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Background: Previous research has shown a marked increase in the levels of anxiety related to climate change in the population and has described that some individuals experience significant impairment in everyday life functioning due to this anxiety. The aim of the current study was to extend those findings using gold standard measures of anxiety and impairment, and to describe and explore the characteristics and the need for psychological support of individuals showing climate anxiety-related impairment. Method: We used a cross-sectional online survey targeting adult individuals who self-identified as being worried about the climate. Participants were recruited in Sweden via social media between September and October 2022. The survey included measures of anxiety, anxiety-maintaining behaviors, impairment, depressive symptoms, and sleep problems, as well as a series of commonly used one-item questions about their climate anxiety, Results: A total of 1221 adults (75% women, mean age 46.3 years) provided data. Previously used one-item measures of anxiety and impairment displayed strong and significant associations with gold standard, dimensional measures of anxiety and impairment. A total of 781 (64%) individuals said that they were very worried about the climate and 153 (13%) were classified as having maladaptive climate anxiety, according to predefined criteria (i.e., a significant and persistent experience of climate anxiety and significant impairment on everyday life functioning attributable to climate anxiety). This classification of maladaptive climate anxiety was validated by a data-driven approach. Individuals with maladaptive climate anxiety were more likely to express higher levels of depressed mood and sleep problems and were also more likely to be engaged in anxiety-maintaining coping behaviors across different domains. While only a minority of respondents with maladaptive climate anxiety (25%) had been in contact with healthcare services, a majority (77%) expressed interest in receiving some form of psychological support. Conclusions: Climate anxiety-related impairment was shown to be relatively prevalent in individuals with climate anxiety. As there is demand for psychological support, an important next step would be to develop and evaluate brief, scalable interventions targeted towards the needs of this group.

Romantic jealousy could be understood as a continuum, from reality-based, transient and functional jealousy to a more chronic form of jealousy with varying insight, intensity and duration. The latter has some overlaps with obsessive-compulsive disorder (here termed obsessional jealousy). Little is known about the nature of obsessional jealousy and its association with functional impairment, perceived negative consequences (drinking, violence), current and past relationship factors (e.g., length of relationship, being in love, infidelity, previous jealousy) or perceived need for professional support.Participants were 1076 adults (55% women) who filled in an anonymous survey.Obsessional jealousy, measured with the Obsessional Jealousy Severity Scale, was strongly associated with functional impairment and verbal violence, and more weakly with physical violence and alcohol consumption. Individuals with a history of previous jealousy had more severe symptoms and were more likely to perceive the need for psychological support. Approximately 25% of the sample expressed interest in treatment.The results suggest that there is a group of individuals with impairing levels of obsessional jealousy who have a perceived need for help with their difficulties. More research is needed on the prevalence and clinical characteristics of these individuals. The development of jealousy-specific psychological models and treatments is warranted.

Introduction: Worries about the immediate and long-term consequences of the COVID-19 pandemic may for some individuals develop into pervasive worry that is disproportionate in its intensity or duration and significantly interferes with everyday life. Objective: The aim of this study was to investigate if a brief self-guided, online psychological intervention can reduce the degree of dysfunctional worry related to the COVID-19 pandemic and associated symptoms. Methods: 670 adults from the Swedish general population reporting daily uncontrollable worry about CO­VID-19 and its possible consequences (e.g., illness, death, the economy, one’s family) were randomised (1:1 ratio) to a 3-week self-guided, online cognitive behavioural intervention targeting dysfunctional COVID-19 worry and associated symptoms, or a waiting list of equal duration. The primary outcome measure was a COVID-19 adapted version of the Generalised Anxiety Disorder 7-item scale administered at baseline and weeks 1–3 (primary endpoint). Follow-up assessments were conducted 1 month after treatment completion. The trial was registered on ClinicalTrials.gov (NCT04341922) before inclusion of the first participant. Results: The main pre-specified intention-to-treat analysis indicated significant reductions in COVID-19-related worry for the intervention group compared to the waiting list (β = 1.14, Z = 9.27, p < 0.001), corresponding to a medium effect size (bootstrapped d = 0.74 [95% CI: 0.58–0.90]). Improvements were also seen on all secondary measures, including mood, daily functioning, insomnia, and intolerance of uncertainty. Participant satisfaction was high. No serious adverse events were recorded. Conclusions: A brief digital and easily scalable self-guided psychological intervention can significantly reduce dysfunctional worry and associated behavioural symptoms related to the COVID-19 pandemic.

Internet-delivered cognitive behaviour therapy (ICBT) is emerging as a powerful tool to fill the gap between demand and availability of evidence-based treatment for paediatric anxiety disorders. However, it is still unclear how to best implement it in routine clinical care. 123 children (8–12 years) with anxiety disorders underwent a 12-week ICBT programme with limited therapist support. Participants were assessed 3- and 12-month post-ICBT (3MFU and 12MFU, respectively). Non-remitters who still fulfilled diagnostic criteria for their principal anxiety disorder at 3MFU were offered additional manualised “face-to-face” (F2F) CBT. The aim of the study was to emulate a stepped-care model of health care delivery, where the long-term treatment gains of ICBT as well as the potential benefit of proving addition treatment to non-remitters of ICBT were evaluated. Remitters of ICBT (n = 73) continued to improve throughout the study period (pre-ICBT to 12MFU; Cohen’s d = 2.42). At 12MFU, 89% (n = 65) were free from their principal anxiety disorder. Of all the participants classed as non-remitters at 3MFU (n = 37), 48.6% (n = 18) accepted the offer to receive additional F2F CBT. These participants also improved with a large effect from pre-ICBT to 12MFU (Cohen’s d = 2.27), with the largest effect occurring during F2F CBT. At 12MFU, 83% (n = 15) were free from their principal anxiety disorders. The majority of non-remitters declining additional F2F CBT (63.2%; n = 12) did so due to already receiving treatment at their local CAMHS, prior to 3MFU. The effects of ICBT for anxiety disorders are durable at least up to 1 year after the end of treatment. Patients who fail to fully benefit from ICBT improved further with additional F2F sessions at our clinic, suggesting that it may be feasible to implement ICBT within a stepped-care model of health care delivery.

Bouts of excessive worry are common across the lifespan, increasing in frequency and complexity during adolescence and adulthood, and are found in several psychiatric disorders, particularly the anxiety disorders. There are evidence-based treatments for adolescents with anxiety disorders but psychological treatments designed specifically to target excessive worrying in adolescents are rare. Intolerance of uncertainty (IU), a cognitive predisposition described as a fear of the unknown, is highly associated with worry among adolescents. This study investigated the feasibility, acceptability, and preliminary efficacy of IU-focused cognitive behavioral therapy (IU-CBT) for adolescents with excessive worry. Twelve participants (aged 13–17 years) with excessive worry, irrespective of psychiatric diagnosis, were provided weekly face-to-face sessions, primarily including therapist and self-guided exposure to situations involving uncertainty. Sessions were supplemented with an internet-delivered educational program for parents, designed to teach parents about worry, IU and helpful parental behaviors. The main outcome measure was the Penn-State Worry Questionnaire for Children (PSWQ-C). The treatment was well tolerated with no dropouts and families reporting being satisfied with the treatment. Participants were able to grasp the notion of IU and its relationship to worry and avoidance. Significant reductions were observed for self-reported worry, anxiety, depression, IU, and parent-reported worry, as were significant increases in global functioning. Based on a clinician rating, 58.3% were categorized as much or very much improved at posttreatment, rising to 66% at 3-month follow-up. Participants with generalized anxiety disorder (GAD) benefitted more from treatment than those with social anxiety disorder. The findings suggest that this IU-focused psychological intervention is acceptable and feasible to adolescents with excessive worry but may be most effective for those with GAD.

Previous studies have found an association between excessive worrying and negative beliefs about worry. It is unclear if change in these beliefs mediate worry reduction. This study aimed to examine (1) if a simplified online metacognitive intervention can reduce worry, (2) whether changes in negative beliefs about worry mediate changes in worry severity, and (3) moderated mediation, i.e., if the mediating effect is more pronounced in individuals with a high degree of negative beliefs about worry at baseline. Adult excessive worriers (N = 108) were randomized to 10-weeks of the online metacognitive intervention (MCI) aimed at reducing negative beliefs about worry, or to wait-list (WL). Outcomes, mediation, and moderated mediation were examined via growth curve modelling. Results indicated a significant reduction in the MCI group (d = 1.6). Reductions in negative beliefs about worry and depressive symptoms separately mediated changes in worry severity during the intervention, but in a multivariate test only the former remained significant. Sensitivity analysis indicated that the hypothesized mediation was robust to possible violations of mediator-outcome confounding. The moderated mediation hypothesis was not supported. The results from this randomized trial add to the growing literature suggesting that negative beliefs about worry play a key role in worry-related problems. ClinicalTrials.gov Identifier: NCT03393156 Funding Agencies|Fredrik and Ingrid Thuring foundation; Strategic Research Area Healthcare Science (SFO-V)

Background: The Work and Social Adjustment Scale (WSAS) is a brief five-item global measure of functional impairment that is widely used as an outcome measure in adult mental health. We have adapted the WSAS for its use in youth, the WSAS-Youth version (WSAS-Y) and WSAS-Parent version (WSAS-P). This study evaluated the psychometric properties of the scale in a large sample of youth seeking help for a range of psychiatric disorders. Method: The internal consistency, factor structure, convergent and divergent validity, test-retest reliability and sensitivity to change of the WSAS-Y/P were studied in 525 children and adolescents with Obsessive-Compulsive Disorder and related disorders (including Body Dysmorphic Disorder, Tourette’s Syndrome, and body-focused repetitive behaviour disorders) receiving treatment across two specialist clinics in London and Stockholm.Results: The internal consistency of the WSAS-Y/P was excellent across diagnostic groups and time points. Exploratory factor analysis extracted a single-factor of functional impairment, explaining in excess of 85% of the variance. The test-retest reliability was adequate. As expected the WSAS-Y/P correlated more strongly with other measures of functional impairment than with measures of symptom severity, indicating good convergent/divergent validity. Finally, the WSAS-Y/P was highly sensitive to change after treatment.Conclusion: The WSAS-Y/P retains the sound psychometric properties of the original WSAS and is highly sensitive to change after treatment.

Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited.To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT).This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study.ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist.The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs.Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group.In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD.ClinicalTrials.gov Identifier: NCT03247075.

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable. Key learning aims (1) To learn about experienced benefits and obstacles of exposure in the treatment of worry. (2) To learn about teenagers’ experiences of working independently with exposure. (3) To consider the impact of parental involvement in psychological treatments for teenagers. (4) To consider pros and cons of online treatment for teenagers and their parents. (5) To consider the use of qualitative research approaches to inform further development of psychological treatments for teenagers with excessive worry.

Introduction: Worries about the immediate and long-term consequences of the COVID-19 pandemic may for some individuals develop into pervasive worry that is disproportionate in its intensity or duration and significantly interferes with everyday life. Objective: The aim of this study was to investigate if a brief self-guided, online psychological intervention can reduce the degree of dysfunctional worry related to the COVID-19 pandemic and associated symptoms.Methods: 670 adults from the general Swedish general population reporting daily uncontrollable worry about COVID-19 and its possible consequences (e.g. illness, death, the economy, one’s family) were randomised (1:1 ratio) to a 3-week self-guided, online cognitive behavioural intervention targeting dysfunctional COVID-19 worry and associated symptoms, or a waiting list of equal duration. The primary outcome measure was a COVID-19 adapted version of the Generalised Anxiety Disorder 7-item scale assessed at baseline and weeks 1-3 (primary endpoint). Follow-up assessments were conducted one month after treatment completion. The trial was registered on ClinicalTrials.gov (NCT04341922) before inclusion of the first participant.Results: The main pre-specified intention-to-treat analysis indicated significant reductions in COVID-19-related worry for the intervention group compared to waiting list (=1.14, Z=9.27, p

Objective: To investigate if a brief self-guided, online cognitive behavioural intervention can reduce the degree of dysfunctional worry related to the covid-19 pandemic.Design: Randomised waiting list controlled trial.Setting: Swedish general population. Participants: Self-referred adults reporting daily uncontrollable worry about covid-19 and its possible consequences. The trial aims to include 670 participants in total. Here we present the results of a pre-specified interim analysis on data from the first 300 randomised participants. Intervention: A brief (3-week) self-guided, online cognitive behavioural intervention targeting dysfunctional worry related to the covid-19 pandemic. Main outcome measure: A covid-19 adapted version of the self-rated Generalised Anxiety Disorder 7-item scale assessed at baseline, week 1, week 2 and week 3 (primary endpoint). Results: The main pre-specified intention-to-treat analysis indicated significant reductions in covid-19-related worry for the intervention compared to waiting list (=2.64, Z=4.02, p

Paediatric anxiety disorders are associated with substantial disability and long-term adverse consequences, but only a small proportion of affected children have access to evidence-based treatment. Internet-delivered cognitive behavioural therapy (ICBT) could help increase accessibility but needs further rigorous assessment. We aimed to assess the efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders.We did a single-blind randomised controlled trial in a clinical research unit within the Child and Adolescent Mental Health Services in Stockholm (Sweden). Eligible participants were children aged 8-12 years with a diagnosis of a principal anxiety disorder (seperation anxiety disorder, generalised anxiety disorder, specific phobia, social anxiety disorder, or panic disorder) of at least moderate severity. We randomly allocated participants (1:1) to ICBT or internet-delivered child-directed play, an active comparator aimed to improve parent-child relationships and increase a child's self-esteem without directly targeting anxiety. Block sizes for the randomisation varied between four and six and were generated using a computer random-number generator, and the allocation was concealed from the researchers by opaque sealed envelopes. Both treatment programmes comprised 12 modules presented over 12 weeks with weekly asynchronous online therapist support, and consisted of texts, films, illustrations, and exercises. The primary outcome was severity rating of the principal anxiety disorder 12-weeks post-treatment, via the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders-IV (a rating of at least 4 corresponds to meeting the criteria for the principal diagnosis), assessed by clinicians masked to treatment allocation. All participants were included in the primary analysis (intention-to-treat). This trial is registered at ClinicalTrials.gov, number NCT02350257.Between March 11, 2015, and Oct 21, 2016, 131 participants were recruited and allocated to either ICBT (n=66) or internet-delivered child-directed play (n=65). The clinician-assessed severity rating of the principal anxiety disorder improved significantly after the 12-weeks treatment period for participants in both ICBT (within-group effect size 1·22, 95% CI 0·78-1·65) and the active control (0·72, 0·44-1·00) groups. However, greater improvement was seen with ICBT than with the active control (estimated mean difference 0·79, 95% CI 0·42-1·16, p=0·002; between-group effect size 0·77, 95% CI 0·40-1·15). 29 (48%) participants in the ICBT group no longer had their principal diagnosis, compared to nine (15%) in the active control group (odds ratio 5·41, 95% CI 2·26 to 12·90, p0·0001); the number needed to treat for ICBT to gain one additional participant in remission was three (95% CI 2·85 to 3·15). ICBT resulted in an average societal-cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported.ICBT is an efficacious and cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care.The Swedish Research Council for Health, Working Life and Welfare, and Stockholm County Council.

Background: This single-masked randomised controlled superiority trial evaluated the efficacy and cost-effectiveness of therapist guided internet-delivered cognitive behavioural therapy (ICBT) for social anxiety disorder (SAD) in youth compared with an active comparator, internet-delivered supportive therapy (ISUPPORT). Methods: Participants were 103 children and adolescents aged 10-17 years with a principal diagnosis of SAD, and their parents. Participants were randomly allocated to 10 weeks of ICBT (n=51) or ISUPPORT (n=52). Both interventions included three video call sessions with a therapist. The primary outcome measure was the Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule (ADIS-C), rated by masked clinicians post treatment and three months after the end of treatment (primary endpoint). Secondary outcomes included clinician-rated diagnostic status of SAD and global functioning, as well as child- and parent-reported social anxiety and comorbid depression. Findings: ICBT was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms with a significant between-group effect size of d=0·66 (95% CI [0·27, 1·11]) at the 3-month follow-up. Similarly, most of the secondary outcome measures demonstrated moderate effect sizes favouring ICBT. The cost-effectiveness analyses indicated cost savings associated with ICBT compared to ISUPPORT. One suicide attempt was reported and managed in the ISUPPORT condition. No other serious adverse events were reported in either condition. Interpretation: ICBT is an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD. Trial Registration: The trial was registered at ClinicalTrials.gov with id NCT03247075 Funding: This work was funded by the Swedish Research Council for Health, Working Life and Welfare (Forte 2014-4052) and Region Stockholm (HNSV 14099). JH was supported by Region Stockholm (Dnr: K0173-2016; clinical postdoctoral appointment: 2017-2020). ES was supported by Region Stockholm (clinical research appointment; 2017-0605). Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. Dr. Mataix-Cols reports personal fees from Elsevier, personal fees from UpToDate, Inc., outside the submitted work. None of the other authors declare any conflict of interests. Ethics Approval Statement: The trial was approved by the Stockholm regional ethical review board (2017/1027-31/2).

BACKGROUND Patient adherence is defined as the extent to which a patient complies with medical or health advice. At present, there is a lack of reliable and valid measures specifically designed to measure adherence to internet-delivered behavioral interventions. OBJECTIVE The objective of this study was to develop and psychometrically evaluate a novel measure of adherence to guided internet-delivered behavioral interventions. METHODS In collaboration with experienced clinicians and researchers in the field, a 5-item, clinician-rated internet intervention Patient Adherence Scale (iiPAS) was developed. The initial scale was tested in a sample of children and adolescents (N=50) participating in internet-delivered cognitive behavioral therapy (ICBT) studies. A revised version of the iiPAS was then administered to a larger sample of children and adolescents (N=148) with various behavioral problems participating in ICBT trials. The scale was evaluated according to a classical test theory framework. RESULTS The iiPAS demonstrated excellent internal consistency. Factor analyses revealed one underlying factor, explaining about 80% of the variance, suggesting that the scale captures a homogeneous adherence construct. The iiPAS was strongly associated with objective measures of patient activity in ICBT (number of logins, number of written characters, and completed modules). Furthermore, mid- and posttreatment ratings of the iiPAS were significantly correlated with treatment outcomes. By contrast, objective measures of patient activity in the Web-based platform did not correlate with treatment outcomes. CONCLUSIONS The iiPAS could be a useful tool to measure adherence in a broad range of internet-delivered behavioral interventions.

Background: One in twenty adolescents experience excessive worry and evidence-based psychological therapies are not sufficiently widespread to reach most of those affected. In this multiple baseline evaluation, we assess the feasibility and preliminary efficacy of a scalable, online cognitive-behavioral intervention for adolescents with excessive worry (BIP worry). Methods: Thirteen adolescents (age 13–17) with excessive worry underwent the 10-week online BIP worry intervention. The treatment also included an online intervention for parents. Completion rates, treatment satisfaction, and adverse events were measures of feasibility. Clinical outcomes included worry severity, symptoms of other anxiety and depression, and general functioning. To control for time and spontaneous fluctuations in symptoms, adolescents were randomized to a 2-, 6-, or 10-week baseline phase prior to treatment. A short measure of worry severity was administered weekly during the baseline and treatment phases. Outcomes were assessed before the baseline-phase, at pre-treatment, post-treatment, and at 1- and 3-month follow-ups. Results: Twelve of 13 included adolescents, together with their parents, participated in BIP worry, with a mean completion rate of 9.8 of the 10 treatment modules. Adolescents reported an average of 4.4 exposures per week as homework during treatment. High levels of treatment adherence, credibility, and satisfaction, and no serious adverse events were reported. Therapists averaged 21 min per week communicating with each family. Linear mixed effects models indicated significant improvements in worry, anxiety, and general functioning from pre- to post-treatment, with these gains maintained at 1- and 3-months follow-up. Reductions in worry severity during treatment were significantly larger than during the baseline phase. The results from the multiple baseline evaluation suggested an association between the introduction of the BIP worry intervention and subsequent symptom change for some but not all adolescents. Conclusions: BIP worry is a feasible and potentially effective treatment. As the treatment is scalable and involves limited therapist contact, it represents a low-cost method for treating adolescents with excessive worry and anxiety. Further investigation under randomized controlled trial (RCT) conditions is warranted.