Christopher Sundström

Background: India’s older adult population is rapidly increasing, accompanied by a growing burden of common mental health problems such as depression, anxiety, sleep disturbances, and cognitive concerns. Promoting healthy aging and preventive mental healthcare has therefore become an important public health priority. Digital health interventions have emerged as promising approaches for improving access to preventive and supportive care among older adults. This study gathers perspectives from older adults, caregivers, and experts to develop content for a self-help digital intervention for older adults (≥ 60 years) in India, with a focus on healthy aging and the prevention of common mental health problems. Methods: A qualitative study, following the COREQ guideline, was conducted from January through September 2024 at two sites in India. Participants included community-dwelling older adults aged ≥ 60 years and their caregivers, as well as experts from diverse medical and allied health disciplines. Data were collected using FGDs, IDIs, KIIs, and free-listing. All interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Transcripts were systematically coded, and codes were grouped into themes across predefined analytical domains. Results: Regular sleep routines, a balanced diet, and physical activity and exercise were considered beneficial for healthy aging. Furthermore, stress management, steering clear of negative thoughts, and practicing meditation were cited as essential for optimum mental health. Health management tips, exercise tutorials, dietary guidelines, mental healthcare advice, and sleep hygiene tips are expected in digital interventions. Conclusions: The findings suggest that digital interventions tailored to the sociocultural needs of older adults may play an important role in promoting healthy aging and supporting mental well-being in India. Stakeholder-informed digital modules addressing physical health, sleep, emotional well-being, social connectedness, and self-care practices may enhance engagement, accessibility, and preventive mental healthcare among older adults. Future research should evaluate the effectiveness, acceptability, and long-term sustainability of such interventions in larger and more diverse populations.

Background: University students show a high prevalence of diverse mental health problems, requiring adaptable interventions to assist them in improving their mental health. Objective: This study aimed to evaluate the feasibility of transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for anxiety and depression in preparation for a randomized controlled trial. ICBT incorporated 2 innovative approaches to increase precision: user-steered content personalization and within-treatment adaptive modification based on early symptom trajectory. Methods: This single-group, open-label study was conducted online in Sweden in the autumn of 2021, recruiting from students who had completed the World Health Organization (WHO) World Mental Health International College Student (WMH-ICS) mental health survey. Participants were eligible if they scored 5-19 on the Patient Health Questionnaire-9 (PHQ-9), or ≥5 on the Generalized Anxiety Disorder-7 (GAD-7), or both. Participants completed an 8-week ICBT program with therapist support. They initially personalized their program by selecting a primary problem orientation, anxiety or depression, and choosing additional elective modules, and could consult their therapist regarding these choices. At midtreatment, stepped care was piloted, in which participants without symptom improvement were randomized to adaptive enhancement of therapist support or to continue treatment as before. The main feasibility outcomes included data on reach and uptake, intervention acceptability, stepped care procedures, and assessment retention up to 6 months. The GAD-7 and PHQ-9 were the primary outcome measures, with changes in scores calculated using mixed effects models. Results: Of 749 invited students, 55 (7%) completed the study screening, and 28 (4%) were included. The GAD-7 baseline score was 9.5 (SD 4.4), and the PHQ-9 baseline score was 11.2 (SD 5.2). Participants opened 6.2 (SD 2.2) out of the 8 treatment modules. The user-directed personalization yielded 27 unique treatment configurations across 28 participants. At week 4, 16/27 (59%) participants remaining in treatment were randomized in the stepped care procedure. Ratings on self-report measures showed acceptable to good therapeutic alliance and treatment satisfaction. Eleven participants reported increased stress associated with the treatment. Reductions in depression and anxiety symptoms were observed at postmeasurement and 6 months follow-up, with 43% attrition at those times. Conclusions: This pioneering study of personalized ICBT with adaptive change among university students demonstrated the overall feasibility of the treatment. To enhance the design of a future definitive trial, modifications are necessary to mitigate assessment attrition and reduce treatment-related stress. Trial Registration: ClinicalTrials.gov NCT05509660; https://clinicaltrials.gov/study/NCT05509660

Background: Employee assistance programs (EAP’s) are resources where employers can receive help when encountering substance abuse among their employees. Such help often entails in-person counselling delivered within the EAP. Internet-delivered cognitive behavior therapy (ICBT), shown to have a robust evidence base and currently being implemented in various health care settings, could potentially serve as an alternative to in-person counselling in EAP’s. However, until now, no studies have investigated ICBT in an EAP context. Methods: The present qualitative study examined experiences of therapist-guided ICBT for employees with problematic alcohol use delivered within an EAP in Sweden. Interviews were conducted with the employees receiving the ICBT (n = 7), with each employee’s employer representative (n = 6), and with psychologists (n = 3) involved in the recruitment and referral of employees to ICBT. The interviews were analyzed for each of these three categories (employees, employer representatives, psychologists) using thematic analysis. Results: Most employees found ICBT useful and reported that their awareness of the negative consequences of excessive drinking had increased during treatment, in parallel with acquisition of tools to reduce their alcohol consumption. Perceived advantages included ICBT anonymity and flexibility, as well as the therapist guidance provided. Although employer representatives expressed some initial skepticism towards using the online delivery format to address alcohol problems, they mainly found ICBT beneficial. The psychologists appeared hesitant to recruit employees to ICBT as they either deemed alcohol problems of employees to be too severe for ICBT or stated that employees had psychiatric comorbidity leading to more complex needs. Conclusions: ICBT for problematic alcohol use appeared beneficial for employees when delivered within an EAP. However, there was initial skepticism among employer representatives and psychologists were hesitant to recommend ICBT. Clinical trials registration: NCT06774716, 2022-05-10.

Background: The proportion of older adults is projected to rise dramatically in most parts of the world, and in 2050, 80% of all older adults (≥65 years) will reside in low- and middle-income countries. Developing digital interventions tailored to this population will be a crucial part in appropriately addressing the challenges associated with the upcoming demographic changes. The objective of this scoping review was to map all published research on digital interventions for common mental health problems among older adults conducted in low- and middle-income countries. Methods: We conducted a literature search in four databases (PubMed, Embase, Scopus and Cochrane Library) and conducted hand searches of existing reviews and reference lists of included studies. Eligibility criteria were that (1) the study investigated or discussed digital interventions for common mental health problems (depression, anxiety, sleep problems and/or substance use problems), (2) the study concerned older adults (at least 60 years or older), (3) the study was conducted in a low- or middle-income country and (4) the study was published in English in a peer-reviewed academic journal. Two reviewers independently screened, reviewed and extracted data. Results: Out of 1344 identified studies, 6 were included. The hand searches rendered no additional studies, leaving a total of six included studies. Four of these studies included quantitative data: of these, three were randomised controlled trials and one was a feasibility study. All focused on depression/loneliness and were published in middle-income countries (South Africa, Brazil and Turkey), and showed promising results in terms of reductions in social isolation and depression. In addition, two expert opinions had been published, both also conducted in a middle-income country (India). Conclusion: Despite the projected demographic transition, surprisingly little research appears to have been conducted on digital interventions for common mental health disorders among older adults in low- and middle-income countries. Registration: https://osf.io/bmdnv Open Science Framework.

BACKGROUND University students show a high prevalence of diverse mental health problems, requiring adaptable interventions to assist them in improving their mental health. OBJECTIVE This study aimed to evaluate the feasibility of transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for anxiety and depression in preparation for a randomized controlled trial. ICBT incorporated 2 innovative approaches to increase precision: user-steered content personalization and within-treatment adaptive modification based on early symptom trajectory. METHODS This single-group, open-label study was conducted online in Sweden in the autumn of 2021, recruiting from students who had completed the World Health Organization (WHO) World Mental Health International College Student (WMH-ICS) mental health survey. Participants were eligible if they scored 5-19 on the Patient Health Questionnaire-9 (PHQ-9), or ≥5 on the Generalized Anxiety Disorder-7 (GAD-7), or both. Participants completed an 8-week ICBT program with therapist support. They initially personalized their program by selecting a primary problem orientation, anxiety or depression, and choosing additional elective modules, and could consult their therapist regarding these choices. At midtreatment, stepped care was piloted, in which participants without symptom improvement were randomized to adaptive enhancement of therapist support or to continue treatment as before. The main feasibility outcomes included data on reach and uptake, intervention acceptability, stepped care procedures, and assessment retention up to 6 months. The GAD-7 and PHQ-9 were the primary outcome measures, with changes in scores calculated using mixed effects models. RESULTS Of 749 invited students, 55 (7%) completed the study screening, and 28 (4%) were included. The GAD-7 baseline score was 9.5 (SD 4.4), and the PHQ-9 baseline score was 11.2 (SD 5.2). Participants opened 6.2 (SD 2.2) out of the 8 treatment modules. The user-directed personalization yielded 27 unique treatment configurations across 28 participants. At week 4, 16/27 (59%) participants remaining in treatment were randomized in the stepped care procedure. Ratings on self-report measures showed acceptable to good therapeutic alliance and treatment satisfaction. Eleven participants reported increased stress associated with the treatment. Reductions in depression and anxiety symptoms were observed at postmeasurement and 6 months follow-up, with 43% attrition at those times. CONCLUSIONS This pioneering study of personalized ICBT with adaptive change among university students demonstrated the overall feasibility of the treatment. To enhance the design of a future definitive trial, modifications are necessary to mitigate assessment attrition and reduce treatment-related stress. CLINICALTRIAL ClinicalTrials.gov NCT05509660; https://clinicaltrials.gov/study/NCT05509660

Background: Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown. Objective: This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety. Methods: All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients’ use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients’ alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores. Results: During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients’ drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week. Conclusions: Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource.

Problem gambling and tobacco use are highly comorbid among adults. However, there are few treatment frameworks that target both gambling and tobacco use simultaneously (i.e., an integrated approach), while also being accessible and evidence-based. The aim of this two-arm open label RCT was to examine the efficacy of an integrated online treatment for problem gambling and tobacco use. A sample of 209 participants (M _age = 37.66, SD = 13.81; 62.2% female) from North America were randomized into one of two treatment conditions (integrated [n = 91] or gambling only [n = 118]) that lasted for eight weeks and consisted of seven online modules. Participants completed assessments at baseline, after treatment completion, and at 24-week follow-up. While a priori planned generalized linear mixed models showed no condition differences on primary (gambling days, money spent, time spent) and secondary outcomes, both conditions did appear to significantly reduce problem gambling and smoking behaviours over time. Post hoc analyses showed that reductions in smoking and gambling craving were correlated with reductions in days spent gambling, as well as with gambling disorder symptoms. Relatively high (versus low) nicotine replacement therapy use was associated with greater reductions in gambling behaviours in the integrated treatment condition. While our open label RCT does not support a clear benefit of integrated treatment, findings suggest that changes in smoking and gambling were correlated over time, regardless of treatment condition, suggesting that more research on mechanisms of smoking outcomes in the context of gambling treatment may be relevant. Problem gambling and tobacco use are highly comorbid among adults. However, there are few treatment frameworks that target both gambling and tobacco use simultaneously (i.e., an integrated approach), while also being accessible and evidence-based. The aim of this two-arm open label RCT was to examine the efficacy of an integrated online treatment for problem gambling and tobacco use. A sample of 209 participants (M_age = 37.66, SD = 13.81; 62.2% female) from North America were randomized into one of two treatment conditions (integrated [n = 91] or gambling only [n = 118]) that lasted for eight weeks and consisted of seven online modules. Participants completed assessments at baseline, after treatment completion, and at 24-week follow-up. While a priori planned generalized linear mixed models showed no condition differences on primary (gambling days, money spent, time spent) and secondary outcomes, both conditions did appear to significantly reduce problem gambling and smoking behaviours over time. Post hoc analyses showed that reductions in smoking and gambling craving were correlated with reductions in days spent gambling, as well as with gambling disorder symptoms. Relatively high (versus low) nicotine replacement therapy use was associated with greater reductions in gambling behaviours in the integrated treatment condition. While our open label RCT does not support a clear benefit of integrated treatment, findings suggest that changes in smoking and gambling were correlated over time, regardless of treatment condition, suggesting that more research on mechanisms of smoking outcomes in the context of gambling treatment may be relevant.

Introduction: Internet interventions for alcohol problems are effective, but not all participants are helped. Further, the importance of adherence has often been neglected in research on internet interventions for alcohol problems. Prediction analysis can help in prospectively assessing participants’ probability of success, and ideally, this information could be used to tailor internet interventions to individual needs. Methods: Data were obtained from a randomized controlled trial on internet interventions for alcohol use disorders. Twenty-nine candidate predictors were run in univariate logistic regressions with two dichotomous dependent outcomes: adherence (defined as completing at least 60% of the treatment modules) and low-risk drinking (defined as drinking within national public health guidelines) at two time points – immediately post-treatment and at the 6-month follow-up. Significant predictors were entered hierarchically into domain-specific logistic regressions. In the final models, predictors still showing significant effects were run in multiple logistic regressions. Results: One predictor significantly predicted adherence: treatment credibility (as in how logical the treatment is and how successful one perceives the treatment to be) assessed during the third week of the intervention. Four predictors significantly predicted low-risk drinking at the post-treatment follow-up: pre-treatment abstinence (i.e., not drinking during the 7 days before treatment started), being of the male gender, and two personality factors – a low degree of antagonism and a high degree of alexithymia. At the 6-month follow-up, pre-treatment abstinence was the only significant predictor. Conclusion: Adherence was not predictive of low-risk drinking. Personality variables may have predictive value and should be studied further. Those who abstain from alcohol during the week before treatment starts have a higher likelihood of achieving low-risk drinking than people who initially continue drinking.

BACKGROUND Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown. OBJECTIVE This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety. METHODS All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients’ use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients’ alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores. RESULTS During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients’ drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week. CONCLUSIONS Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource.

Background: Internet-delivered cognitive behavioral therapy (ICBT) for alcohol misuse has potential to radically improve access to evidence-based care, and there is a need to investigate ways to optimize its delivery in clinical settings. Guidance from a clinician has previously been shown to improve drinking outcomes in ICBT, and some studies suggest that pre-treatment assessments may contribute in initiating early change. The objective of this study was to investigate the added and combined effects of a pre-treatment assessment interview and guidance on the outcomes of ICBT for alcohol misuse delivered in an online therapy clinic. Methods: A 2X2 factorial randomized controlled trial was conducted where participants received access to an 8-week ICBT program, and either a pre-treatment assessment interview (Factor 1), guidance (Factor 2), a combination of these, or neither of these. Participants were 270 individuals (66.8% female, mean age = 46.5) scoring 8 or more on the Alcohol Use Disorders Identification Test and consuming 14 standard drinks or more in the preceding week. Primary outcomes were number of drinks consumed and number of heavy drinking days during the preceding week, 3 months post-treatment. Results: Large within-group effects were found in terms of alcohol reductions (d_w ≥ 0.82, p < 0.001), but neither of the factors significantly improved drinking outcomes. Guidance was associated with greater adherence (i.e. completed modules). Conclusions: Neither a pre-treatment assessment interview nor guidance from a clinician appears to improve drinking outcomes resulting from internet-delivered cognitive behaviour therapy for alcohol misuse when delivered in a routine online therapy clinic. Trial registration: NCT03984786. Registered 13 June 2019, https://clinicaltrials.gov/ct2/show/NCT03984786