Our research group for digital health and care has pioneered the development of knowledge regarding internet-based cognitive behavioural therapy (I-CBT) in the treatment of psychological distress in patients with somatic disease.
Through several randomized studies, we know today that I-CBT can be used to reduce depression and anxiety in patients with heart disease and/or non-cardiac chest pain, both in the short and long term. Our results also show that treating psychological distress in these patients also leads to better quality of life and self-care ability. It has been suggested that physical activity can be used to treat psychological distress in these patients. This may be questionable, as in one of our studies we have found that depression must decrease before the physical activity rate begins to increase. A possible reason for this is that many of these patients are afraid that the heart may be damaged if they perform physically strenuous activity. So, we would suggest that these patients are offered a combination of CBT and physical activity. We also have preliminary results that show that I-CBT also leads to an increased “self-efficacy” but this is also a result of a reduced psychological distress. Overall, this shows the importance of reducing psychological distress in these patients.
In I-CBT treatment of patients with somatic disease, it is beneficial if the therapist has knowledge and experience of working with these patients. In our studies, the treatment was delivered by nurses with experience in cardiac care and patients with non-cardiac chest pain and with only a brief course in CBT. There are several explanations for why this works in I-CBT. One is that the therapeutic aspect of I-CBT is imbedded in the texts and homework assignments and not primarily therapist-related. A second explanation is that in I-CBT, the role of the therapist is more focused on encouraging and confirming the patient and therefore it is important that the person who acts as the therapist can meet the needs of the patient medically and psychologically. Another aspect is that the CBT program itself needs to be designed so that the patient recognizes himself, i.e., that the content is adapted to the context of heart disease or non-cardiac chest pain.
In several interview studies, patients have described that the I-CBT program and the therapist have been perceived as trustworthy and knowledgeable and that they have felt understood, seen, and heard. They describe experiencing an affinity with therapists and programs. CBT is a kind of school and is about learning. The patients have described that through CBT treatment they have just learned to understand and be able to manage their disease. But they also described that the treatment can be laborious and require them to be active themselves. But at the same time, this is probably what also leads to positive results for the patient. We have previously found that reducing depression was linked to how many times the patient logged on to the treatment platform.
Healthcare currently has a lack of access to CBT and many of the patients are at risk of not receiving any treatment for their psychological distress. Our results show that I-CBT can increase access to CBT and is cost-effective, from a health economic perspective. For example, on average, about 2 hours per patient are consumed during an I-CBT treatment. For a nine-week course of treatment, this results in a saving of approximately 5.5 hours per patient, or 75%, of the treatment time that would have been consumed during a standard CBT treatment. We have also reported that I-CBT for depression in patients with CVD is within the levels required to be described as a cost-effective treatment. Another advantage is that I-CBT can be obtained at home and at times that suit the patients regardless of where they live geographically. In our studies, the treatment has been based on Campus Norrköping and provided to patients living in south-eastern Sweden. Thus, I-CBT can be considered “Nära Vård”.
- Westas M, Mourad G, Andersson G, Lundgren J, Johansson P. Effects of internet-delivered cognitive behavioral therapy adapted for patients with cardiovascular disease and depression. A long-term follow-up of a randomized controlled trial at 6 and 12 months post treatment. Eur J Cardiovasc Nurs. 2022 Jan 21:zvab131. doi:10.1093/eurjcn/zvab131.
- Mourad G, Leibon-Eriksson M, Karlström P, Johansson P. The effect of Internet-delivered cognitive behavioural therapy vs. psychoeducation only on psychological distress in patients with non-cardiac chest pain: a randomized controlled trial. J Med Internet Res. 2022 Jan 28;24(1):e31674. doi: 10.2196/31674
- Neher M, Nygårdh A, Broström A, Lundgren J, Johansson P. Perspectives of Policy Makers and Service Users Concerning the Implementation of eHealth in Sweden: Interview Study. J Med Internet Res. 2022: 24(1):e28870. doi: 10.2196/28870
- Furukawa T, Suganuma A, Ostinelli E, … Johansson P, Lundgren J, et al. Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data. Lancet Psychiatry 2021 https://doi.org/10.1016/S2215-0366(21)00077-8
- Siebmans S, Johansson P, Johansson L, Ulander M, Andersson G, Broström A. The effect of nurse-led internet-based cognitive behavioural therapy for insomnia on patients with cardiovascular disease: A randomised controlled trial with a six-month follow-up. Nursing Open Feb. 2021
- Johansson P. Svensson E, Andersson G, Lundgren. Trajectories and associations between depression and physical activity in patients with cardiovascular disease during participation in an internet-based cognitive behavioural therapy programme. European Journal of Cardiovascular Nursing July 2020.
- Westas M, Mourad G, Neher M, Lundgren J, Johansson P. How health care professionals in cardiac care address depressive symptoms: Experiences of patients with cardiovascular disease. J Cardiovasc Nurs Dec 2019.
- Johansson P. Andersson G, Jaarsma T, Lundgren J. The impact of internet-based cognitive behavioural therapy and depressive symptoms on self-care behaviour in patients with heart failure. A secondary analysis of a randomised controlled trial. Int J Nurs Stud Oct 2019.
- Johansson P. Westas M, Andersson G, Alehagen U, Broström A, Jaarsma T, Mourad G, Lundgren J. Internet-Based Cognitive Behavioral Therapy Program Adapted to Patients With Cardiovascular Disease and Depression: Randomized Controlled Trial. Journal Medical Internet Research Mental Health. 2019 Oct 3;6(10):e14648. doi: 10.2196/14648