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AbstractIn higher education, students’ trust in the university management may affect both mental health and academic self-efficacy. This longitudinal study, conducted during the most challenging course of the COVID-19 pandemic, uses multinomial regression and causal inference to estimate the effects of students’ trust in their universities’ strategies for managing the pandemic, on students’ self-reported changes in mental health and academic self-efficacy. The analyzed sample (N = 2796) was recruited through online advertising and responded to a baseline online survey in the late spring of 2020, with two follow-up surveys five and ten months later. Results show that positive trust in university management of the pandemic protected against experiencing one’s mental health and academic self-efficacy as worse rather than unchanged, both five and ten months after the baseline assessment. The findings emphasize the importance of developing and maintaining trust-building measures between academia and students to support students’ mental health and academic self-efficacy in times of uncertainty.

Abstract Background Emerging adulthood is often associated with mental health problems. About one in three university students report symptoms of depression and anxiety that can negatively affect their developmental trajectory concerning work, intimate relationships, and health. This can interfere with academic performance, as mood and anxiety disorders are key predictors of dropout from higher education. A treatment gap exists, where a considerable proportion of students do not seek help for mood and anxiety symptoms. Offering internet interventions to students with mental health problems could reduce the treatment gap, increase mental health, and improve academic performance. A meta-analysis on internet interventions for university students showed small effects for depression and none for anxiety. Larger trials are recommended to further explore effects of guidance, transdiagnostic approaches, and individual treatment components. Methods This study will offer 1200 university students in Sweden participation in a three-armed randomized controlled trial (RCT) evaluating a guided or unguided transdiagnostic internet intervention for mild to moderate depression and anxiety, where the waitlist control group accesses the intervention at 6-month follow-up. Students reporting suicidal ideation/behaviors will be excluded and referred to treatment within the existing healthcare system. An embedded study within the trial (SWAT) will assess at week 3 of 8 whether participants in the guided and unguided groups are at higher risk of failing to benefit from treatment. Those at risk will be randomized to an adaptive treatment strategy, or to continue the treatment as originally randomized. Primary outcomes are symptoms of depression and anxiety. Follow-ups will occur at post-treatment and at 6-, 12-, and 24-month post-randomization. Between-group outcome analyses will be reported, and qualitative interviews about treatment experiences are planned. Discussion This study investigates the effects of a transdiagnostic internet intervention among university students in Sweden, with an adaptive treatment strategy employed during the course of treatment to minimize the risk of treatment failure. The study will contribute knowledge about longitudinal trajectories of mental health and well-being following treatment, taking into account possible gender differences in responsiveness to treatment. With time, effective internet interventions could make treatment for mental health issues more widely accessible to the student group.

Abstract Background Approximately 50% of the patients who globally seek help in psychiatry have been assessed with problematic substance use or been diagnosed with substance use disorder (SUD). Given the high treatment gap for mental health care, in particular SUD, these individuals risk poorer treatment outcomes in psychiatry. Integrated treatment for psychiatric and SUD disorders has been proposed to reduce the treatment gap for SUD, but access to integrated treatment is low. Digital interventions addressing SUD in psychiatry could potentially make treatment available to patients who otherwise would not have access. In this study “digital interventions” comprise an umbrella term covering all kinds of interventions from minimal motivational app-based interventions to internet-based interventions with and without human guidance, up to remote sessions in telepsychiatry. This study aims to explore healthcare staff perceptions of referring patients to digital interventions for reducing problematic substance use, whether or not diagnosed as SUD, in the psychiatric outpatient setting. Method The study was exploratory with a qualitative design. Data were collected in the Swedish outpatient psychiatry setting, via individual semi-structured interviews with managers, and focus groups with healthcare staff. An adapted form of phenomenological hermeneutical analysis was used to analyze the data. Results Three themes emerged from the analysis. The first theme was Encountering obstacles on the path to future implementation of digital interventions, with sub-themes: Lacking resources and Feeling concerned about technical solutions. The second theme was Searching for ways forward to achieve increased access to care, with sub-themes: Blended care could facilitate integrated care and Addressing variations in patients’ technical skills. The third theme was Taking steps towards the future, with sub-themes: Wanting to know more about digital interventions and Formulating a vision for the future. Conclusions The study reveals a concern that implementing digital interventions in psychiatry will create additional work or be technically challenging. The staff see significant advantages from the patient perspective, but they feel that they themselves need training in implementing digital interventions. In order to establish constructive implementation of digital interventions for SUD in psychiatry, staff attitudes and concerns need to be considered and addressed. This study was conducted within the Swedish healthcare system and the findings may not generalize to other countries with differing healthcare systems.

Abstract Objectives The Gambling Disorder Identification Test (GDIT) is a recently developed self‐report measure. The GDIT includes items with multiple response options that are either based on frequency or time, and item response theory evaluations of these could yield vital knowledge on its measurement performance. Methods The GDIT was evaluated using Rasch analysis in a study involving 597 Swedish gamblers. Results In a three‐dimensional Rasch model, the item response difficulty range extended from −1.88 to 4.06 and increased with higher time‐ and frequency‐based responses. Differential item functioning showed that some GDIT items displayed age and gender‐related differences. Additionally, person‐separation reliability indicated the GDIT could reliably be divided into three to four diagnostic levels. Conclusions The frequency‐ and time‐based item response options of the GDIT offer excellent measurement, allowing for elaborate assessment across both lower and higher gambling severity. The GDIT can be used to detect DSM‐5 Gambling Disorder, thereby holding significance from both epidemiological and clinical standpoints. Notably, the 3‐item GDIT Gambling Behavior subscale also shows potential as a brief screening tool for identifying at‐risk gambling behavior.

The Theory of Planned Behavior (TPB) is a highly influential and powerful behavior change model that offers promising guidance on promoting urgently needed, pro-environmental action. Recent pro-environmental research has successfully augmented TPB using anticipated emotions—the emotions an individual consciously predicts they will experience in relation to possible outcomes of their decision. However, immediate emotions—the emotions an individual actually experiences during decision-making—have received far less attention. Given that immediate emotions are relevant to pro-environmental decision-making and can address the theoretical and empirical limitations of TPB, we contend that pro-environmental studies should explicitly examine immediate emotions within the TPB framework. This article aims to stimulate rigorous research that enhances pro-environmental communication and policymaking by providing integrative insights into immediate emotions along with recommendations for evaluating immediate emotions in a pro-environmental TPB context.

Abstract Background In many health care systems, primary care is tasked with offering psychological treatment for common mental disorders. Resources are often limited, which complicates widespread dissemination of traditional psychological treatments. Stepped care models where the less resource-intensive interventions are delivered first, can be employed, but often do not eliminate the need for a thorough diagnostic assessment, which can be time-consuming, has the potential to bottleneck patient intake, and can add to waiting times. Novel low-threshold formats are needed to improve access to mental health care in the primary care setting. Methods This was a single-group prospective cohort study (N = 91). We assessed the feasibility of a video-delivered course as a first-line intervention for patients seeking help for mental health problems at a primary care center. The course had a transdiagnostic approach, suitable for both depression and anxiety disorders, and was based on cognitive behavioral techniques. Patients in need of psychosocial assessment, which usually entailed a four- to six-week wait, were referred by physicians or triage nurses. Study participants could start within a week, without the need for conventional diagnostic assessment, and were informed that they would be offered assessment after the course if needed. Key feasibility outcomes included participant satisfaction, attendance rates, the proportion of participants in need of additional clinical intervention after the course, and the rate of clinically significant improvement in anxiety and depression symptoms. Results Participants scored a mean of 21.8 (SD = 4.0, 9–32, n = 86) on the Client Satisfaction Questionnaire-8; just below our target of 22. The mean attendance rate was 5.0/6 lectures (SD = 1.6, range: 0–6, n = 91). Forty-six percent (37/81) reported experiencing no need of further clinical intervention after the course. The rate of clinically significant improvement was 59% (27/46) for anxiety and 48% (22/46) for depression. No serious adverse event was reported. Conclusions Delivering a low-threshold online video-delivered mental health course in primary care appears to be feasible. Adjustments to further improve patient satisfaction are warranted, such as offering the choice of participating online or face-to-face. Trial Registration (ClinicalTrials.gov NCT04522713) August 21, 2020.

Abstract Background Despite their crucial role in bridging science and practice, not much is known about counselors offering treatment for Problem Gambling (PG). This study maps current treatment, the type of change techniques that are prioritized in treatment and how counselors perceive their clinical competence in their work with PG clients. Methods A sample of PG counselors from the healthcare and social services (N = 188, mean age: 49 years, 67% women) completed an online survey. A principal component analysis was conducted to map prioritized types of change techniques, and a multiple regression analysis was carried out to analyze predictors of counselors’ role adequacy in their clinical work. Results There was a large variation in the type of treatments offered for PG (mean 3.6). Cognitive Behavioral Therapy (CBT) and Motivational Interviewing were the most common treatments offered and motivation was rated as the most important type of change technique prioritized in the treatment of PG. A principal component analysis identified four components reflecting different types of change techniques prioritized by the counselors: (1) standard CBT, e.g., gambling cognitions, craving management, and finding alternative activities, (2) assessment of PG, (3) family orientation, i.e., involvement of concerned significant others in treatment, and (4) focus on exposure strategies. Counseling more clients monthly was associated with higher levels of willingness, adequacy and legitimacy in their clinical work with clients with PG. Additionally, offering CBT was a predictor for higher role adequacy and providing counseling on the origins of and consequences of PG. Conclusion There was a large heterogeneity among the treatments offered and what change techniques that were prioritized among the PG counselors. Clinical experience is of importance for developing competence in treating clients with PG. This finding suggests there could be benefits to establishing specialized, more visible treatment units where PG counselors could gain adequate clinical experience, thus increasing clinical competence for treating PG.

Alcohol Use Disorders (AUD) are widespread and have serious consequences, but are among the most undertreated mental disorders. Internet interventions have been found effective in treating AUD, but we know little about long-term outcomes, two years or more after treatment. This study explored 12- and 24-month outcomes in alcohol consumption following initial 6-month improvements after a therapist-guided high-intensity internet intervention and an unguided low-intensity internet intervention among individuals with alcohol use disorder. Between-group comparisons were analyzed, as well as within-group comparisons with (1) pre-treatment measurements (2) post-treatment measurements. Participants consisted of a general population sample of internet help-seekers in Sweden. A total of 143 adults (47% men) with a score of 14 (women)/16 (men) or more on the Alcohol Use Disorders Identification Test, alcohol consumption of 11 (women)/14 (men) or more standard drinks the preceding week and ≥ 2 DSM-5 alcohol use disorder (AUD) criteria based on a diagnostic interview were included. The high- and low-intensity internet interventions (n = 72 and n = 71 respectively) consisted of modules based on relapse prevention and cognitive-behavioral therapy. The primary outcome was self-reported alcohol consumption in the preceding week measured as (1) number of standard drinks and (2) number of heavy drinking days. Attrition from self-reported questionnaires was 36% at the 12-month follow-up and 53% at the 24-month follow-up. No significant between-group differences occurred in outcomes at either long-term follow-up. Regarding within-group differences, compared to pre-treatment, alcohol consumption was lower in both high- and low-intensity interventions at both long-term follow-ups [within-group standard drinks effect sizes varied between g = 0.38–1.04 and heavy drinking days effect sizes varied between g = 0.65–0.94]. Compared to post-treatment, within-group alcohol consumption in the high intensity intervention increased at both follow-ups; for the low-intensity intervention, within-group consumption decreased at 12-month follow-up, but did not differ compared to post-treatment at 24 months. Both high- and low-intensity internet interventions for AUD were thus associated with overall reductions in alcohol consumption at long term follow-ups, with no significant differences between the two. However, conclusions are hampered by differential and non-differential attrition.

Abstract Background From a clinical perspective, knowledge of the psychological processes involved in maintaining gambling disorder has been lacking. This qualitative study formulated hypotheses on how gambling disorder is maintained by identifying clinically relevant behaviors at an individual level, as a means to guide the development of new cognitive behavioral interventions. Methods Six individuals from a treatment study, diagnosed with gambling disorder and with diverse symptom profiles of psychiatric comorbidity, were recruited. Participants were interviewed using an in-depth semi-structured functional interview and completed self-report measures assessing gambling behavior. Results Functional analysis was used as a theoretical framework for a thematic analysis, which yielded the following categories: 1) antecedents that may increase or decrease gambling; 2) experiences accompanying gambling; 3) control strategies; 4) consequences of gambling behavior; and 5) events terminating gambling behavior. Few differences were identified in relation to symptom profiles of psychiatric comorbidity, although some gamblers did not report experiencing abstinence when not being able to gamble. Conclusions Gambling is a secluded activity mainly triggered by access to money. Positive and negative emotions could be both antecedents and functions of gambling behavior. Avoidance-based strategies used to control gambling might result in a failure to learn to control gambling behavior. Anticipation, selective attention, and chasing could be important reinforcers, which should be addressed in new developments in cognitive behavioral treatment for gambling disorder.

Abstract Objective The present study investigates if symptoms of COVID-19 contagion in different social contexts (cohabitants, family, acquaintances, and others) are associated with university students' own self-reported symptoms of COVID-19 contagion, mental health, and study capacity. This was investigated by a cross-sectional survey administrated in Sweden during the first wave of the COVID-19 pandemic, at the time when universities were locked down to limit viral spread and contagion. Results Mild to moderate symptoms of COVID-19 in cohabitants and family members were associated with student’s self-reported symptoms of contagion, while no associations could be seen in relation to mental health and study capacity. Symptoms of COVID-19 contagion in acquaintances and others were not associated with students’ self-reported symptoms, nor with their mental health and study capacity. To conclude, during the initial lockdown of universities students’ self-reported symptoms of contagion were mainly associated with cohabitants and family members, while symptoms of contagion in different social contexts were not associated with mental health and study capacity. Findings suggest that lockdown of universities may have contributed to limiting infection pathways, while still allowing students to focus on their studies despite significant contagion among others known to the student.

Abstract Background Despite the association of Gambling Disorder (GD) with poor mental health, treatment options generally lack components targeting emotional difficulties. This study investigated the feasibility and acceptability of adding strategies of emotion regulation to an eight-session weekly group treatment. Method This non-randomized pilot study recruited 21 treatment-seeking adults with GD, (mean age = 36.3, 19% females) from addiction care. In a mixed methods design, measures of within-group changes in self-reported symptoms of GD were complemented with thematic analysis of post-treatment interviews regarding the feasibility of the treatment. Results Within-group scores on the Gambling Symptoms Assessment Scale (G-SAS) showed a 47% decrease (β: -0.1599, 95% CI: − 0.2526 to − 0.0500) from pre-treatment to 12-month follow-up, with Hedges’ g = 1.07 (CI: 0.57–1.60). The number of GD-symptoms according to the Structured Clinical Interview for Gambling Disorder (SCI-GD) decreased from 7.0 (SD = 1.60) at pre-treatment to 2.1 (SD = 2.36) at 12-month follow-up. Participants completed an average of 6.3 sessions and rated the intervention high in satisfaction and acceptability. Feasibility interviews showed no noticeable negative effects or ethical issues. Furthermore, helpful components in the treatment were: increased awareness of emotional processes and strategies to deal with difficult emotions. Conclusions Adding emotion regulation strategies in the treatment of GD is feasible and acceptable and warrants further investigation in a controlled trial. Trial registration This study was registered with ClinicalTrials.gov (Identifier NCT03725735 ).

BackgroundInternet interventions are a promising avenue for delivering alcohol prevention to employees. The objective of this scoping review was to map all research on alcohol internet interventions aimed at employees regardless of design, to gain an overview of current evidence and identify potential knowledge gaps.MethodsWe conducted a literature search in three data bases (PsycInfo, PubMed, and Web of Science). Eligibility criteria were that (1) the study targeted employees age ≥18 years; (2) the intervention was delivered predominantly online; (3) the study focused specifically or in part on alcohol use; and (4) the study was published in English in a peer-reviewed academic journal. Two reviewers independently screened, reviewed, and extracted data.ResultsTwenty studies were included, of which 10 were randomized controlled trials, five were secondary analyses, three were feasibility trials, one was a cohort study and one described the rationale and development of an intervention. No qualitative studies were found. Randomized trials tended to show effects when interventions were compared to waitlists but not when more intensive interventions were compared to less intensive ones. We identified two design-related aspects where studies differed; (1) whether all applicants were included regardless of alcohol use level and (2) whether the intervention was explicitly framed as alcohol-focused or not. Significant recruitment problems were noted in several studies.ConclusionsAlcohol internet interventions hold promise in delivering alcohol prevention to employees, but heterogeneity in study design and difficulties in recruitment complicate interpretation of findings.Systematic review registrationhttps://osf.io/25x7e/, Open Science Framework.

Abstract Objective During the COVID pandemic, government authorities worldwide have tried to limit the spread of the virus. Sweden’s distinctive feature was the use of voluntary public health recommendations. Few studies have evaluated the effectiveness of this strategy. Based on data collected in the spring of 2020, this study explored associations between compliance with recommendations and observed symptoms of contagion in others, using self-report data from university students. Results Compliance with recommendations ranged between 69.7 and 95.7 percent. Observations of moderate symptoms of contagion in “Someone else I have had contact with” and “Another person” were markedly associated with reported self-quarantine, which is the most restrictive recommendation, complied with by 81.2% of participants. Uncertainty regarding the incidence and severity of contagion in cohabitants was markedly associated with the recommendation to avoid public transportation, a recommendation being followed by 69.7%. It is concluded that students largely followed the voluntary recommendations implemented in Sweden, suggesting that coercive measures were not necessary. Compliance with recommendations were associated with the symptoms students saw in others, and with the perceived risk of contagion in the student’s immediate vicinity. It is recommended that voluntary recommendations should stress personal relevance, and that close relatives are at risk.

Abstract Background High comorbidity exists between mental illness and substance use disorders (SUD). Patients in psychiatry living with problematic alcohol or drug consumption can experience a sense of exclusion, where seeking help for SUD can be perceived as stigmatizing. The aim of this study is to illuminate staff experiences of encountering patients with SUD within the psychiatric outpatient context. Methods The study was exploratory, with a qualitative design. Interviews with outpatient psychiatry managers and focus groups with clinical staff focused on the experience of encountering patients with SUD. Data were evaluated using content analysis inspired by phenomenological-hermeneutic methodology. Results Three themes were identified and each illuminated by two sub-themes. Bridging the organizational gap included sub-themes of having an established collaboration and facing difficulties in the collaboration; Having beliefs about the patient you encounter included sub-themes of working with patients who are exposed to prejudicial thoughts and expressing prejudicial thoughts about the patient. Striving to achieve a therapeutic alliance included sub-themes of having a feeling of developing together and supporting the patient towards recovery. Conclusion A life-world perspective, used to interpret results, indicated that caring for patients with SUD in psychiatry was perceived as difficult, where collaboration between psychiatry and addiction care was often experienced as problematic. Based on these findings, we believe that the current gap between the psychiatry and addiction care could be reduced to some extent by offering patients digital treatment for SUD. In this way, patients could remain under the care of their regular psychiatric clinic without having to physically visit SUD services. Thus, a virtual bridge could be established to bring psychiatry and addiction care closer to each other for the patients’ benefit.

Abstract Background Problem gambling and gambling disorder are major public health concerns worldwide, and awareness of associated negative consequences is rising. In parallel, treatment demand has increased, and Internet interventions offer a promising alternative for providing evidence-based treatment at scale to a low cost. Method We developed a novel Internet-delivered cognitive behavioral treatment for gambling, based on qualitative interviews with treatment-seeking gamblers, behavioral research on gambling behavior, and the pathway model for problem gambling. This research protocol describes a non-randomized pilot and feasibility trial conducted in routine addiction care with adult treatment-seeking patients (max N = 25) with problem gambling. The primary aim is to ensure acceptability and safety, measured by satisfaction, credibility, working alliance, and possible negative effects. Secondary aims are feasibility of study procedures in terms of recruitment and measurement procedures as well as potential effectiveness measured weekly by gambling symptoms as primary outcome and gambling behavior, quality of life, symptoms of depression and anxiety, alcohol, and drug use as secondary outcomes. Potential mediators measured weekly are loss of control, verbal rules, and well-being. Discussion This study is innovative in several respects, regarding both treatment development and implementation. The results of the study will guide a future randomized controlled trial, as well as the development of the intervention and intervention implementation within ordinary addiction care. Trial registration Clinical trials.gov, NCT ID: NCT03946098 . Registered 10 May 2019

Abstract Background Alcohol use disorder (AUD) is highly prevalent and presents a large treatment gap. Self-help internet interventions are an attractive approach to lowering thresholds for seeking help and disseminating evidence-based programs at scale. Internet interventions for AUD however suffer from high attrition and since continuous outcome measurements are uncommon, little is known about trajectories and processes. The current study investigates whether data from a non-mandatory alcohol consumption diary, common in internet interventions for AUD, approximates drinks reported at follow-up, and whether data from the first half of the intervention predict treatment success. Methods N = 607 participants enrolled in a trial of online self-help for AUD, made an entry in the non-mandatory consumption diary (total of 9117 entries), and completed the follow-up assessment. Using multiple regression and a subset of calendar data overlapping with the follow-up, scaling factors were derived to account for missing entries per participant and week. Generalized estimating equations with an inverse time predictor were then used to calculate point-estimates of drinks per week at follow-up, the confidence intervals of which were compared to that from the measurement at follow-up. Next, calendar data form the first half of the intervention were retained and summary functions used to create 18 predictors for random forest machine learning models, the classification accuracies of which were ultimately estimated using nested cross-validation. Results While the raw calendar data substantially underestimated drinks reported at follow-up, the confidence interval of the trajectory-derived point-estimate from the adjusted data overlapped with the confidence interval of drinks reported at follow-up. Machine learning models achieved prediction accuracies of 64% (predicting non-hazardous drinking) and 48% (predicting AUD severity decrease), in both cases with higher sensitivity than specificity. Conclusions Data from a non-mandatory alcohol consumption diary, adjusted for missing entries, approximates follow-up data at a group level, suggesting that such data can be used to reveal trajectories and processes during treatment and possibly be used to impute missing follow-up data. At an individual level, however, calendar data from the first half of the intervention did not have high predictive accuracy, presumable due to a high rate of missing data and unclear missing mechanisms.

Background: There is a growing interest in offering therapist-guided internet interventions for alcohol use disorders (AUD) in regular addiction services. Elucidating the therapeutic processes during these interventions may help improve clinical delivery. The aim of this paper was to investigate written messages from client to therapist in a therapist-guided internet intervention for AUD. Methods: Data was extracted from the therapist-guided arm (n = 57) of a randomized trial of internet interventions for AUD. Qualitative content analysis was used to identify distinct categories of client behaviors in written messages to therapists. Coding was deductive (applying categories from past literature) as well as inductive (identifying new categories from the data). Subsequently, exploratory correlational and regression analyses were conducted to investigate whether identified client behaviors predicted module completion and drinking outcomes. Also, client questions posed in messages to therapists were categorized separately. Results: Eleven distinct behavior categories were identified, of which the two most common were alliance (26.6% of total categorizations) and identifying patterns and problem behaviors (22.8%). Confrontational alliance rupture was the least common category (0.4%). One new behavior category was identified inductively – alcohol-related setback (4.1%). In the exploratory analyses, no categories consistently predicted module completion or drinking outcomes. Client questions were most commonly posed to improve understanding or use of program content or skills. Discussion: The behavior categories, although not predictive of module completion or outcomes, may be of use for therapists, treatment developers and health care providers as a tool for understanding therapeutic processes in internet interventions for AUD.

This study aimed to investigate changes in gambling behaviors during the first and second waves of the COVID-19 pandemic in Sweden. Participants who had gambled within the past year were recruited from social media and the Swedish National Helpline (n = 325, mean age 39.8 years, 64.8% males, 31.3% with problem gambling) and completed an online survey measuring gambling behaviors, consequences of the pandemic in general and worries related to the pandemic. A sub-sample (n = 139) completed a follow-up survey, during the second wave. The results showed no significant associations between COVID-19 consequences (financial or increased isolation) and increased monthly gambling behavior. No major migrations were observed between game types. However, gambling on a high-risk game (OR = 7.44, p < 0.001) and worrying about mental health due to the pandemic (OR = 2.85, p < 0.001) were significantly associated with past year gambling problems and increased monthly gambling problems from the first to the second wave. More longitudinal research is needed in vulnerable populations, to fully understand the long-term consequences of the pandemic.

Abstract Background Swedish national guidelines recommend that all health care settings systematically screen patients for alcohol use and illicit substance use. When hazardous use is identified, it should immediately be addressed, preferably through brief interventions (BI). It is well known that the prevalence of alcohol use and illicit substance use among psychiatric patients is high, but it is not known to what extent screening and BI are routinely carried out in such clinics. Methods Two online surveys investigating the use of screening and BI for alcohol and illicit substances were constructed; one for psychiatric outpatient clinic directors and one for staff at these clinics. The main analyses were calculated as simple frequencies. In secondary analyses, we investigated the associations between substance abuse training, type of clinic and screening/BI delivery. For these analyses, the Chi square test was used. Results Most clinic directors reported that they have guidelines to screen for alcohol (93.1%) and illicit substance use (78.9%) at initial assessment. Fifty percent reported having guidelines for delivering BI when identifying hazardous alcohol use (35.9% for hazardous illicit substance use). Among staff, 66.6% reported always screening for alcohol use and 57.8% reported always screening for illicit substance use at initial assessment. Further, 36.7% reported that they usually deliver BI when identifying hazardous alcohol use (35.7% for hazardous illicit substance use). Secondary analyses indicated that staff with substance abuse training were significantly more likely to screen for alcohol use than staff without such training. Further, staff at psychosis clinics were significantly less likely to screen for both alcohol and substance use than staff at both general and specialist psychiatric clinics. Conclusions Most clinic directors reported having clear guidelines for staff to screen for alcohol use and illicit substance use, but fewer staff members than expected indicated that these guidelines were adhered to. Providing training about substance use disorders for staff may increase use of screening for alcohol use, and psychosis clinics may need to improve their screening routines.

Introduction: The COVID-19 outbreak will likely have a public health impact beyond immediate disease transmission. Little is known about whether social distancing and other societal changes has provoked an increase in gambling, whether decreased betting opportunities due to paused sports events spurred gamblers to transition to online casino gambling, or whether any of these factors have had an impact on problem gambling.Methods: Data on lookup queries against the Swedish Gambling Paus registry, logging all initiated gambling sessions by all licensed gambling providers, from 2019-01-01 (start of registry) to 2020-04-08 (well into the first phase of the outbreak) were analyzed using TBATS time series forecasting to estimate trends after the first domestic COVID-19 death. Obfuscated data on daily total wagered and deposited amounts, split by modality (casino or betting, and low and high intensity, respectively) for the equivalent period were supplied by a licensed online gambling provider.Results: Total gambling activity decreased by 13.29% during the first phase of the outbreak compared to forecast. Analyses of online gambling data revealed that although betting decreased substantially in synchrony with a slight increase in online casino gambling, there was no increase in likely problematic, high-intensity gambling and neither did total online gambling increase.Conclusions: This first, preliminary study revealed no increase in Swedish gambling activity, total or specifically online, in the first phase of the COVID-19 outbreak. Future research should examine whether pandemic-induced transitioning between gambling modalities and/or increased participation in gambling, leads to long-term effects on prevalence of problem gambling.

Alcohol is one of the leading risk factors for global disease burden and overconsumption leads to a wide variety of negative consequences in everyday life. Digital interventions have shown small positive effects in contributing to reductions in problematic use. Specific research on smartphone apps is sparse and the few studies published indicate effects ranging from negative or null to small or moderate. TeleCoach™, a web-based skills training smartphone app, has shown positive effects in non-treatment-seeking university students with excessive drinking. This pilot trial aimed to evaluate app effects in a sample of internet help-seekers from the general population in Sweden. A total of 89 participants were recruited via online advertisement. Following baseline assessment for hazardous use, they were randomized to TeleCoach or a web-based control app offering brief information and advice regarding problematic alcohol use. The primary outcome was number of standard drinks per week; secondary outcomes included drinking quantity and frequency, binge drinking and blood alcohol count measures as well as app user data and comorbidity related to depression, anxiety, and drug use. Analysis of baseline and 6-week follow-up outcomes showed significant within-group effects on alcohol consumption but no significant between-group differences. Effect sizes for the within-group changes in the primary outcome over time were significant [F(1, 55)=43.98; p < 0.001], with a Cohen's d of 1.37 for the intervention group and 0.92 for the control group. This difference in effect sizes indicated that continuation of the study as a large randomized, controlled trial with up to 1,000 participants could be worthwhile.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier NCT03696888.

Abstract Background Evidence-based practice for healthy lifestyle promotion in primary health care is supported internationally by national policies and guidelines but implementation in routine primary health care has been slow. Referral to digital interventions could lead to a larger proportion of patients accessing structured interventions for healthy lifestyle promotion, but such referral might have unknown implications for clinicians with patients accessing such interventions. This qualitative study aimed to explore the perceptions of clinicians in primary care on healthy lifestyle promotion with or without digital screening and intervention. Methods Focus group interviews were conducted at 10 primary care clinics in Sweden with clinicians from different health professions. Transcribed interviews were analyzed using content analysis, with inspiration from a phenomenological-hermeneutic method involving naïve understanding, structural analysis and comprehensive understanding. Results Two major themes captured clinicians’ perceptions on healthy lifestyle promotion: 1) the need for structured professional practice and 2) deficient professional practice as a hinder for implementation. Sub-themes in theme 1 were striving towards professionalism, which for participants meant working in a standardized fashion, with replicable routines regardless of clinic, as well as being able to monitor statistics on individual patient and group levels; and embracing the future with critical optimism, meaning expecting to develop professionally but also being concerned about the consequences of integrating digital tools into primary care, particularly regarding the importance of personal interaction between patient and provider. For theme 2, sub-themes were being in an unmanageable situation, meaning not being able to do what is perceived as best for the patient due to lack of time and resources; and following one’s perception, meaning working from a gut feeling, which for our participants also meant deviating from clinical routines. Conclusions In efforts to increase evidence-based practice and lighten the burden of clinicians in primary care, decision- and policy-makers planning the introduction of digital tools for healthy lifestyle promotion will need to explicitly define their role as complements to face-to-face encounters. Our overriding hope is that this study will contribute to maintaining meaningfulness in the patient-clinician encounter, when digital tools are added to facilitate patient behavior change of unhealthy lifestyle behaviors.

Abstract Objective The primary objective was to evaluate 6-month outcomes for brief and extensive automated telephony interventions targeting problematic alcohol use, in comparison to an assessment-only control group. The secondary objective was to compare levels of problematic alcohol use (hazardous, harmful or probable dependence), gender and age among study participants from clinical psychiatric and addiction outpatient settings and from population-based telephone helpline users and Internet help-seeker samples. Results The Alcohol Use Disorders Identification Test (AUDIT) was used for screening of problematic alcohol use and 6-month follow-up assessment. A total of 248 of help-seekers with at least hazardous use (AUDIT scores of ≥ 6/≥ 8 for women/men) were recruited from clinical and general population settings. Minor recruitment group differences were identified with respect to AUDIT scores and age at baseline. One hundred and sixty persons (64.5%) did not complete the follow-up assessment. The attrition group had a higher proportion of probable dependence (71% vs. 56%; p = 0.025), and higher scores on the total AUDIT, and its subscales for alcohol consumption and alcohol problems. At follow up, within-group problem levels had declined across all three groups, but there were no significant between-group differences. Trial registration ClinicalTrials.gov NCT01958359, Registered October 9, 2013. Retrospectively registered

Abstract Background A large proportion of individuals with alcohol problems do not seek psychological treatment, but access to such treatment could potentially be increased by delivering it over the Internet. Cognitive behavior therapy (CBT) is widely recognized as one of the psychological treatments for alcohol problems for which evidence is most robust. This study evaluated a new, therapist-guided internet-based CBT program (entitled ePlus) for individuals with alcohol use disorders. Methods Participants in the study (n = 13) were recruited through an alcohol self-help web site ( www.alkoholhjalpen.se ) and, after initial internet screening, were diagnostically assessed by telephone. Eligible participants were offered access to the therapist-guided 12-week program. The main outcomes were treatment usage data (module completion, treatment satisfaction) as well as glasses of alcohol consumed the preceding week, measured with the self-rated Timeline Followback (TLFB). Participant data were collected at screening (T0), immediately pre-treatment (T1), post-treatment (T2) and 3 months post-treatment (T3). Results Most participants were active throughout the treatment and found it highly acceptable. Significant reductions in alcohol consumption with a large within-group effect size were found at the three-month follow-up. Secondary outcome measures of craving and self-efficacy, as well as depression and quality of life, also showed significant improvements with moderate to large within-group effect sizes. Conclusions Therapist-guided internet-based CBT may be a feasible and effective alternative for people with alcohol use disorders. In view of the high acceptability and the large within-group effect sizes found in this small pilot, a randomized controlled trial investigating treatment efficacy is warranted. Trial registration ClinicalTrials.gov ( NCT02384278 , February 26, 2015).

The One-to-One program aims to reduce criminal recidivism among prisoners shortly awaiting release, and among probationers. Of 1,484 program participants in Sweden, 776 contained adequate data for analysis. Pre- and post-program scores were available for the Alternative Thinking Test, Levenson's Locus of Control Scale, Skill Survey, Citizen Scale, and Problem Checklist, all areas addressed in the program. This study examined predictive properties of test scores and background characteristics regarding recidivism, as well as differences between sub-groups. All post-tests indicated pro-social changes. Older participants were more likely to complete the program. The most potent predictor for non-recidivism was program completion, with non-completers 64% more likely to re-offend. Significant associations occurred between recidivism and the tests measuring skill improvement over time, chance locus of control pre- and post-program, and attitudes and values (Citizen Scale), partly supporting the theory behind the program.

Low breast cancer screening rates are often found among ethnic minority groups and those born outside the host country. This is of particular concern for high-risk groups, who should benefit from ongoing trials aimed at optimizing screening strategies for breast, as well as ovarian cancer. Both of these issues are germane for Jewish women in Europe. We systematically review the literature concerning breast cancer early detection practices (BCEDP) among Jewish women, and examine European surveillance studies of high-risk for breast and/or ovarian cancer that had imaging in the surveillance protocol, in order to assess the likelihood of adequately including women from minority ethnic groups. No studies were found about BCEDP among Jewish women in Europe. Twenty-one research groups from Israel or the US addressed BCEDP among Jewish women. Some Jewish women in the US and Israel, including recent immigrants, are under-screened. Twenty-four research groups reported imaging surveillance of women at increased risk for breast and/or ovarian cancer in Europe. There was a clear benefit to magnetic resonance imaging and/or more intensive screening for women with increased breast cancer risk. Some of these surveillance studies considered ethnic minority groups at high risk, including Jewish women, but none provided adequate outreach to ensure that these groups were included in their programs. The specific screening needs of Jewish and other high-risk ethnic minority groups in Europe have not been met regarding breast and ovarian cancer. A European-wide, population-based approach is suggested, with cultural sensitivity being vital for these efforts.