on internet interventions (SWEsrii), Uppsala University, Sweden, 4-4

  Conference

  Traditional evidence-based treatments for psychological disorders are often specific to one diagnosis. Some criticize this approach for not accounting for individual variation in symptoms. Transdiagnostic treatments aim to address this issue by being applicable to a wider range of patients. This study, called TRAbee, compares two transdiagnostic modalities: Unified Protocol (=Cognitive Behavior Therapy) and Affect Phobia Therapy (= Psychodynamic Psychotherapy). The study design is a randomized controlled trial with n=2400 participants who are divided into 12 subgroups based on treatment modality (CBT vs. PDT vs. waitlist), duration (8 or 16 weeks of treatment), and discussion forum access (yes/no). Participants were randomly assigned and measured weekly during treatment and then at 6, 12 and 24 months. Inclusion criteria: 18 years or older, ability to read/write Swedish, access to smartphone/computer, GAD-7 score ≥5, and/or PHQ-9 score ≥10. Exclusion criteria: current psychological treatment, recent medication change, severe depression/suicidality. Outcome measures include GAD7, PHQ9, PID- 5, RFQ-8, NEQ, and quality of life. Follow-up data is still being collected, but preliminary results including 12 month follow-up will be available at the SWErii conference.

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• Using psychodynamic principles in guided internet-delivered therapy (IPDT)

  2023. Daniel Maroti (et al.). Psychoanalytic Psychotherapy 37 (1), 63-83

  Article

  During the last years, a number of trials on internet-delivered psychodynamic treatment (IPDT) have shown promising results. In this article we discuss whether two important facets of psychodynamic therapy, that of the therapeutic relationship (especially the transference) and that of emotional processing, are applicable and useful in IPDT. We argue that the therapist role in IPDT does not need to be mainly a supportive one. In this article we try to illustrate that working with the transference relationship and facilitating deep emotional processing is possible in IPDT, potentially adding to the effect of solely taking a supportive stance in guiding through the self-help material. We argue that unguided treatments might make less sense when based on psychodynamic theory due to the lack of a therapeutic relationship and conclude by stating that future research on IPDT could use dismantling designs to establish what therapeutic techniques that are associated with change. 

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• Therapist-guided internet-based psychodynamic therapy versus cognitive behavioural therapy for adolescent depression in Sweden: a randomised, clinical, non-inferiority trial

  2022. Jakob Mechler (et al.). The Lancet Digital Health 4 (8), e594-e603

  Article

  Background: Adolescent major depressive disorder (MDD) is highly prevalent and associated with lifelong adversity. Evidence-based treatments exist, but accessible treatment alternatives are needed. We aimed to compare internet-based psychodynamictherapy (IPDT) with an established evidence-based treatment (internet-based cognitive behavioural therapy [ICBT]) for the treatment of adolescents with depression.

  Methods: In this randomised, clinical trial, we tested whether IPDT was non-inferior to ICBT in the treatment of adolescent MDD. Eligible participants were 15–19 years old, presenting with a primary diagnosis of MDD according to DSM-5. Participants were recruited nationwide in Sweden through advertisements on social media, as well as contacts with junior and senior high schools, youth associations, social workers, and health-care providers. Adolescents who scored 9 or higher on the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR) in an initial online screening were contacted by telephone for a diagnostic assessment using the Mini International Neuropsychiatric Interview. Participants were randomly assigned to ICBT or IPDT. Both interventions comprised eight self-help modules delivered over 10 weeks on a secure online platform. The primary outcome was change in depression severity measured weekly by the QIDS-A17-SR. Primary analyses were based on an intention-to-treat sample including all participants randomly assigned. A non-inferiority margin of Cohen's d=0·30 was predefined. The study is registered at ISRCTN, ISRCTN12552584.

  Findings: Between Aug 19, 2019, and Oct 7, 2020, 996 young people completed screening; 516 (52%) were contacted for a diagnostic interview. 272 participants were eligible and randomly assigned to ICBT (n=136) or IPDT (n=136). In the ICBT group, 51 (38%) of 136 participants were classified as remitted, and 54 (40%) of 136 participants were classified as remitted in the IPDT group. Within-group effects were large (ICBT: within-group d=1·75, 95% CI 1·49 to 2·01; IPDT: within-group d=1·93, 1·67 to 2·20; both p<0·0001). No statistically significant treatment difference was found in the intention-to-treat analysis. Non-inferiority for IPDT was shown for the estimated change in depression during treatment (d=–0·18, 90% CI –0·49 to 0·13; p=0·34). All secondary outcomes showed non-significant between-group differences.

  Interpretation: IPDT was non-inferior to ICBT in terms of change in depression for the treatment of adolescents with MDD. This finding increases the range of accessible and effective treatment alternatives for adolescents with depression.

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• Unpacking the active ingredients of internet-based psychodynamic therapy for adolescents

  2022. Liat Leibovich (et al.). Psychotherapy Research

  Article

  Internet-based psychodynamic psychotherapy (iPDT) for adolescents has been found to be effective for treating depression, but not much is known about its active ingredients. Objective: To explore the techniques used in chat sessions in an iPDT program for depressed adolescents, and to investigate whether they predicted improvement in depression symptoms. Method: The study uses data collected from a pilot study. The iPDT consisted of 8 modules delivered over 10 weeks that included text, video, exercises, and a weekly text-based chat session with a therapeutic support worker (TSW). The participants were 23 adolescents meeting criteria for depression. The TSWs were 9 psychology master’s students. A depression inventory QIDS-A17-SR was filled weekly by the participants, and a self-rated techniques inventory (MULTI-30) was filled by the TSWs after each chat session. Results: Common factor techniques were the most widely used techniques in the chat sessions. Both common factors and psychodynamic techniques predicted improvement in depression, with psychodynamic techniques predicting improvement at the following week. CBT techniques were also used but did not predict improvement in depression. Conclusion: iPDT seem to work in line with theory, where the mechanisms thought to be important for change in treatment were predictive of outcome. 

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• TRAbee: Internet-delivered transdiagnostic self-help treatments for anxiety and/or depression: Preliminary results from a full-factorial designed randomized control trial

  2022. Per Carlbring (et al.). Abstracts from the 11th Swedish Congress on internet interventions (SWEsrii), Gothenburg, Sweden, 23-24 May 2022, 14-15

  Conference

  Traditional evidence-based psychological treatments are often diagnosis-specific, with treatment manuals being developed for specific diagnoses. This methodology has been criticized by some for not corresponding with the clinical reality of individual variability of symptoms, comorbitity with other psychiatric diagnoses and subclinical symptoms of other conditions. A possible way of adapting treatments to clinical reality is through transdiagnostic modes of treatment.

  Transdiagnostic treatments have the great advantage of potentially being suitable to a larger, and likely more representative population. Within psychological treatment there are two main transdiagnostic modalities; Unified Protocol and Affect Phobia Therapy. Unified Protocol is based on Cognitive Behaviour Therapy and is directed at emotional regulation as an important maintaining, transdiagnostic factor. Affect phobia therapy has its theoretical roots in modern Psychodynamic Theory and is focused on breaking unconscious maladaptive patterns. Unified Protocol and Affect Phobia Therapy have to our knowledge never been compared with each other, which this study aims to accomplish.

  The current study is a randomized controlled trial with a full factorial design. A total of 2400 participants will be divided into 12 different subgroups (2 * treatment duration [8 vs 16 weeks], 2 * discussion forum access [yes vs. no], and 3 * treatment [Unified Protocol vs. Affect Phobia Therapy vs. Waitlist).

  Inclusion criteria for the study are the following: Ability to read and write Swedish, access to smartphone or computer, minimum age of 18 years, and total GAD-7 ≥ 5 points and/or PHQ-9 ≥ 10 points.

  Exclusion criteria for the study are the following: Concurrent psychological treatment, initiation of or change in medication for anxiety or depression within the previous month, or self-reported severe depression (PHQ-9 total score ≥ 20) or suicidality (PHQ-9, item 9 > 2). Participants who report severe depression or suicidality will be excluded and recommended to seek other treatment.

  GAD7 and PHQ9 are the main outcome measures. Secondary measures are: Personality Inventory for DSM Short Form, Reflective Functioning Questionnaire 8, Negative Effects Questionnaire, and Brunnsviken Brief Quality of Life Scale.

  The study is still recruiting, but preliminary results will be available at the time of the SWErii conference.

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• Transdiagnostic self-help treatments for anxiety and/or depression: A full-factorial RCT investigating psychotherapeutic modalities, discussion boards and treatment length

  2022. Per Carlbring (et al.). International Society for Research onInternet Interventions 11th Scientific Meeting, 19-19

  Conference

  Context

  Typically, internet-based treatment programs are effective for a wide range of specific psychiatric diagnoses. However, diagnosing, and matching treatments to an individuals' need, is a challenge and potentially resource intensive. In this study, a computer automatically made the decision on inclusion and exclusion.

  Methods: A total of 2400 participants presenting with anxiety and/or depression were randomized into 12 subgroups (n=200 each) based on treatment modality (Cognitive Behavior Therapy vs. Psychodynamic Therapy vs. Waitlist), duration (8 vs. 16 weeks) and moderated discussion forum (Yes vs. No). Weekly measurements using PHQ9 and GAD7 were the primary outcome measures.

  Intervention (if relevant): Unified Protocol is a transdiagnostic Cognitive Behavior Therapy method for symptoms of anxiety and depression. The Affect Phobia treatment program was based on Psychodynamic models and treatment principles. The participants were also randomly assigned to either having (50%) or not having (50%) access to a discussion forum that was moderated by a clinician. Finally, all participants of the two treatment groups and the waitlist-control group were also randomly assigned to either an 8- or 16-week intervention duration.

  Results: All 2400 participants have been recruited. However, all post-assessment data is not yet collected at the time of writing (but will be by the time of the conference). The results will show if transdiagnostic treatment is better than a waitlist, if there is a relative difference between Cognitive Behavior Therapy and Psychodynamic treatment, if there is a relative difference between a 8 or 16 week long treatment, and if a discussion group has any added value.

  Conclusions: Since weekly assessment of outcome has been collected the statistical power is strong, especially since the total number of participants is 2400.

  Implications: The outcome will give a clear answer to several dissemination questions including treatment length, the added value of discussion boards and type of treatment (CBT vs. PDT).

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• Lessons learned from 'TRAbee' – a large full-factorial designed study (n=2400) targeting depression and/or anxiety

  2022. Per Carlbring (et al.). EABCT 2022: Re-Thinking CBT: providing startegies for a new way of living, 117-117

  Conference

  Background: Typically, internet-based treatment programs are effective for various psychological problems. However, diagnosing, and matching treatments to an individual's need, is a challenge and potentially resource-intensive. In addition, it is unknown what the optimal treatment length is and whether access to an online forum is beneficial for treatment adherence and subsequent outcome. In this study, the Iterapi platform fully automated all decisions and communication with the participants, maximizing scalability.

  Methods: A total of 2400 participants presenting with anxiety and/or depression were randomized into 12 subgroups (n=200 each) based on treatment modality, duration, and moderated discussion forum (Yes vs. No). Weekly measurements using PHQ9 and GAD7 were the primary outcome measures.The treatments were based on Cognitive Behavior Therapy (Unified Protocol) or Psychodynamic models and treatment principles (Affect Phobia). Both Unified Protocol and the Affect Phobia treatment program are transdiagnostic methods targeting symptoms of anxiety and depression. The participants were also randomly assigned to either having (50%) or not having (50%) access to a discussion forum that a clinician moderated. Finally, all participants of the two treatment groups and the waitlist-control group were randomly assigned to either an 8- or 16-week intervention duration.

  Results: All 2400 participants have been recruited. However, all post-assessment data is not yet collected at the time of writing (but will be by the time of the conference). This talk will focus on design considerations and lessons learned from the 'TRAbee' study.

  Discussion: Since the weekly assessment of outcome has been collected, the statistical power is strong, especially since the total number of participants is 2400. The outcome will answer several dissemination questions, including treatment length, discussion boards' added value, and treatment type (CBT vs. PDT).

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• Adverse effects in internet-based cognitive-behavior versus psychodynamic therapy

  2022. Per Carlbring (et al.). EABCT 2022: Re-Thinking CBT: providing startegies for a new way of living, 66-66

  Conference

  Background: Internet-based psychological treatments provide many benefits for patients with psychiatric disorders, but research also suggests that negative effects might occur from the interventions involved.

  Methods: A total of 2400 participants presenting with anxiety and/or depression were randomized into 12 subgroups (n=200 each) based on treatment modality (Cognitive Behavior Therapy vs. Psychodynamic Therapy vs. Waitlist), duration (8 vs. 16 weeks), and moderated discussion forum (Yes vs. No). In addition to weekly measurements of the primary outcome measure (PHQ-9 & GAD-7), the Negative Effects Questionnaire was administered post-treatment. The Negative Effects Questionnaire has been proposed as a valuable instrument for investigating the negative effects of psychological treatments. An exploratory factor analysis suggested a six-factor solution: symptoms (“I felt more worried”), quality (“I did not always understand my treatment”), dependency (“I think that I have developed a dependency on my treatment”), stigma (“I became afraid that other people would find out about my treatment”), hopelessness (“I started thinking that the issue I was seeking help for could not be made any better”), and failure (“I lost faith in myself”).

  Results: All 2400 participants have been recruited. However, all post-assessment data is not yet collected at the time of writing (but will be by the time of the conference). This talk will focus on the occurrence and characteristics of the potential negative effects of internet-based treatment in the 12 subgroups.

  Discussion: Negative effects of psychotherapy are multifaceted, warranting careful considerations for them to be monitored and reported in research settings and routine care.

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• “Good job!”: Therapists' encouragement, affirmation, and personal address in internet-based cognitive behavior therapy for adolescents with depression

  2022. Ida Berg (et al.). Internet Interventions 30

  Article

  Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.

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• “I didn’t have to look her in the eyes”—participants’ experiences of the therapeutic relationship in internet-based psychodynamic therapy for adolescent depression

  2022. Karin Lindqvist (et al.). Psychotherapy Research

  Article

  Objective: To explore young people’s perceptions of the relationship with the therapist in internet-based psychodynamic treatment for adolescent depression.

  Method: As a part of a randomized controlled trial, 18 adolescents aged 15–19 were interviewed after participating in treatment. Interviews followed a semi-structured interview schedule and were analyzed using thematic analysis.

  Results: The findings are reported around four main themes: “a meaningful and significant relationship with someone who cared”, “a helping relationship with someone who guided and motivated me through therapy”; “a relationship made safer and more open by the fact that we didn’t have to meet” and “a nonsignificant relationship with someone I didn’t really know and who didn’t know me”.

  Conclusion: Even when contact is entirely text-based, it is possible to form a close and significant relationship with a therapist in internet-based psychodynamic treatment. Clinicians need to monitor the relationship and seek to repair ruptures when they emerge.

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• Connecting over the internet

  2022. Rose Mortimer (et al.). Clinical Child Psychology and Psychiatry

  Article

  Internet-based treatments have been developed for youth mental health difficulties, with promising results. However, little is known about the features of therapeutic alliance, and how it is established and maintained, in text-based interactions between adolescents and therapists in internet-based treatments. This study uses data collected during a pilot evaluation of a psychodynamic internet-based therapy for depressed adolescents. The adolescents had instant-messaging chats with their therapists once a week, over 10 weeks. The adolescents also rated the therapeutic alliance each week, using the Session Alliance Inventory. The present study uses qualitative methods to analyse transcripts of text-based communication between the young people and their therapists. The aim is to identify and describe the key features of therapeutic alliance, and reflect upon the implications for theory and clinical practice. Analysis identified three 'values' that may underpin a strong therapeutic alliance: togetherness, agency and hope. A number of therapist techniques were also found, which seemed to create a sense of these values during text-chat sessions. These findings are discussed, alongside implications for future research.

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• The Depression

  2021. Nick Midgley (et al.). International Journal of Environmental Research and Public Health 18 (24)

  Article

  Introduction: Face-to-face therapy is unavailable to many young people with mental health difficulties in the UK. Internet-based treatments are a low-cost, flexible, and accessible option that may be acceptable to young people. This pilot study examined the feasibility, acceptability and effectiveness of an English-language adaptation of internet-based psychodynamic treatment (iPDT) for depressed adolescents, undertaken during the COVID-19 pandemic in the UK.

  Methods: A single-group, uncontrolled design was used. A total of 23 adolescents, 16–18 years old and experiencing depression, were recruited to this study. Assessments were made at baseline and end of treatment, with additional weekly assessments of depression and anxiety symptoms.

  Results: Findings showed that it was feasible to recruit to this study during the pandemic, and to deliver the iPDT model with a good level of treatment acceptability. A statistically significant reduction in depressive symptoms and emotion dysregulation was found, with large effect size, by the end of treatment. Whilst anxiety symptoms decreased, this did not reach statistical significance.

  Conclusions: The findings suggest that this English-language adaptation of iPDT, with some further revisions, is feasible to deliver and acceptable for adolescents with depression. Preliminary data indicate that iPDT appears to be effective in reducing depressive symptoms in adolescents.

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• Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents

  2020. Jakob Mechler (et al.). Psychotherapy Research

  Article

  Objective: Sudden gains (SGs) have often been found associated with better treatment outcome across different psychiatric disorders. However, no studies have evaluated SGs in internet-based treatment targeting adolescent depression. Method: The sample consisted of 66 adolescents diagnosed with major depressive disorder, attending psychodynamic internet-based treatment. Effects of SGs were evaluated at posttreatment and 6-month follow-up. We also evaluated effects of large intersession improvements (LIIs; sudden and relatively large gains, between sessions, without the stability criterion). Effects of SGs and LIIs early in treatment were also investigated. Results: A total of 17 patients (25.75%) experienced an SG. The effect of having an SG or early SG was non-significant after treatment (d = 0.48) and at follow-up (d= 0.66). However, having an LII was related to better outcome after treatment (d = 0.97) and at follow-up (d = 0.76). Early LIIs were associated with significantly better results at end of treatment (d = 0.72).Conclusions: The original criteria of SGs might be overly conservative and thus miss important improvements in depression. Relatively large intersession gains, regardless of stability, seem to be predictive of outcome.

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• Emotion Regulation as a Time-Invariant and Time-Varying Covariate Predicts Outcome in an Internet-Based Psychodynamic Treatment Targeting Adolescent Depression

  2020. Jakob Mechler (et al.). Frontiers in Psychiatry 11

  Article

  Objective: Although psychodynamic psychotherapy is efficacious in the treatment of depression, research on mechanisms of change is still scarce. The aim of this study was to investigate if and how emotion regulation affects outcome both as a time-invariant and a lagged time-varying predictor.

  Method: The sample consisted of 67 adolescents diagnosed with major depressive disorder, attending affect-focused psychodynamic internet-based treatment (IPDT). Linear mixed models were used to analyze emotion regulation as a baseline predictor and to assess the effect of within-person changes in emotion regulation on depression.

  Results: Analyses suggested that emotion regulation at baseline was a significant predictor of outcome, where participants with relatively larger emotion regulation deficits gained more from IPDT. Further, the results showed a significant effect of improved emotion regulation on subsequent depressive symptomatology. When not controlling for time, increased emotion regulation explained 41.23% of the variance in subsequent symptoms of depression. When detrending the results were still significant, but the amount of explained variance was reduced to 8.7%.

  Conclusion: The findings suggest that patients with relatively larger deficits in emotion regulation gain more from IPDT. Decreased emotion regulation deficits seem to act as a mechanism of change in IPDT as it drives subsequent changes in depression.

  International Standard Randomised Controlled Trial Number (ISRCTN) 16206254, https://doi.org/10.1186/ISRCTN16206254.

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• Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression

  2020. Jakob Mechler (et al.). Trials 21

  Article

  Background: Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

  Methods: The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15–19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

  Discussion: This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about “what works for whom” and the pathways of change for two distinct types of interventions.

  Trial registration: ISRCTN12552584, Registered on 13 August 2019.

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• Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression

  2020. Karin Lindqvist (et al.). Journal of Medical Internet Research 22 (3)

  Article

  Background: Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.

  Objective: This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.

  Methods: The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.

  Results: IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules.

  Conclusions: IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

  Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254

  Read more about Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression

• Inadequate Reporting of a Randomized Trial Comparing Cognitive-Behavioral Therapy and Psychodynamic Therapy for Depression

  2019. Falk Leichsenring (et al.). Journal of Nervous and Mental Disease 207 (6), 421-422

  Article

  Read more about Inadequate Reporting of a Randomized Trial Comparing Cognitive-Behavioral Therapy and Psychodynamic Therapy for Depression

Show all publications by Jakob Mechler at Stockholm University