Stimulus control for insomnia: A systematic review and meta-analysis.

Stimulus control (SC) is commonly viewed as an evidence-based treatment for insomnia, but it has not been evaluated comprehensively with modern review and meta-analytic techniques. The aim of the current study was thus to perform a systematic review and meta-analysis of trials that examine the efficacy of stimulus control for insomnia. A systematic search for eligible articles and dissertations was conducted in six online bibliographic databases. The 11 included studies, with the majority published between 1978 and 1998, were randomised controlled and experimental studies in adults, comparing stimulus control for insomnia with passive and active comparators and assessing insomnia symptoms as outcomes. A random effects model was used to determine the standardised mean difference Hedge's g at post-treatment and follow-up for three sleep diary measures: the number of awakenings, sleep onset latency, and total sleep time. A test for heterogeneity was conducted, forest plots were produced, the risk of publication bias was estimated, and the study quality was assessed. In the trials identified, stimulus control resulted in small to large improvements on sleep onset latency and total sleep time, relative to passive comparators (g = 0.38-0.85). Compared with active comparators, the improvements following stimulus control were negligible (g = 0.06-0.30). Although methodological uncertainties were observed in the included trials, stimulus control appears to be an efficacious treatment for insomnia when compared with passive comparators and with similar effects to active comparators. More robust studies are, however, warranted before stronger conclusions are possible to infer.

Adverse Events of Psychological Interventions: Definitions, Assessment, Current State of the Research and Implications for Research and Clinical Practice.

BACKGROUND: The effectiveness of psychological interventions is undisputed. But while in other fields of health care the safety of interventions is studied alongside effectiveness, adverse events (AEs) have only recently been assessed in clinical studies of psychological interventions. This critical review summarizes the definition, assessment and current research status of AEs of psychological interventions. SUMMARY: AEs are defined as any untoward event or unfavorable change that occurs in the course of a psychological intervention. AEs that are caused by the intervention can be classified into side effects of correctly applied treatment, malpractice (i.e., incorrectly applied treatment) and unethical conduct (e.g., sexual abuse). Ideally, they are assessed by independent raters or alternatively by self-report questionnaires that should also cover serious adverse events (SAEs, e.g., suicide attempts or self-injurious behaviors). About 1 to 2 in 3 patients report at least 1 AE and results of meta-analyses suggest that treatments might differ in frequency and/or severity of AE and in treatment acceptability (measured as dropout rates). KEY MESSAGES: Measures of AEs and SAEs as well as more nuanced descriptions of dropout should be included in all clinical studies of psychological interventions. If this happens, we might learn that psychological interventions differ with respect to AEs, SAEs and acceptability. As many psychological interventions are about equally effective, they might one day be chosen based on differences in their safety profile rather than their differential effectiveness. Ideally, reducing AEs might also lead to more effective interventions.

Effects of stricter legislation on coercive measures in child and adolescent psychiatric care: a qualitative interview study with staff.

BACKGROUND: Legislators often want to positively affect psychiatric inpatient care and reduce coercion by a stricter judicial regulation. However, staff experiences and comprehension of such legal changes are largely unknown, yet essential in obtaining the intended outcomes. We examined staff understanding and implementation of a July 1, 2020 legal change in Sweden regarding the use of coercive measures (e.g., restraint, seclusion, and forced medication) in child and adolescent psychiatric inpatient care. METHODS: During 2021, semi-structured interviews were conducted with nine child and adolescent psychiatric inpatient staff (nurses, senior consultants, and head of units). Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We used an implementation outcomes framework to relate data to a wider implementation science context. RESULTS: The legislative change was viewed as both positive and negative by participating staff. They reported mixed levels of preparedness for the legislative change, with substantial challenges during the immediate introduction, including insufficient preparations and lack of clear guidelines. A knowledge hierarchy was evident, affecting various professional roles differently. While the law was positively viewed for its child-centred approach, we found notable distrust in legislators' understanding of the clinical reality, leading to practical difficulties in implementation. Care practices after the legal change varied, with some participants reporting little change in the use of coercive measures, while others noted a shift towards more seclusion and sedative medication usage. The work environment for consultants was described as more challenging due to increased bureaucratic procedures and a heightened pressure for accuracy. CONCLUSIONS: The study highlights the complexities and challenges in implementing legislative changes in psychiatric care, where stricter legislation does not necessarily entail reduced use of coercion.

Treating perfectionism via the Internet: a randomized controlled trial comparing cognitive behavior therapy to unified protocol.

Perfectionism can be problematic when your self-worth is dependent on achievements and leads to inflexible standards, cognitive biases, and rigid behaviors. Cognitive behavior therapy for perfectionism is shown to be effective, including for targeting psychiatric symptoms and when delivered via the Internet (iCBT-P). However, few studies have compared it to an active comparator. The current study randomly assigned 138 participants seeking help for perfectionism to iCBT-P or Internet-based Unified Protocol (iUP). Both treatments provided guidance on demand from a therapist and were eight weeks in duration. The results indicated large within-group effects of Cohen's d 2.03 (iCBT) and 2.51 (iUP) on the Clinical Perfectionism Questionnaire at post-treatment, and maintained effects at 6- and 12-month follow-up, but no between-group difference (ß = 0.02, SE = 1.04, p = .98). Secondary outcomes of depression, anxiety, quality of life, self-compassion, procrastination, and stress ranged from small to large, with no differences between the conditions. Both treatments were deemed credible, relevant, of high quality, and well-adhered by the participants. Further research needs to be conducted, but the findings could indicate a lack of specificity, perhaps suggesting there is no need to differentiate between different treatments that are transdiagnostic in nature.

A psychometric evaluation of the Swedish translation of the Perceived Stress Scale: a Rasch analysis.

BACKGROUND: Stress reflects physical and psychological reactions to imposing demands and is often measured using self-reports. A widely-used instrument is the Perceived Stress Scale (PSS), intended to capture more general aspects of stress. A Swedish translation of the PSS is available but has not previously been examined using modern test theory approaches. The aim of the current study is to apply Rasch analysis to further the understanding of the PSS' measurement properties, and, in turn, improve its utility in different settings. METHODS: Data from 793 university students was used to investigate the dimensionality of different version of the PSS (14, 10, and 4 items) as well as potential response patterns among the participants. RESULTS: The current study demonstrates that the PSS-14 has two separate factors, divided between negatively worded items (perceived stress) and positively worded items (perceived [lack of] control), although with only the negative subscale exhibiting good reliability. Response patterns were analyzed using Differential Item Functioning, which did not find an influence of gender on any of the items, but for age regarding the positive subscale (items 6 and 9). The PSS-10 also demonstrated adequate reliability for the negative subscale, but the PSS-4 was not deemed suitable as a unidimensional scale. CONCLUSIONS: Based on the results, none of the versions of the PSS should be used by sum-scoring all of the items. Only the negative items from the PSS-14 or PSS-10 can be used as unidimensional scales to measure general aspects of stress. As for different response patterns, gender may nevertheless be important to consider, as prior research has found differences on several items. Meanwhile, content validity is discussed, questioning the relevance of anger and being upset when measuring more general aspects of stress. Finally, a table to convert the PSS-7 (i.e., negative items) ordinal sum scores to interval level scores is provided.

Informing patients about possible negative effects of psychological treatment: A survey of Swedish clinical psychologists' attitudes and practices.

OBJECTIVE: The present study explored Swedish clinical psychologists' attitudes and practices of informing patients about possible negative effects of psychological treatment. METHOD: An anonymous online survey with closed and open-ended questions was distributed via Facebook and two mailing lists. In total, 320 clinical psychologists (age M = 38.6, SD = 10.3; 76% women; 77.3% Cognitive Behavior Therapy) completed the survey. Responses were analyzed using χ2, binominal regression analysis, and thematic analysis. RESULTS: No significant associations were identified between demographic variables selected a priori and informing patients about possible negative effects, i.e., years in practice, therapeutic orientation, age, and male gender. The thematic analysis resulted in several positive (e.g., creating realistic expectations of treatment and increasing resilience) and negative attitudes (e.g., causing excessive worry) of sharing patients with information about possible negative effects. It also revealed various factors that prevent an open discussion on the topic, despite being seen as important. CONCLUSION: The need to offer patients information about possible negative effects should be included in ethical guidelines, codes of conduct, and taught during clinical training. Lack of knowledge, fear, lack of time, and patient characteristics however seem to prevent therapists from discussing the issue during the informed consent procedure.

Paradoxical intention for insomnia: A systematic review and meta-analysis.

Paradoxical intention (PI) has been considered an evidence-based treatment for insomnia since the 1990s, but it has not been evaluated with modern review techniques such as meta-analysis. The present study aimed to conduct the first systematic review and meta-analysis of studies that explore the effectiveness of PI for insomnia on insomnia symptomatology and theory-derived processes. A systematic review and meta-analysis was conducted by searching for eligible articles or dissertations in six online bibliographic databases. Randomised controlled trials and experimental studies comparing PI for insomnia to active and passive comparators and assessing insomnia symptoms as outcomes were included. A random effects model was estimated to determine the standardised mean difference Hedge's g at post-treatment. Test for heterogeneity was performed, fail-safe N was calculated, and study quality was assessed. The study was pre-registered at International Prospective Register of Systematic Reviews (PROSPERO, CRD42019137357). A total of 10 trials were identified. Compared to passive comparators, PI led to large improvements in key insomnia symptoms. Relative to active comparators, the improvements were smaller, but still moderate for several central outcomes. Compared to passive comparators, PI resulted in great reductions in sleep-related performance anxiety, one of several proposed mechanisms of change for PI. PI for insomnia resulted in marked clinical improvements, large relative to passive comparators and moderate compared to active comparators. However, methodologically stronger studies are needed before more firm conclusions can be drawn.

Stress and work-related mental illness among working adults with ADHD: a qualitative study.

BACKGROUND: Though many adults with ADHD underperform professionally, are more stressed, and have more days of sickness absence compared to adults without ADHD, few studies have explored the experience of working as an adult with ADHD. This study explores the general experience of working with ADHD, including stress and work-related mental illness. METHODS: Semi-structured telephone interviews were conducted with 20 working adults with ADHD. Interview topics included how the ADHD diagnosis and/or symptoms of ADHD may have affected participants on the job, how work may have affected participants' well-being, and the need for support and accommodation. Qualitative content analysis was used to explore verbatim transcripts from the interviews. RESULTS: The analysis yielded three themes that describe some of the challenges of working with ADHD: Working and living with ADHD, Needs, and Special abilities, with a total of eight subcategories. Subcategories were Specific challenges; Relationships and cooperation; Negative consequences; Planning, prioritization, organization, and structure; Support, interventions, accommodations, and aids; Openness, understanding, and acceptance; Strategies; Strengths and qualities. CONCLUSION: Further knowledge about the challenges of working with ADHD is needed in workplaces; where organizational support is lacking, much in terms of accommodations and aids is up to the employee, and the disclosure of diagnoses may be associated with great dilemma.

Gamblers' Perception of the Playscan Risk Assessment: A Mixed-Methods Study.

Responsible gambling (RG) tools are globally widespread; they aim to prevent or decrease the harm caused by gambling. However, existing research suggests that several included features do not decrease gambling or significantly reduce the subsequent harm. Most of the previous studies have used gambling data to understand the changes in gambling behavior. However, the literature lacks research regarding gamblers' experience and perception of RG tools, which may provide insight into increasing the usage and effectiveness of RG tools. This mixed-methods study aimed to explore gamblers' perception of their risk assessment in the RG tool Playscan regarding developing harmful gambling problems. Overall, 757 participants rated the perceived accuracy of their risk assessment and their perception of the overall RG tool that conducted the assessment. Participants were also allowed to leave a comment providing feedback, which was analyzed using thematic analysis. Quantitative data was analyzed using logistic regression and structural equation modeling. Qualitative analyses revealed that most of the participants were pleased with the risk assessment and found it helpful. Moderated mediation analysis showed that participants' assessment agreement partially mediated the association between expressing a negative view and their general view of Playscan. These results highlight the need to decrease the level of disagreement for promoting a better general view of RG tools to potentially increase their usage and effectiveness.

Patient-controlled admissions to inpatient care: A twelve-month naturalistic study of patients with schizophrenia spectrum diagnoses and the effects on admissions to and days in inpatient care.

BACKGROUND: Patients with schizophrenia spectrum diagnoses have a poor prognostic outlook and rates of recovery. Inpatient care is common, but the decision to initiate such care is not solely up to the patient but also influenced by the healthcare providers. Recent ideas about shared decision-making however challenges this idea. Patient-Controlled Admissions (PCA) refers to a care model where a patient signs a contract that allows the decision for admission into inpatient care to be transferred onto the patient. METHODS: In Region Stockholm's public healthcare PCA was introduced to patients with schizophrenia spectrum diagnoses deemed to have the greatest care needs. Outcomes of a 12-month naturalistic within-group follow-up was analyzed using Wilcoxon signed-rank test. RESULTS: In total, 56 patients fulfilled the study's inclusion criteria, with between 20 to 42 patients having complete data and being able to analyze statistically, depending on the variable. Number of admissions, inpatient days, number of involuntary admissions, and involuntary admission days decreased, but only significantly so for inpatient days, p < .01 (a mean reduction of 11.5 days). Neither self-rated well-being, as assessed using the EQ5D-3L, or a clinician-administered rating of overall health status, the Clinical Global Impression Scale, demonstrated a significant change. CONCLUSIONS: The use of PCA points towards a trend in decreased hospitalization for patients with schizophrenia spectrum diagnoses, although this needs to be explored further in larger samples and over a longer follow-up.

Knowledge gain and usage of knowledge learned during internet-based CBT treatment for adolescent depression - a qualitative study.

BACKGROUND: The role of explicit learning of treatment content in internet-based cognitive-behavioural treatment (ICBT) is an emerging field of research. The objective of this study was to explore clients experiences of their ICBT treatment for depression with a focus on knowledge gain and usage of knowledge learned during treatment. METHODS: A strategic sample of ten adolescents, aged between 15 and 19 years, who had received ICBT for major depression within a clinical controlled trial were recruited for the study. Semi-structured interviews were conducted 6 months following trial completion. Data were transcribed and analysed using thematic analysis. The participants had a general adherence rate of 6-8 opened modules out of 8 possible. RESULTS: Two main themes were identified; "Active agents of CBT" and "Passive agents of CBT", with each theme consisting of three and two sub-themes. Active agents of CBT reflect a tendency to specifically remember and actively apply specific CBT principles in present life situations. Passive agents of CBT reflect a tendency to remember CBT treatment principles vaguely and express a passive or reactive usage of learned therapy content. CONCLUSION: The findings suggest that young clients can remember and apply CBT principles 6 months after their treatment. However, while experiencing benefits of treatment, clients recall and application of treatment strategies vary. The study emphasizes the importance of exploring client recall of CBT components and how valuable it is to explicitly remember contents of a treatment in order to improve and maintain improvement. Further studies on the role of knowledge and memory of ICBT for adolescent populations are warranted.

Standardized multimodal intervention for stress-induced exhaustion disorder: an open trial in a clinical setting.

BACKGROUND: Long-term sick-leave due to stress-related ill-health is increasing in several economically developed countries. Even though different forms of interventions are administered in regular care for stress-related disorders, such as Stress-induced Exhaustion disorder (SED), the scientific evidence for the effectiveness of such treatments is sparse. The objective of this study was to explore changes in SED-symptoms and return-to-work-rates in a large group of SED-patients participating in a standardized Multimodal intervention (MMI) in a clinical setting. METHOD: This open clinical trial tracked 390 patients who fulfilled the criteria for SED undergoing a 24-week MMI, including return-to-work-strategies. Before inclusion, all patients underwent a multi-professional assessment by a team of licensed physicians, licensed psychologists, and licensed physiotherapists. Self-rated questionnaires were administered before treatment, at treatment-start, mid-treatment, post-treatment, and at 12-month follow-up. Within-group change was evaluated over time with mixed-effects models. Beyond different symptoms, working time, sick-leave compensation, and adverse effects were also measured. RESULTS: There were significant improvements in symptoms of SED, burnout, anxiety, depression, and insomnia, with large within-group effect sizes (d = 0.91-1.76), improvements that were maintained at 12-month follow-up. Furthermore, there was a significant increase in quality of life and large improvements in average working time and sick-leave compensation. Some adverse effects were reported, mainly concerning an increase in stress, anxiety, and worry. CONCLUSION: SED-patients participating in this standardized MMI reported large symptom alleviation, increased working time and reduced sick-leave compensation, indicating a beneficial treatment. There were some adverse effects, but no more so than other psychological treatments. This study confirms previous findings that high levels of depression and anxiety decrease to sub-clinical levels during treatment, while symptoms of SED also decline, yet still persists above sub-clinical levels at 12-month follow-up. On the whole, this open clinical trial suggests that a standardized MMI, administered in a clinical setting, improves symptoms and return-to-work rates in a clinically representative SED-population. TRIAL REGISTRATION: This study was registered on Clinicaltrials.gov 2017.12.02 (Identifier: NCT03360136 ).

Beyond perfect? A case illustration of working with perfectionism using cognitive behavior therapy.

Perfectionism can result in negative consequences for those who set unattainable goals and repeatedly strive to achieve high standards. Relying on inflexible behaviors and building one's self-worth around success can become problematic and affect performance, interpersonal relationships, and cause mental distress. In the current case illustration, perfectionism's negative implications are depicted through a client named Sara, a stressed-out junior physician who just graduated from medical school. Struggling with issues related to self-worth, depression, worry, independence, and interpersonal difficulties, Sara underwent cognitive behavior therapy during 15 sessions. The case illustration shows how an individualized conceptualization of perfectionism can be made and what is important to target in treatment, such as preventing the need for repeated checking, conducting surveys to refute dysfunctional beliefs, and introducing activities that are unrelated to accomplishments. Current research on the efficacy of treating perfectionism is also summarized and interventions particularly relevant for clinical practice are presented.

Reconsidering perfect: a qualitative study of the experiences of internet-based cognitive behaviour therapy for perfectionism.

BACKGROUND: Internet-based cognitive behaviour therapy (ICBT) is a promising format for treating different psychiatric disorders. In addition, several clinical trials have found positive results when using it to target transdiagnostic processes, such as perfectionism. However, few qualitative investigations have been conducted on the experiences of clients undergoing such treatments. METHOD: In the current study, clients completing 12-week guided ICBT for perfectionism responded to open-ended questions at post-treatment. In total, 30 out of 62 (48.4%) described their impressions of its content and the support provided by their guide. RESULTS: The results were analysed qualitatively using thematic analysis. Five themes were found in the responses: Learning how to do things differently, Noticing the positives, Feeling safe to be honest, A comfortable treatment format and Barriers to treatment. CONCLUSIONS: The results suggest that many clients were able to achieve a change in perspective in relation to their perfectionism and started facing their fears. They were also able to report the benefits of doing things differently as part of treatment, such as an improvement in their interpersonal relationships. Most clients were also positive about the treatment format, enjoying its flexibility and the encouragement offered by their therapist. However, obstacles such as conflicting commitments, personal difficulties, time-consuming and comprehensive treatment modules, and a desire for more support were brought up by some, suggesting that there are aspects that could be considered in the future.

Adaptation of the negative effects questionnaire into the Czech context.

Objective: The aim of this study was to adapt the Negative Effects Questionnaire (NEQ) into the Czech context and to assess its psychometric properties as well as the extent to which it covers important areas of the negative aspects of psychotherapy. Method: A total of 226 respondents answered an online survey. Confirmatory and exploratory factor analyses were conducted to assess the NEQ factor structure. Thematic analysis was used to analyze the open-ended NEQ item. Results: In terms of confirmatory factor analysis, the six-factor model proposed by the authors of the NEQ did not demonstrate an adequate fit. In a subsequent exploratory factor analysis, a more parsimonious, five-factor solution was proposed instead. Furthermore, a thematic analysis revealed some areas underrepresented in the NEQ, particularly clients' relationships with their relatives. Conclusions: The NEQ is a reliable instrument with a high added value for research and practice. Several directions for future development are suggested.

The Negative Effects Questionnaire: psychometric properties of an instrument for assessing negative effects in psychological treatments.

BACKGROUND: Psychological treatments provide many benefits for patients with psychiatric disorders, but research also suggests that negative effects might occur from the interventions involved. The Negative Effects Questionnaire (NEQ) has previously been developed as a way of determining the occurrence and characteristics of such incidents, consisting of 32 items and six factors. However, the NEQ has yet to be examined using modern test theory, which could help to improve the understanding of how well the instrument works psychometrically. AIMS: The current study investigated the reliability and validity of the NEQ from both a person and item perspective, establishing goodness-of-fit, item bias, and scale precision. METHOD: The NEQ was distributed to 564 patients in five clinical trials at post-treatment. Data were analysed using Rasch analysis, i.e. a modern test theory application. RESULTS: (1) the NEQ exhibits fairness in testing across sociodemographics, (2) shows comparable validity for a final and condensed scale of 20 instead of 32 items, (3) uses a rating scale that advances monotonically in steps of 0 to 4, and (4) is suitable for monitoring negative effects on an item-level. CONCLUSIONS: The NEQ is proposed as a useful instrument for investigating negative effects in psychological treatments, and its newer shorter format could facilitate its use in clinical and research settings. However, further research is needed to explore the relationship between negative effects and treatment outcome, as well as to test it in more diverse patient populations.

Guided Web-Based Cognitive Behavior Therapy for Perfectionism: Results From Two Different Randomized Controlled Trials.

BACKGROUND: Perfectionism can become a debilitating condition that may negatively affect functioning in multiple areas, including mental health. Prior research has indicated that internet-based cognitive behavioral therapy can be beneficial, but few studies have included follow-up data. OBJECTIVE: The objective of this study was to explore the outcomes at follow-up of internet-based cognitive behavioral therapy with guided self-help, delivered as 2 separate randomized controlled trials conducted in Sweden and the United Kingdom. METHODS: In total, 120 participants randomly assigned to internet-based cognitive behavioral therapy were included in both intention-to-treat and completer analyses: 78 in the Swedish trial and 62 in the UK trial. The primary outcome measure was the Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale (FMPS CM). Secondary outcome measures varied between the trials and consisted of the Clinical Perfectionism Questionnaire (CPQ; both trials), the 9-item Patient Health Questionnaire (PHQ-9; Swedish trial), the 7-item Generalized Anxiety Disorder scale (GAD-7; Swedish trial), and the 21-item Depression Anxiety Stress Scale (DASS-21; UK trial). Follow-up occurred after 6 months for the UK trial and after 12 months for the Swedish trial. RESULTS: Analysis of covariance revealed a significant difference between pretreatment and follow-up in both studies. Intention-to-treat within-group Cohen d effect sizes were 1.21 (Swedish trial; 95% CI 0.86-1.54) and 1.24 (UK trial; 95% CI 0.85-1.62) for the FMPS CM. Furthermore, 29 (59%; Swedish trial) and 15 (43%; UK trial) of the participants met the criteria for recovery on the FMPS CM. Improvements were also significant for the CPQ, with effect sizes of 1.32 (Swedish trial; 95% CI 0.97-1.66) and 1.49 (UK trial; 95% CI 1.09-1.88); the PHQ-9, effect size 0.60 (95% CI 0.28-0.92); the GAD-7, effect size 0.67 (95% CI 0.34-0.99); and the DASS-21, effect size 0.50 (95% CI 0.13-0.85). CONCLUSIONS: The results are promising for the use of internet-based cognitive behavioral therapy as a way of targeting perfectionism, but the findings need to be replicated and include a comparison condition.

Overcoming procrastination: one-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy.

Procrastination is a common self-regulatory failure that can have a negative impact on well-being and performance. However, few clinical trials have been conducted, and no follow-up has ever been performed. The current study therefore aimed to provide evidence for the long-term benefits and investigate predictors of a positive treatment outcome among patients receiving Internet-based cognitive behavior therapy (ICBT). A total of 150 self-recruited participants were randomized to guided or unguided ICBT. Self-report measures of procrastination, depression, anxiety, and quality of life were distributed at pre-treatment assessment, post-treatment assessment, and one-year follow-up. Mixed effects models were used to investigate the long-term gains, and multiple linear regression for predictors of a positive treatment outcome, using the change score on the Irrational Procrastination Scale as the dependent variable. Intention-to-treat was implemented for all statistical analyses. Large within-group effect sizes for guided and unguided ICBT, Cohen's d = .97-1.64, were found for self-report measures of procrastination, together with d = .56-.66 for depression and anxiety. Gains were maintained, and, in some cases, improved at follow-up. Guided and unguided ICBT did not differ from each other, mean differences -.31-1.17, 95% CIs [-2.59-3.22], and none of the predictors were associated with a better result, bs -1.45-1.61, 95% CIs [-3.14-4.26]. In sum, ICBT could be useful and beneficial in relation to managing procrastination, yielding great benefits up to one year after the treatment period has ended, with comparable results between guided and unguided ICBT.

Negative effects of internet interventions: a qualitative content analysis of patients' experiences with treatments delivered online.

Internet interventions are defined as the delivery of health care-related treatments via an online or a smartphone interface, and have been shown to be a viable alternative to face-to-face treatments. However, not all patients benefit from such treatments, and it is possible that some may experience negative effects. Investigations of face-to-face treatments indicate that deterioration occurs in 5-10% of all patients. The nature and scope of other negative effects of Internet interventions is, however, largely unknown. Hence, the current study explored patients' reported negative experiences while undergoing treatments delivered via the Internet. Data from four large clinical trials (total N = 558) revealed that 9.3% of patients reported some type of negative effects. Qualitative content analysis was used to explore the patients' responses to open-ended questions regarding their negative experiences. Results yielded two broad categories and four subcategories of negative effects: patient-related negative effects (insight and symptom) and treatment-related negative effects (implementation and format). Results emphasize the importance of always considering negative effects in Internet-based interventions, and point to several ways of preventing such experiences, including regular assessment of negative events, increasing the flexibility of treatment schedules and therapist contact, as well as prolonging the treatment duration.