Viktor Kaldo

Background: Up to 50% of patients treated with internet-delivered cognitive behavioral therapy (ICBT) for depression and anxiety disorders do not experience clinically significant symptom reduction. Identifying these patients prior to the initiation of ICBT can support treatment planning. Objective: The aim of this study was to enhance baseline prediction of clinically meaningful improvement in patients treated with ICBT for common psychiatric disorders in routine care, which could ultimately inform treatment planning at intake. Methods: We developed multimodal predictive models integrating clinical, sociodemographic, and genetic data available pretreatment to predict clinically meaningful improvement in a sample of 1790 patients treated with ICBT for major depressive disorder, panic disorder, and social anxiety disorder. We applied machine learning algorithms of varying complexity (logistic regression, random forest [RF], extreme gradient boosting, support vector machines, soft voting, and stacking ensemble), with nested cross-validation, elastic net variable selection, multiple imputation, and temporal validation in a 20% holdout test set (n=356). The primary performance measure was the area under the receiver operating characteristic curve (AUC). Results: All full phenotypic models showed comparable performance (AUC _test 0.732‐0.749), with RF achieving the best holdout discrimination (AUC _test 0.749, 95% CI 0.698-0.797). Compared with the benchmark model based on self-reported screening data (AUC _test 0.695, 95% CI 0.637-0.748), RF and both ensemble models incorporating register data showed higher discrimination in paired DeLong tests ( P =.04, P =.02, and P =.03, respectively), whereas polygenic scores added no independent predictive value in this cohort and modeling setup ( P =.97). Conclusions: These promising results support the feasibility of baseline prognostic prediction of clinically meaningful improvement after ICBT and provide a basis for the prospective validation of model-informed risk stratification.

Background: Internet-based interventions for insomnia show promise, but understanding the process variables, such as knowledge acquisition and psychological acceptance, is crucial for enhancing digital adherence and clinical effectiveness. Objective: This study aimed to evaluate the feasibility, adherence, and preliminary clinical signals of 2 therapist-assisted interventions—internet-delivered cognitive behavioral therapy (iCBT) and internet-delivered acceptance and commitment therapy (iACT)—for insomnia in a primary care setting. Methods: This was a pilot randomized controlled trial. Adults seeking help for insomnia (n=18) were recruited via primary care and randomized to either a 5-module iCBT or iACT program delivered via a secure digital platform with weekly therapist feedback. Blinding of participants and therapists was not possible due to the nature of the interventions. Primary outcomes included the Insomnia Severity Index; secondary outcomes included the 9-item Patient Health Questionnaire, 7-item Generalized Anxiety Disorder, and WHO Disability Assessment Schedule. A novel sleep knowledge test was used as a process variable. The data were analyzed using split-plot analyses of variance (intention-to-treat or last observation carried forward and complete case analysis) and nonparametric Friedman and Kruskal-Wallis tests. Results: A total of 18 participants were randomized (iCBT: n=9; iACT: n=9). High attrition was observed, with only 33.3% (n=3) of iCBT and 55.6% (n=5) of iACT participants completing all modules. The iACT group demonstrated a significant within-group reduction in insomnia severity ( P =.01, Friedman test), whereas iCBT results were nonsignificant ( P =.10, Friedman test). No significant between-group differences were found for any clinical or process variables. Participants rated both treatments as credible (Credibility/Expectancy Questionnaire scores remained stable), though qualitative feedback indicated a need for more flexible, less burdensome content. Conclusions: This pilot study demonstrates that while internet-delivered insomnia treatments are feasible and credible in primary care, high attrition remains a significant barrier. Preliminary signals suggest that iACT may be a viable alternative to iCBT, potentially offering better adherence. Larger, fully powered pilot randomized controlled trials (estimated N=404) with refined recruitment and automated retention strategies are required to determine definitive comparative efficacy and the mediating role of sleep knowledge and acceptance.

BACKGROUND Up to 50% of patients treated with internet-delivered cognitive behavioral therapy (ICBT) for depression and anxiety disorders do not experience clinically significant symptom reduction. Identifying these patients prior to ICBT initiation can optimize treatment effect. OBJECTIVE The aim of this study was to enhance baseline prediction of clinically meaningful improvement in patients treated with ICBT for common psychiatric disorders in routine care, which could ultimately inform treatment allocation at intake. METHODS We developed multimodal predictive models integrating clinical, sociodemographic, and genetic data to predict clinically meaningful improvement in a sample of n=1790 patients treated with ICBT for major depressive disorder, panic disorder, and social anxiety disorder. Only data available pre-treatment were used to enable baseline prediction. We applied machine learning algorithms of varying complexity (logistic regression, random forest, XGBoost, support vector machines, soft voting, and stacking ensemble), with nested cross-validation, elastic net variable selection, multiple imputation, and temporal validation in a 20% holdout test set (n=356). The primary performance measure was area under the receiver operating characteristic curve (AUC). RESULTS All models showed comparable performance, with random forest achieving the best discrimination (AUCtest 0.749, 95% CI [0.698, 0.797]). Models that included data from national registers outperformed a benchmark model based on self-reported screening data (AUCtest 0.732–0.749 vs 0.695), whereas polygenic scores added no independent predictive value (DeLong test P=.966). CONCLUSIONS These promising results provide a foundation for a future prospective trial to ascertain that baseline prediction can effectively guide tailored interventions for at-risk patients.

Cognitive behavioral therapy (CBT) is a well‐established, evidence‐based treatment for common mental disorders such as depression, anxiety disorders, and obsessive‐compulsive disorder (OCD). However, treatment outcomes vary widely, and a substantial proportion of patients do not achieve sufficient improvement. Robust predictors of individual differences in symptom change are currently lacking. Genetic differences have been suggested to play a role, but existing evidence is inconclusive. This study investigated the extent to which common genetic variants—single nucleotide polymorphisms (SNPs)—contribute to variability in symptom change. The sample was derived from the MULTI‐PSYCH and NORDiC cohorts, comprising 3113 adults and children treated with CBT for depression, panic disorder, social anxiety disorder, or OCD. We performed a genome‐wide association study (GWAS) of symptom change following CBT and estimated the proportion of variance attributed to SNPs. Secondary analyses included GWAS and SNP‐based heritability estimation of additional clinically relevant outcomes: pre‐ and post‐treatment symptom severity and remission status. No variants reached genome‐wide significance. We estimated SNP‐based heritability of symptom change at = 0.221 (SE = 0.123). These results suggest that common genetic variation may contribute modestly to treatment outcomes. Much larger samples would be required to obtain more precise estimates and to detect genome‐wide significant loci.

Therapist-guided internet-based cognitive behavioural therapy (iCBT) has improved access to treatment for depression and anxiety, but scalability is limited by reliance on trained therapists. This feasibility trial evaluated a tailored digital self-help intervention for adults with depressive and anxiety symptoms, delivered with or without clinician guidance. In total, 124 participants in Sweden with at least mild depressive or anxiety symptoms were recruited through social media and randomized (1:1) to an eight-week program with (n = 63) or without (n = 61) clinician guidance. All participants completed telephone assessments before and after the intervention. The primary aim was to assess feasibility of both versions, while considering outcome advantages of guidance and reduced clinician time with self-help. Feasibility outcomes included adherence, credibility, satisfaction, and adverse events. The intervention was perceived as credible, with high satisfaction and engagement: most participants used the program weekly, and two thirds completed at least three of five modules. Outcomes were similar across groups, though participants with guidance reported higher satisfaction. Clinician time averaged 36 minutes for self-help participants and 66 minutes for those receiving guidance. Both groups showed large symptom reductions (Cohen's d = 1.05-1.10), supporting feasibility and motivating future trials comparing self-help and clinician-guided delivery.

Telepsychiatry is increasingly used for mental health triage, but real-world implementation remains underreported, and barriers include technical reliability, patient trust, privacy and coordination across levels of care. Objective: To describe and evaluate an app- and video-based triage service, Immediate Psychiatry (IP), implemented in Region Stockholm, Sweden, focusing on service use, patient characteristics, acceptability, feasibility and team experiences. Methods: Adults (≥18) registered with participating primary care centres accessed IP via the regional health app, completed a digital brief screening questionnaire, and had a 45-min video consultation with a mental health professional. A mixed-methods design was employed combining medical-record abstractions, a patient-satisfaction survey, interviews with the IP team and a clinician acceptability questionnaire administered to primary care clinicians. Quantitative data were analysed descriptively; qualitative data underwent content analysis. Results: A total of 172 participants were included, predominantly presenting with stress-related, depressive and anxiety disorders. High patient satisfaction was reported for IP, particularly in terms of ease of contact, patient involvement and respectful treatment. The IP team described that the triage process was challenging yet meaningful, relying heavily on an interprofessional team with strong clinical expertise and a person-centred approach. Improved integration with regular care could further enhance the service. The response rate among primary care clinicians was low, with responses indicating moderate acceptability. Conclusions: Telepsychiatry for triage delivered through a regional app was feasible, acceptable and may improve access to timely assessments. The findings also highlight important organizational and implementation challenges, particularly regarding integration with primary care, which should be addressed alongside evaluations of long-term outcomes, healthcare use and costs and policy barriers in future studies.

Therapist-guided internet-based cognitive behavioural therapy has improved access to treatment for depression and anxiety, but scalability is limited by reliance on trained therapists. This feasibility trial evaluated a tailored digital self-help intervention for adults with depressive and anxiety symptoms, delivered with or without clinician guidance. In total, 124 participants in Sweden with at least mild depressive or anxiety symptoms were recruited mainly through social media and randomized (1:1) to an eight-week program with (n = 63) or without (n = 61) clinician guidance. All participants completed telephone assessments before and after the intervention. The primary aim was to assess feasibility of both versions, while also considering outcome advantages of guidance and reduced clinician time with self-help. Feasibility outcomes included adherence, credibility, acceptability, and adverse events. The intervention was perceived as credible, with high satisfaction and engagement: most participants used the program weekly, and two thirds completed at least three of five modules. Outcomes were similar across groups, though participants with guidance reported higher satisfaction. Clinician time averaged 36 minutes for self-help participants and 66 minutes for those receiving guidance. Both groups showed large symptom reductions (Cohen’s d = 1.05–1.10), supporting feasibility and motivating future trials comparing self-help and clinician-guided delivery.

Background: Dental phobia (DP) and injection phobia (IP) are common in pediatric populations, resulting in inability to receive dental care. Internet-based cognitive behavioral therapy (ICBT) has demonstrated efficacy, but its long-term effects are unexplored. Objective: This study aimed to evaluate the long-term effects of ICBT on DP and IP in children and adolescents. Methods: In total, 49 participants (mean age 11.1 years, SD 2.1) with DP, IP, or both underwent a 12-week, parent-guided, exposure-based ICBT, supplemented by visits at local dental clinics and weekly psychologist correspondence. Assessments occurred at baseline, posttreatment, and 1-year follow-up. Primary outcomes included diagnostic status (clinical interview) and ability to receive dental procedures. Secondary outcomes included measures of dental anxiety, injection anxiety, negative cognitions, and self-efficacy. The study was conducted in Sweden. Results: Of the 49 participants, 42 (86%) completed the 1-year follow-up. At 1-year follow-up, 19 (53%) of 36 (86%) participants who initially met the criteria for DP no longer did (P<.001), and 17 (46%) of 37 (88%) participants who initially met the criteria for IP did not fulfill the IP diagnosis (P<.001). Repeated-measures ANOVA showed significant improvements, with large effect sizes for self-reported ability to undergo dental procedures (d=1.1, P<.001), dental fear (d=1.0, P<.001), negative cognitions (d=0.9, P<.001), injection fear (d=0.7, P<.001), and self-efficacy (d=1.1, P<.001). Predictor analysis showed greater improvements in older participants and males. Conclusions: This study discussed the clinical implications of and approaches to ICBT implementation. ICBT for children and adolescents with DP and IP maintains its effects over a 1-year follow-up period, facilitating improved self-reported willingness to undergo dental treatment. Given its accessibility and sustained efficacy, ICBT should be considered for managing severe dental fear in pediatric dentistry. Trial Registration: ClinicalTrials.gov NCT02588079; https://clinicaltrials.gov/study/NCT02588079

Introduction: Prostate cancer treatment commonly affects sexual function. However, how effective rehabilitation programmes should be constructed is yet to be determined. The aim of this study was to describe the expectations, experiences and preliminary effects of a digital sexual rehabilitation programme among couples after radical prostatectomy and to determine its feasibility. Research design and methods: 19 couples were included in the study, of which 15 completed the programme. Data were collected through semi-structured interviews at baseline and after programme completion using an interview guide developed for this study. Reflexive thematic analysis was used to interpret qualitative data, and descriptive statistics summarised quantitative outcomes from questionnaires. Results: Participants found the programme meaningful and helpful. The digital format was valued for its flexibility and accessibility. Participants desired more tailored content and interactive elements. The programme positively impacted communication about sexual issues within couples. Participants also highlighted the need for peer support and more structured guidance on physical and pharmaceutical strategies. Some joined the programme to support others rather than for personal need, which may have influenced perceived effects. Questionnaire data showed changes in sexual function among patients and stable relationship satisfaction, though interpretation is limited. Conclusion: The digital programme was feasible and well-received, with positive effects on communication and perceived support. Findings highlight the importance of clear inclusion criteria, timing of intervention delivery and tailoring content to individual needs. These insights can inform future development of digital psychosocial interventions for sexual rehabilitation in cancer care.

Background: There has recently been an increased emphasis on patient empowerment and collaboration within their healthcare. However, there is widely a lack of clarity to the concept of empowerment and existing measurement tools lack uniformity, covering diverse domains and related concepts. Objectives: This study aims to conduct a psychometric evaluation of the Swedish version of the Empowerment Scale– Making Decisions, focusing on its structural validity and reliability in assessing patient empowerment. This includes a detailed examination of the factor structure across two different contexts, psychiatric care (n = 211) and primary care (n = 210). We will compare several confirmatory factor analysis (CFA) models proposed in previous research to identify the best fit. If no models provide a good fit, we intend to suggest a new scale for further evaluation. Method: The dimensionality of the scale was tested by comparing four CFA models, together with a one-factor solution, to identify the best fit for the two samples. Reliability measures were determined by coefficient Omega (ω) as well as Cronbach’s alpha (α). Results: There was limited support for the one-factor solution in both samples, challenging the scale’s assumed unidimensionality (primary care sample: x²(350) = 1074, p <.001, CFI = 0.58, TLI = 0.54, RMSEA = 0.10 (90% CI: 0.09 − 0.11), SRMR = 0.11; psychiatric care sample: (x²(350) = 1307, p = < 0.001, CFI = 0.66, TLI = 0.63, RMSEA = 0.11 (90% CI:0.11;0.12), SRMR = 0.10). None of the previously suggested factor solutions demonstrated satisfactory fit. However, a three factor-solution entailed the less complexity and best model fit (primary care sample: (x²(270) = 503, p = < 0.001),CFI = 0.85, TLI = 0.84, RMSEA = 0.06 (90% CI 0.06;0.07), SRMR = 0.07; psychiatric care sample: (x²(270) = 622, p <.001), CFI = 0.87, TLI = 0.86, RMSEA = 0.08 (90% CI 0.07;0.09), SRMR = 0.07). Based on this, we continued with exploratory refinements of this solution and arrived at two adjusted three-factor models based on each sample. These two adjusted models displayed only slight differences, and in a last step we removed the items that differed between the samples to arrive at one solution appropriate for use in health care settings in general. As a result, an improved and shortened adaptation of the scale was put forward that included 18 items targeting the subscales Self-Esteem, Powerlessness and Activism. This solution remained relatively clear to the previously proposed solutions (primary care sample:(x²(131) = 240, p <.001), CFI = 0.91, TLI = 0.90, RMSEA = 0.06 (90% CI 0.05;0.08), SRMR = 0.07; psychiatric care sample: (x²(131) = 379, p <.001), CFI = 0.88, TLI = 0.86, RMSEA = 0.09 (90% CI 0.08;0.10), SRMR = 0.07; combined sample: (x²(131) = 432, p <.001), CFI = 0.91, TLI = 0.90, RMSEA = 0.07 (90% CI 0.07;0.08), SRMR = 0.06). Conclusion: The results reinforce the difficulties in measuring empowerment given the complexity of this concept. The improved and shortened adaptation of the scale could potentially be used within health care settings to measure empowerment, but further research is needed to conceptualize and measure empowerment in patients with mental health problems. Given scarce support for the scale’s unidimensionallity, future research should explore using multiple instruments targeting different constructs to measure patient empowerment more comprehensively.