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Cognitive-behavioral therapy (CBT) has received strong research support for anxiety disorders such as panic disorder, agoraphobia, social anxiety disorder, and generalized anxiety disorder. However, less is known about how CBT performs when delivered in routine clinical care. A systematic review and meta-analysis were conducted of CBT for these anxiety disorders in adults treated in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for articles published until May 2022. The effectiveness of CBT, methodological quality, and moderators of treatment outcome were examined, and benchmarked by meta-analytically comparing with efficacy studies for the same disorders. Sixty-six studies were included, comprising 6,113 participants. Large within-group effect sizes (ESs; Hedges’s g) were detected for anxiety measures at posttreatment (1.09) and follow-up (1.39), as well as for the secondary outcome of depression measures (0.80 at both assessment points). Attrition rate across the disorders was 15.9%. The benchmarking analysis showed that effectiveness studies had very similar ES (1.09) as efficacy studies (1.07) at posttreatment and at follow-up (1.39 vs. 1.30), and there were no significant differences in remission rates. Thus, the outcomes of effectiveness studies for these anxiety disorders are comparable with the results obtained in efficacy studies.

Introduction Patient-controlled admissions (PCAs) represent a change in psychiatric inpatient care where patients are allowed to decide for themselves when hospitalisation might be required. Prior research has demonstrated that PCA increase the number of admissions, but decrease days in inpatient care, while both the admissions to and days in involuntary care decrease. However, investigations have been restricted to specific patient groups arid have not examined other possible benefits, such as effects on symptoms, quality of life and autonomy. Methods and analysis This study explores the implementation process and effects of PCA in Region Stockholm, who is currently introducing PCA for all patients with severe psychiatric conditions and extensive healthcare utilisation. In total, the study comprises approximately 45 inpatient wards, including child and adolescent psychiatry. In a naturalistic evaluation, patients assigned PCA will be followed up to 36 months, both with regard to hospitalisation rates and self-reported outcomes. In addition, qualitative studies will explore the experiences of patients, caregivers of adolescents and healthcare providers. Ethics and dissemination Approval has been granted by the Swedish Ethical Review Authority (Dnr: 2020-06498). The findings from this study will be disseminated via publications in international peer-reviewed journals, at scientific conferences, as part of two doctoral theses, and through the Swedish Partnership for Mental Health.

Cognitive behavioural therapy (CBT) can effectively treat common mental disorders (CMDs), but access to treatment is insufficient. Guided self-help (GSH) CBT has shown effects comparable to face-to-face CBT and may be a resource-efficient treatment alternative. However, not all patients respond to GSH. Learning more about predictors of outcome may increase knowledge regarding which patients respond to GSH. The aim of this study was to investigate predictors of outcome for GSH CBT for patients with CMDs in primary care. Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia or stress-related disorders were included. All patients received GSH CBT. Outcomes were remission status, reliable change and post-treatment depression ratings. Predictors investigated were clinical, demographic and therapy-related variables. Analyses were conducted using logistic and linear regression. Higher educational level predicted remission, higher quality of life ratings predicted remission and decreased depression, and higher age at onset predicted reliable change. Therapy-related variables, i.e. patient adherence to treatment and patients? and clinicians? estimation of treatment response, were all related to outcome. More large-scale studies are needed, but the present study points at the importance of therapy-related variables such as monitoring and supporting treatment adherence for an increased chance of remission.

The aim of this study was to evaluate specific effects for patients with adjustment or exhaustion disorder, the Stress subgroup (n = 152), regarding symptom severity and sick leave after CBT, a return-to-work intervention (RTW-I), and a combination of them (COMBO), using data from a randomized trial. In the original study, primary care patients on sick leave (N = 211) were randomized to CBT (n = 64), RTW-I (n = 67), or COMBO (n = 80). Blinded Clinician Severity Rating (CSR) of symptoms and sick leave registry data were primary outcomes. Subgroup analyses showed that for the Stress subgroup, CBT led to greater reduction of symptoms than RTW-I posttreatment, but COMBO did not differ from CBT or RTW-I. Regarding sick leave, there was no difference between treatments in the Stress subgroup. An exploratory analysis of the treatment effects in a subgroup of patients with depression, anxiety or insomnia indicates that RTW-I reduced sick leave faster than CBT. We conclude that CBT may be promising as an effective treatment of stress and exhaustion disorder.

Background: Stress-related disorders are associated with significant suffering, functional impairment, and high societal costs. Internet-based cognitive behavioral therapy (ICBT) is a promising treatment for stress-related disorders but has so far not been subjected to health economic evaluation. Objective: The objective of this study was to evaluate the cost-effectiveness and cost-utility of ICBT for patients with stress-related disorders in the form of adjustment disorder (AD) or exhaustion disorder (ED). We hypothesized that ICBT, compared with a waitlist control (WLC) group, would generate improvements at low net costs, thereby making it cost-effective. Methods: Health economic data were obtained in tandem with a randomized controlled trial of a 12-week ICBT in which patients (N=100) were randomized to an ICBT (n=50) or a WLC (n=50) group. Health outcomes and costs were surveyed pre-and posttreatment. We calculated incremental cost-effectiveness ratios (ICERs) based on remission rates and incremental cost-utility ratios (ICURs) based on health-related quality of life. Bootstrap sampling was used to assess the uncertainty of our results. Results: The ICER indicated that the most likely scenario was that ICBT led to higher remission rates compared with the WLC and was associated with slightly larger reductions in costs from pre- to posttreatment. ICBT had a 60% probability of being cost-effective at a willingness to pay (WTP) of US $0 and a 96% probability of being cost-effective at a WTP of US $1000. The ICUR indicated that ICBT also led to improvements in quality of life at no net societal cost. Sensitivity analyses supported the robustness of our results. Conclusions: The results suggest that ICBT is a cost-effective treatment for patients suffering from AD or ED. Compared with no treatment, ICBT for these patients yields large effects at no or minimal societal net costs.

Background: Common mental disorders (CMDs) cause great individual suffering and high societal costs including long-term sick leave. Cognitive behavioural therapy (CBT) can effectively treat CMDs, but access to treatment is insufficient. Moreover, sick leave is not reduced to the same extent as psychiatric symptoms after CBT. Little is known about predictors of outcome after CBT, especially concerning guided self-help. Aims: The aim of the present thesis was to systematically review the effects and evidence of psychological treatments on sick leave and assess the effects in a meta-analysis of published treatment trials (Study I), evaluate the effect of CBT and a novel return-to-work intervention (RTW-I) on sick leave and psychiatric symptoms for patients with CMDs (Study II), test a stepped care CBT model for CMDs in primary care (Study III), and investigate predictors of outcome for guided self-help CBT (Study IV). Methods: In Study I, a systematic review and meta-analysis (45 studies) was conducted regarding effects of psychological interventions on sick leave and symptoms. In Study II (N = 211) and III (N = 396) patients from four primary care centres in Stockholm were treated with disorder specific CBT for CMDs. In Study II, patients on sick leave were randomised to CBT, RTW-I, or a combination of the two, and were followed up one year after treatment regarding sick leave and symptoms. In Study III all patients received disorder specific guided self-help CBT for nine weeks. Non-responders were then randomised to face-to-face CBT or continued guided self-help. In Study IV predictors of outcome for guided self-help CBT in Study III were investigated. Results: Study I showed that psychological interventions were more effective than care as usual in reducing sick leave and psychiatric symptoms but the effect sizes were small (g = 0.15 and 0.20, respectively). There was no significant difference in effect between work focused interventions, problem solving therapy, CB

Background Common mental disorders (CMD) cause large suffering and high societal costs. Cognitive behavioural therapy (CBT) can effectively treat CMD, but access to treatment is insufficient. Guided self-help (GSH) CBT, has shown effects comparable with face-to-face CBT. However, not all patients respond to GSH, and stepping up non-responders to face-to-face CBT, could yield larger response rates. The aim was to test a stepped care model for CMD in primary care by first evaluating the effects of GSH-CBT and secondly, for non-responders, evaluating the additional effect of face-to-face CBT. Methods Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia, adjustment or exhaustion disorder were included. In Step I, all patients received GSH-CBT. In Step II, non-responders were randomized to face-to-face CBT or continued GSH. The primary outcome was remission status, defined as a score below a pre-established cutoff on a validated disorder-specific scale. Results After GSH-CBT in Step I, 40% of patients were in remission. After Step II, 39% of patients following face-to-face CBT were in remission compared with 19% of patients after continued GSH (p = 0.004). Using this stepped care model required less than six therapy sessions per patient and led to an overall remission rate of 63%. Conclusions Stepped care can be effective and resource-efficient to treat CMD in primary care, leading to high remission rates with limited therapist resources. Face-to-face CBT speeded up recovery compared with continued GSH. At follow-ups after 6 and 12 months, remission rates were similar in the two groups.

Sick leave due to common mental disorders (CMDs) increase rapidly and present a major societal challenge. The overall effect of psychological interventions to reduce sick leave and symptoms has not been sufficiently investigated and there is a need for a systematic review and meta-analysis of the field. The aim of the present meta-analysis was to calculate the effect size of psychological interventions for CMDs on sick leave and psychiatric symptoms based on all published randomized controlled trials. Methodological quality, the risk of bias and publication bias were also assessed. The literature searches gave 2240 hits and 45 studies were included. The psychological interventions were more effective than care as usual on both reduced sick leave (g = 0.15) and symptoms (g = 0.21). There was no significant difference in effect between work focused interventions, problem-solving therapy, cognitive behavioural therapy or collaborative care. We conclude that psychological interventions are more effective than care as usual to reduce sick leave and symptoms but the effect sizes are small. More research is needed on psychological interventions that evaluate effects on sick leave. Consensual measures of sick leave should be established and quality of psychotherapy for patients on sick leave should be improved.