Adult psychiatric and psychosocial outcomes of children with mild intellectual disability: a register follow-up of a population-based cohort.

BACKGROUND: Very few longitudinal psychiatric and psychosocial outcome studies of children with mild intellectual disability (MID) have been performed. METHODS: The study group was population based and consisted of 82 individuals, born in 1979-1985 and diagnosed in childhood at ages between 3 and 15 years with MID. In the present study, register data regarding school attendance, employment, economic situation, psychiatric diagnoses and criminal sentences were retrieved for the years 1997-2018, when the individuals were up to 39 years old. RESULTS: At follow-up, data were obtained for 78 of the 82 individuals (47 male and 31 female). Mean age at follow-up was 36 years. Of the 78 individuals, 57 (73%) had exclusively received education for pupils with MID, but 21 (27%) had graduated from regular education of some sort (at least 9 years). Forty-four (56%) had never been employed, and 34 (44%) had been registered as employed for at least a shorter period. Forty-seven (60%) had received a sick pension at some point in adulthood. Of the 78 individuals, 44 (56%) had any psychiatric disorder recorded and about half of these (n = 21) had had inpatient treatment. A total of 31 of the 44 individuals in psychiatric care (70%) had ID noted as one of their diagnoses. Of the 78 individuals, 48 (62%) had support from the Act concerning Support and Service for Persons with Certain Functional Impairments (Swedish LSS law) as adults. Twenty-one individuals (27%) had had a criminal conviction, of whom five male individuals had been incarcerated. CONCLUSIONS: Individuals with MID constitute a heterogeneous group with regard to severity of functional impairment, co-occurring psychiatric disorders and need of support from society. Primary health care, psychiatry and habilitation services need to work together in order to meet the multiple needs of this group.

The specific effect of systematic exposure in irritable bowel syndrome: complier average causal effect analysis using growth mixture modeling.

BACKGROUND: We reanalyzed data from a previously published randomized component study that aimed to test the incremental effect of systematic exposure in an internet-delivered cognitive behavioral treatment (ICBT) for irritable bowel syndrome (IBS). METHODS: Three hundred and nine individuals with IBS were randomly assigned to either the full treatment protocol (experimental condition) or the same treatment protocol without systematic exposure (control). Participants were assessed weekly for IBS symptoms over the active treatment phase. We used a complier average causal effect (CACE) analysis, in the growth mixture modeling framework, to (1) examine the specific effect of exposure among those who received the intervention (i.e. compliers), and (2) explore the associations of pre-treatment patient characteristics with compliance status and outcome changes. RESULTS: Fifty-five per cent of those assigned to the experimental condition were classified as compliers. The CACE analysis that took into account compliance status demonstrated that the magnitude of the incremental effect of systematic exposure on IBS symptoms was larger than the effect observed in an intention-to-treat analysis that ignored compliance status (d = 0.81 v. d = 0.44). Patients with university education showed more improvement during the exposure phase of the treatment. Pre-treatment patient characteristics did not predict compliance status. CONCLUSIONS: The effect of systematic exposure on IBS symptoms is of substantial magnitude among those individuals who actually receive the intervention (CACE). Studying the subsample of individuals who discontinue treatment prematurely and tailoring interventions to improve compliance may increase overall improvement rates in ICBT for IBS.

Cognitive Behavioral Therapy for Children with Dental Anxiety: A Randomized Controlled Trial.

Dental anxiety affects approximately 9% of children and is associated with poor oral health, pain, and psychosocial problems. The objective of this study was to investigate the efficacy of cognitive behavioral therapy (CBT) for children with dental anxiety in specialist pediatric dentistry. The study used a parallel-group superiority randomized controlled trial design. The primary outcome measure was the behavioral avoidance test; assessors were blind to treatment allocation. Participants were 8 boys and 22 girls 7 to 18 y old (mean ± SD, 10 ± 3.1). Children fulfilling the diagnostic criteria for dental anxiety were randomized to CBT (n = 13) or treatment as usual (n = 17), such as various sedation methods. Psychologists provided 10 h of CBT based on a treatment manual. Treatments were conducted in a naturalistic real-world clinical setting. Assessments were conducted before the treatment, 3 mo after the start of treatment, and at 1-y follow-up. The analyses of the primary outcome measure by repeated-measures analysis of variance and independent t test showed that children receiving CBT made superior, statistically significant improvements at follow-up (16.8 ± 2.4) compared with treatment as usual (11.4 ± 3.1, P < 0.01). A large between-group effect size (Cohen's d = 1.9) was found. Following treatment, 73% of those in the CBT group managed all stages of the dental procedures included in the behavioral avoidance test compared with 13% in the treatment-as-usual group. Furthermore, 91% in the CBT group compared with 25% in the treatment-as-usual group no longer met the diagnostic criteria for dental anxiety at the 1-y follow-up according to the secondary outcome measure. Measures of dental anxiety and self-efficacy showed larger improvements in the CBT group compared with controls. We conclude that CBT is an efficacious treatment for children and adolescents with dental anxiety and should be made accessible in pediatric dentistry (ClinicalTrials.gov: NCT01798355). Knowledge transfer statement: The results of this study can be used by decision makers and clinicians when planning to implement evidence-based treatment in pediatric dentistry and give children and adolescents access to methods for treating dental anxiety. The results can also be used by parents of children with dental anxiety when asking dentists to cooperate with psychologists using cognitive behavioral therapy.

Economic evaluations of Internet interventions for mental health: a systematic review.

BACKGROUND: Internet interventions are assumed to be cost-effective. However, it is unclear how strong this evidence is, and what the quality of this evidence is. METHOD: A comprehensive literature search (1990-2014) in Medline, EMBASE, the Cochrane Central Register of Controlled Trials, NHS Economic Evaluations Database, NHS Health Technology Assessment Database, Office of Health Economics Evaluations Database, Compendex and Inspec was conducted. We included economic evaluations alongside randomized controlled trials of Internet interventions for a range of mental health symptoms compared to a control group, consisting of a psychological or pharmaceutical intervention, treatment-as-usual (TAU), wait-list or an attention control group. RESULTS: Of the 6587 abstracts identified, 16 papers met the inclusion criteria. Nine studies featured a societal perspective. Results demonstrated that guided Internet interventions for depression, anxiety, smoking cessation and alcohol consumption had favourable probabilities of being more cost-effective when compared to wait-list, TAU, group cognitive behaviour therapy (CBGT), attention control, telephone counselling or unguided Internet CBT. Unguided Internet interventions for suicide prevention, depression and smoking cessation demonstrated cost-effectiveness compared to TAU or attention control. In general, results from cost-utility analyses using more generic health outcomes (quality of life) were less favourable for unguided Internet interventions. Most studies adhered reasonably to economic guidelines. CONCLUSIONS: Results of guided Internet interventions being cost-effective are promising with most studies adhering to publication standards, but more economic evaluations are needed in order to determine cost-effectiveness of Internet interventions compared to the most cost-effective treatment currently available.

Long-term efficacy of Internet-based cognitive behavior therapy for obsessive-compulsive disorder with or without booster: a randomized controlled trial.

BACKGROUND: As relapse after completed cognitive behavior therapy (CBT) for obsessive-compulsive disorder (OCD) is common, many treatment protocols include booster programs to improve the long-term effects. However, the effects of booster programs are not well studied. In this study, we investigated the long-term efficacy of Internet-based CBT (ICBT) with therapist support for OCD with or without an Internet-based booster program. METHOD: A total of 101 participants were included in the long-term follow-up analysis of ICBT. Of these, 93 were randomized to a booster program or no booster program. Outcome assessments were collected at 4, 7, 12 and 24 months after receiving ICBT. RESULTS: The entire sample had sustained long-term effects from pre-treatment to all follow-up assessments, with large within-group effect sizes (Cohen's d = 1.58-2.09). The booster group had a significant mean reduction in OCD symptoms compared to the control condition from booster baseline (4 months) to 7 months, but not at 12 or 24 months. Participants in the booster group improved significantly in terms of general functioning at 7, 12 and 24 months, and had fewer relapses. Kaplan-Meier analysis also indicated a significantly slower relapse rate in the booster group. CONCLUSIONS: The results suggest that ICBT has sustained long-term effects and that adding an Internet-based booster program can further improve long-term outcome and prevent relapse for some OCD patients.

Laser in caries treatment--patients' experiences and opinions.

OBJECTIVES: The aim of this study was to obtain a deeper understanding of patient's experiences and perspectives after dental caries treatment with Er:YAG laser technology. METHODS: Twelve patients aged 15-30 years who had undergone at least one laser caries excavation agreed to participate in an interview study. All the interviews were tape recorded and transcribed by a transcription agency. The transcribed texts were analysed using manifest and latent qualitative content analysis. RESULTS: The categories in this study were identified as choosing laser, understanding laser, encouraging dental care and my oral health. The motivation for laser treatment was described as dental fear in general, specific fear of needles or discomfort with the drill. The informants described the dentist's role as initiators of treatment and willing or unwilling facilitators. Laser treatment was described as safer and more carefully considered treatment. They felt generally safe with laser and were able to relax during the treatment. All interviewers described a positive impression of the laser, and words like 'up to date' and 'future-oriented' were used to describe laser. Laser treatment was considered less painful. CONCLUSIONS: The results indicate that patients find laser a feasible and convenient treatment option.

Adolescents' experiences of a two-year oral health intervention programme in two Swedish secondary schools.

OBJECTIVES: To describe adolescents' experiences of participating in a school-based oral health intervention programme for 2 years containing education about oral health and fluoride varnish treatment at the school clinic. METHODS: Sixteen adolescents aged 13-16 were interviewed in three focus group sessions. A phenomenographic approach was used for analysis. RESULTS: The results are presented as three themes and seven descriptive categories. The three themes were 'Seeing the dental hygienist', 'Treatments at the dental hygiene clinic' and 'Education about oral health in class'. The results demonstrate satisfaction with the intervention, such as accessibility, time gain and expanding knowledge. On the other hand, feelings of vulnerability in the treatment sessions were expressed. The fluoride varnish treatment was given both positive and negative reviews. The contact between the participants and the dental hygienist was important, and the opportunity to ask questions about oral health issues was emphasized. CONCLUSIONS: Both positive and negative experiences of the programme were found. Adolescence is a transitional period of life, and for this reason, it is important to create a good working alliance between students and the dental hygienist in future school-based oral health interventions.

Effectiveness of internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care.

OBJECTIVE: Guided Internet-based cognitive behaviour therapy (ICBT) for panic disorder has been shown to be efficacious in several randomized controlled trials. However, the effectiveness of the treatment when delivered within routine psychiatric care has not been studied. The aim of this study was to investigate the effectiveness of ICBT for panic disorder within the context of routine psychiatric care. METHOD: We conducted a cohort study investigating all patients (n = 570) who had received guided ICBT for panic disorder between 2007 and 2012 in a routine care setting at an out-patient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Panic Disorder Severity Scale-Self-report (PDSS-SR). RESULTS: Participants made large improvements from screening and pretreatment assessments to posttreatment (Cohen's d range on the PDSS-SR = 1.07-1.55). Improvements were sustained at 6-month follow-up. CONCLUSION: This study suggests that ICBT for panic disorder is as effective when delivered in a routine care context as in the previously published randomized controlled trials.

Cost-effectiveness and long-term effectiveness of internet-based cognitive behaviour therapy for severe health anxiety.

BACKGROUND: Severe health anxiety is a common condition associated with functional disability, making it a costly disorder from a societal perspective. Internet-based cognitive behaviour therapy (ICBT) is a promising treatment but no previous study has assessed the cost-effectiveness or long-term outcome of ICBT for severe health anxiety. The aim of this study was to investigate the cost-effectiveness and 1-year treatment effects of ICBT for severe health anxiety. METHOD: Cost-effectiveness and 1-year follow-up data were obtained from a randomized controlled trial (RCT) comparing ICBT (n = 40) to an attention control condition (CC, n = 41). The primary outcome measure was the Health Anxiety Inventory (HAI). A societal perspective was taken and incremental cost-effectiveness ratios (ICERs) were calculated using bootstrap sampling. RESULTS: The main ICER was -£1244, indicating the societal economic gain for each additional case of remission when administering ICBT. Baseline to 1-year follow-up effect sizes on the primary outcome measure were large (d = 1.71-1.95). CONCLUSIONS: ICBT is a cost-effective treatment for severe health anxiety that can produce substantial and enduring effects.

Changes in dopamine D2-receptor binding are associated to symptom reduction after psychotherapy in social anxiety disorder.

The dopamine system has been suggested to play a role in social anxiety disorder (SAD), partly based on molecular imaging studies showing reduced levels of striatal dopaminergic markers in patients compared with control subjects. However, the dopamine system has not been examined in frontal and limbic brain regions proposed to be central in the pathophysiology of SAD. In the present study, we hypothesized that extrastriatal dopamine D2-receptor (D2-R) levels measured using positron emission tomography (PET) would predict symptom reduction after cognitive behavior therapy (CBT). Nine SAD patients were examined using high-resolution PET and the high-affinity D2-R antagonist radioligand [(11)C]FLB 457, before and after 15 weeks of CBT. Symptom levels were assessed using the anxiety subscale of Liebowitz Social Anxiety Scale (LSAS(anx)). At posttreatment, there was a statistically significant reduction of social anxiety symptoms (P<0.005). Using a repeated measures analysis of covariance, significant effects for time and time × LSAS(anx) change on D2-R-binding potential (BP(ND)) were shown (P<0.05). In a subsequent region-by-region analysis, negative correlations between change in D2-R BP(ND) and LSAS(anx) change were found for medial prefrontal cortex and hippocampus (P<0.05). This is the first study to report a direct relationship between symptom change after psychological treatment and a marker of brain neurotransmission. Using an intra-individual comparison design, the study supports a role for the dopamine system in cortical and limbic brain regions in the pathophysiology of SAD.

Internet-based cognitive behaviour therapy for obsessive-compulsive disorder: a randomized controlled trial.

BACKGROUND: Cognitive behaviour therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD) but access to CBT is limited. Internet-based CBT (ICBT) with therapist support is potentially a more accessible treatment. There are no randomized controlled trials testing ICBT for OCD. The aim of this study was to investigate the efficacy of ICBT for OCD in a randomized controlled trial. METHOD: Participants (n=101) diagnosed with OCD were randomized to either 10 weeks of ICBT or to an attention control condition, consisting of online supportive therapy. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (YBOCS) administered by blinded assessors. RESULTS: Both treatments lead to significant improvements in OCD symptoms, but ICBT resulted in larger improvements than the control condition on the YBOCS, with a significant between-group effect size (Cohen's d) of 1.12 (95% CI 0.69-1.53) at post-treatment. The proportion of participants showing clinically significant improvement was 60% (95% CI 46-72) in the ICBT group compared to 6% (95% CI 1-17) in the control condition. The results were sustained at follow-up. CONCLUSIONS: ICBT is an efficacious treatment for OCD that could substantially increase access to CBT for OCD patients. Replication studies are warranted.

Clinical and genetic outcome determinants of Internet- and group-based cognitive behavior therapy for social anxiety disorder.

OBJECTIVE: No study has investigated clinical or genetic predictors and moderators of Internet-based cognitive behavior therapy (ICBT) compared with cognitive behavioral group therapy for (CBGT) for SAD. Identification of predictors and moderators is essential to the clinician in deciding which treatment to recommend for whom. We aimed to identify clinical and genetic (5-HTTLPR, COMTval158met, and BDNFval66met) predictors and moderators of ICBT and CBGT. METHOD: We performed three types of analyses on data from a sample comprising participants (N = 126) who had undergone ICBT or CBGT in a randomized controlled trial. Outcomes were i) end state symptom severity, ii) SAD diagnosis, and iii) clinically significant improvement. RESULTS: The most stable predictors of better treatment response were working full time, having children, less depressive symptoms, higher expectancy of treatment effectiveness, and adhering to treatment. None of the tested gene polymorphisms were associated with treatment outcome. Comorbid general anxiety and depression were moderators meaning that lower levels were associated with a better treatment response in ICBT but not in CBGT. CONCLUSION: We conclude that demographic factors, symptom burden, adherence, and expectations may play an important role as predictors of treatment outcome. The investigated gene polymorphisms do not appear to make a difference.

Oral health education for schoolchildren: a qualitative study of dental care professionals' view of knowledge and learning.

AIM: The aim of the study was to describe and interpret dental professionals' view of knowledge, learning, health promotion and their expectations of and attitudes to the response from schoolchildren. METHODS: A qualitative study design was used with discourse method. Nine dental hygienists and dental nurses, who have practised oral health education among schoolchildren, described their work in tape-recorded, semi-structured interviews. The discourse method stresses the variation and distinctions in the statements, and to understand the content of the text, its contextual dependence must be taken into account. RESULTS: The preventive discourse could be found in all interviews, but it was concentrated on disease prevention and less on maintaining health. The biomedical view of knowledge dominated. Children's and parent's own responsibility for healthy habits was stressed, but no reflection of ethical considerations associated with influencing people's life-style was found. The text revealed discrepancy between the informants, and even within the same individual, showing ambivalence towards oral health education. Some individuals suggested lessons guided by communication with the children, while others wanted to maintain methods based on information about oral diseases to a greater extent. CONCLUSIONS: Different perspectives were found. The expression 'oral health promotion' was frequently used and supported by all the interviewed informants, but the statements did not reveal the informant's definition of the concept. Several educators focused on signs of diseases and less on the individual's view of their own health. In the future, oral health education programme needs to focus on quality of life, behavioural variables and indicators of empowerment rather than just disease outcomes.

Cytosolic glucocorticoid receptor-interacting proteins.

Studies of GR-interacting proteins can provide valuable insights into the regulation of GR cellular signalling. The cytoplasmic localization of GR and reports of GR interaction with such a plethora of other cytoplasmic proteins may point to a unique role for GR in modulating and integrating other signalling pathways. A better insight into these interactions could serve as a tool when trying to understand and modify GR signalling.