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The purpose was to present a total description, distribution, and ranking of chronic pain conditions in the general population. This was based on structured clinical examinations of a random sample from a population-based survey (HUNT3) with a calculated oversampling of participants with chronic pain. Supplemented with access to hospital reports, the examination was performed by experienced physicians and psychologists using a consistent definition of chronic pain as well as ICD-10- and the new ICD-11-classification. The main findings were that a higher proportion of the 551 participants had chronic pain assessed by clinical examination (399) than by self-report in a survey the same day (337). Among those with examination-verified chronic pain estimated from HUNT3 to represent 27.9% of the general population, 63% had chronic primary pain, 81% musculoskeletal pain, and 77% more than one chronic pain condition. When separating chronic primary from chronic secondary pain according to ICD-11, the weighted prevalence was 17.7% for chronic pain conditions of unknown and 10.2% of known cause. When all the participants’ conditions were accounted for, the most prevalent were nonspecific low back (10.8%) and neck pain (7.6%). Participants with chronic primary pain did not have significantly more psychopathology than those with chronic secondary pain: 14.5% vs. 12.5%. Perspective: Since this study confirms the high prevalence in self-report surveys and indicates that two thirds of chronic pain conditions cannot be explained by underlying diseases, this huge health and societal problem should be solved primarily on a public health level directed towards prevention and rehabilitation.

Research indicates that therapist competence in assigning homework may play a prominent role for outcome in cognitive therapy (CT) with various psychiatric disorders, including Cluster C personality disorders. Potentially cofounding factors need to be addressed though, and the present study examined to what extent therapist competence in (a) assigning homework and (b) agenda setting, as well as (c) the quality of the therapeutic alliance, contributes uniquely to a positive outcome in CT with cluster C personality disorders. Twenty-four patients receiving CT were taken from a previously published randomized controlled trial, and a residualized composite score of psychopathology/distress was used as outcome measure. The quality of the therapeutic alliance was rated by patients at session four, whereas therapist competence in assigning homework and agenda setting was assessed by independent raters in an early session (typically session six). Therapist competence in assigning homework was a strong predictor of outcome in CT, even when taking into account potentially confounding factors such as the quality of the therapeutic alliance and therapist competence in agenda setting. Structuring sessions to increase the benefits of homework assignments appear to be important in CT with cluster C personality disorders.

BACKGROUND Treatment based on the Fear-Avoidance (FA) model has been found to be effective with chronic low back pain (CLBP), and in-vivo exposure of fear evoking movements is proposed as a key change mechanism. Exposure tasks may be conducted in the session (in-session exposure; ISE), in other real-life situations (between sessions exposure) as part of homework assignments, or both. Utilising a randomized, controlled dismantling study design, the aim of this study was to examine the unique effects of ISE in FA-treatment of CLBP. METHODS Patients (N = 90) with CLBP as primary medical complaints were randomized to receive six sessions of either (a) FA-treatment with ISE (FA-ISE) or (b) FA-treatment without ISE (FA), allowing for between sessions exposure in both treatment groups. Patients were assessed with a large battery of outcome measures at four time-points (pre-treatment, post-treatment, after a booster-session and at 1-year follow-up) including pain intensity, pain catastrophising, self-efficacy, physical performance and quality of life. RESULTS Both treatment groups (FA-ISE, FA) demonstrated statistically significant improvements on primary and most secondary outcomes, with mostly non-significant between-group differences. CONCLUSIONS No added benefit was found for the inclusion of ISE of feared movements in FA-treatment for CLBP, delivered in a group format to participants with moderately elevated levels of fear-avoidance beliefs. Clinical trials: NCT01158339. SIGNIFICANCE This study adds to the existing research literature demonstrating FA-treatment to be effective with CLBP, but further experimental studies are needed in order to examine under what circumstances ISE of feared movements may add to positive treatment outcomes.

Using data from 1721 participants in a community-based randomized control trial of digital cognitive behavioural therapy for insomnia compared with patient education, we employed linear mixed modelling analyses to examine whether chronotype moderated the benefits of digital cognitive behavioural therapy for insomnia on self-reported levels of insomnia severity, fatigue and psychological distress. Baseline self-ratings on the reduced version of the Horne-Östberg Morningness-Eveningness Questionnaire were used to categorize the sample into three chronotypes: morning type (n = 345; 20%); intermediate type (n = 843; 49%); and evening type (n = 524; 30%). Insomnia Severity Index, Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression Scale were assessed pre- and post-intervention (9 weeks). For individuals with self-reported morning or intermediate chronotypes, digital cognitive behavioural therapy for insomnia was superior to patient education on all ratings (Insomnia Severity Index, Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression Scale) at follow-up (p-values ≤ 0.05). For individuals with self-reported evening chronotype, digital cognitive behavioural therapy for insomnia was superior to patient education for Insomnia Severity Index and Chalder Fatigue Questionnaire, but not on the Hospital Anxiety and Depression Scale (p = 0.139). There were significant differences in the treatment effects between the three chronotypes on the Insomnia Severity Index (p = 0.023) estimated difference between evening and morning type of -1.70, 95% confidence interval: -2.96 to -0.45, p = 0.008, and estimated difference between evening and intermediate type -1.53, 95% confidence interval: -3.04 to -0.03, p = 0.046. There were no significant differences in the treatment effects between the three chronotypes on the Chalder Fatigue Questionnaire (p = 0.488) or the Hospital Anxiety and Depression Scale (p = 0.536). We conclude that self-reported chronotype moderates the effects of digital cognitive behavioural therapy for insomnia on insomnia severity, but not on psychological distress or fatigue.

Background and aims Pain catastrophizing has consistently been related to a variety of negative outcomes within chronic pain conditions, but competing models exist explaining the role of catastrophizing. According to the fear-avoidance model (FAM), catastrophizing is primarily related to the appraisal of pain (i.e. “intrapersonal”), whereas the communal coping model (CCM) suggests that catastrophizing is a strategy to elicit support (i.e. “interpersonal”). In order to examine the interpersonal nature of catastrophizing, this cross-sectional study examined interpersonal problems as a predictor of pain catastrophizing in a sample of patients (n = 97) with chronic pain. Methods Self-report data was taken from patients entering a multidisciplinary, inpatient rehabilitation program. The four quadrants of the Inventory of Interpersonal Problems circumplex model (Hostile-Dominant, Hostile-Submissive, Friendly-Submissive, Friendly-Dominant) were used as predictors of pain catastrophizing in a series of separate, hierarchical regression analyses. Results After controlling for relevant confounding variables such as demographics (gender, age), pain severity, psychiatric symptoms (anxiety/depression, fatigue, insomnia), adverse life experiences and perceived social support, higher levels of Hostile-Dominant interpersonal problems predicted higher levels of pain catastrophizing (p ≤ 0.01, d = 0.56). Conclusions The results add support to the notion that pain catastrophizing may serve a communicative functioning, as predicted by the CCM, with cold, dominant and controlling behaviors as a maladaptive interpersonal strategy to elicit support. It may thus be useful to consider the broader interpersonal context of the individual, and not only the patient’s appraisal of pain, when conceptualizing the role of pain catastrophizing in patients with chronic pain. Implications Future psychosocial research and treatment of chronic pain could be informed by including interpersonal theory as a useful theoretical framework, which may help shed more light on how interpersonal problems relates to pain catastrophizing.

IntroductionInsomnia is highly prevalent in outpatients receiving treatment for mental disorders. Cognitive–behavioural therapy for insomnia (CBT-I) is a recommended first-line intervention. However, access is limited and most patients with insomnia who are receiving mental healthcare services are treated using medication. This multicentre randomised controlled trial (RCT) examines additional benefits of a digital adaptation of CBT-I (dCBT-I), compared with an online control intervention of patient education about insomnia (PE), in individuals referred to secondary mental health clinics.Methods and analysisA parallel group, superiority RCT with a target sample of 800 participants recruited from treatment waiting lists at Norwegian psychiatric services. Individuals awaiting treatment will receive an invitation to the RCT, with potential participants undertaking online screening and consent procedures. Eligible outpatients will be randomised to dCBT-I or PE in a 1:1 ratio. Assessments will be performed at baseline, 9 weeks after completion of baseline assessments (post-intervention assessment), 33 weeks after baseline (6 months after the post-intervention assessment) and 61 weeks after baseline (12 months after the post-intervention assessment). The primary outcome is between-group difference in insomnia severity 9 weeks after baseline. Secondary outcomes include between-group differences in levels of psychopathology, and measures of health and functioning 9 weeks after baseline. Additionally, we will test between-group differences at 6-month and 12-month follow-up, and examine any negative effects of the intervention, any changes in mental health resource use, and/or in functioning and prescription of medications across the duration of the study. Other exploratory analyses are planned.Ethics and disseminationThe study protocol has been approved by the Regional Committee for Medical and Health Research Ethics in Norway (Ref: 125068). Findings from the RCT will be disseminated via peer-reviewed publications, conference presentations, and advocacy and stakeholder groups. Exploratory analyses, including potential mediators and moderators, will be reported separately from main outcomes.Trial registration numberClinicalTrials.gov Registry (NCT04621643); Pre-results.

A recent meta-analysis has questioned the relevance of attention bias modification (ABM) for depression out- comes. However, there might be patient characteristics not yet accounted for, that are relevant to the outcome. In the context of personalized treatment, the lack of moderator studies have limited the potential for matching ABM-treatment to individual patient characteristics. Subjects (N = 301) were randomly assigned 1:1 to receive either active or placebo Attention Bias Modification (ABM) twice daily for 14 days in a double-blind design (placebo n = 148; ABM n = 153). The outcome was change in symptoms based on the Hamilton Depression Rating Scale (HDRS). Moderator variables were self-reported depression (Beck Depression Inventory-II; BDI-II), anxiety (Beck Anxiety Inventory; BAI) and attentional bias (AB) assessed at baseline. This trial was registered with ClinicalTrials.gov, number NCT02658682. Only BAI (p for interaction = .01, Bootstrap 95% CI [0.046, 0.337]) moderated the effects of ABM on change in clinician rated depressive symptoms. Interactions were significant for BAI scores ≥8. The relative effect of the intervention increased with the highest symptom load. ABM was not effective in patients with the lowest symptom load. Future research should validate this finding and continue investigating moderators of the ABM-intervention to further enhance personalization of treatment to individual symptom characteristics. The Department of Psychology, University of Oslo has also supported the project.

Existing studies on cognitive impairments in chronic pain do not investigate peripheral neuropathic pain (PNP) or compare pain conditions in a satisfactory manner. Here we aimed to compare executive dysfunctions in PNP patients with fibromyalgia (FM) and healthy controls (HC). Patients who self-reported cognitive impairments were assessed according to criteria for PNP or FM. Seventy-three patients met criteria and completed testing on executive functioning and IQ measures. We also included twenty matched healthy controls. Regression models controlling for age, sex and IQ, tested associations between group category (PNP, FM or HC) and outcomes. If a substantial association was detected, we followed up with head-to-head comparisons between PNP and FM. Multivariate regression models then tested associations between executive functioning and pain type, controlling for significant confounders. Results from head-to-head comparison between pain conditions showed significant differences on years lived with pain (FM > PNP), the use of anticonvulsants (PNP > FM) and use of analgesics (PNP > FM). When controlled for all significant differences, PNP patients had significantly lower scores on an attention-demanding cued-recall task compared to FM. Poor performance on attention-demanding cued-recall task was associated with PNP, which translate into problems with retaining fast-pace or advanced information.

Impairments in executive functioning are prevalent in chronic pain conditions, with cognitive inflexibility being the most frequently reported. The current randomized, cross-over trial, piloted a computerized cognitive training (CCT) program based on Relational Frame Theory, targeting improvement in cognitive flexibility. At baseline, 73 chronic pain patients completed testing on pre-selected outcomes of executive functioning, alongside IQ measures. When tested three times over the course of 5 months, there was a drop-out rate of 40% at the third time point, leaving 44 patients who had data at all time points. The results showed that there was a substantial learning effect from the MINDFLEX training and a substantial time-dependent improvement on the primary outcomes of increased flexibility, but that this could not be tied to active training. In conclusion, this small study indicated a learning effect as well as improvement on primary outcomes. Based on the current results, a larger trial with improved feasibility of training is warranted. Copyright © 2020 Jacobsen, Klungsøyr, Landrø, Stiles and Roche. This is an openaccess article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Study Objectives Digital Cognitive Behavioral Therapy for Insomnia (dCBT-I) has demonstrated efficacy in reducing insomnia severity in self-referred and community samples. It is unknown, however, how dCBT-I compares to individual face-to-face (FtF) CBT-I for individuals referred to clinical secondary services. We undertook a randomized controlled trial to test whether fully automated dCBT-I is non-inferior to individual FtF CBT-I in reducing insomnia severity. Methods Eligible participants were adult patients with a diagnosis of insomnia disorder recruited from a sleep clinic provided via public mental health services in Norway. The Insomnia Severity Index (ISI) was the primary outcome measure. The non-inferiority margin was defined a priori as 2.0 points on the ISI at week 33. Results Individuals were randomized to FtF CBT-I (n = 52) or dCBT-I (n = 49); mean baseline ISI scores were 18.4 (SD 3.7) and 19.4 (SD 4.1), respectively. At week 33, the mean scores were 8.9 (SD 6.0) and 12.3 (SD 6.9), respectively. There was a significant time effect for both interventions (p < 0.001); and the mean difference in ISI at week 33 was −2.8 (95% CI: −4.8 to −0.8; p = 0.007, Cohen’s d = 0.7), and −4.6 at week 9 (95% CI −6.6 to −2.7; p < 0.001), Cohen’s d = 1.2. Conclusions At the primary endpoint at week 33, the 95% CI of the estimated treatment difference included the non-inferiority margin and was wholly to the left of zero. Thus, this result is inconclusive regarding the possible inferiority or non-inferiority of dCBT-I over FtF CBT-I, but dCBT-I performed significantly worse than FtF CBT-I. At week 9, dCBT-I was inferior to FtF CBT-I as the 95% CI was fully outside the non-inferiority margin. These findings highlight the need for more clinical research to clarify the optimal application, dissemination, and implementation of dCBT-I. Clinicaltrials.gov: NCT02044263: Cognitive Behavioral Therapy for Insomnia Delivered by a Therapist or on the Internet: a Randomized Controlled Non-inferiority Trial.

Study Objectives Digital cognitive behavioral therapy for insomnia (dCBT-I) is an effective treatment for insomnia. However, less is known about mediators of its benefits. The aim of the present study was to test if intraindividual variability in sleep (IIV) was reduced with dCBT-I, and whether any identified reduction was a mediator of dCBT-I on insomnia severity and psychological distress. Methods In a two-arm randomized controlled trial (RCT), 1720 adults with insomnia (dCBT-I = 867; patient education about sleep = 853) completed the Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS) and sleep diaries, at baseline and 9-week follow-up. Changes in IIV were analyzed using linear mixed modeling followed by mediation analyses of ISI, HADS, and IIV in singular sleep metrics and composite measures (behavioral indices (BI-Z) and sleep disturbance indices (SI-Z)). Results dCBT-I was associated with reduced IIV across all singular sleep metrics, with the largest between-group effect sizes observed for sleep onset latency (SOL). Reduced IIV for SOL and wake after sleep onset had the overall greatest singular mediating effect. For composite measures, SI-Z mediated change in ISI (b = −0.74; 95% confidence interval (CI) −1.04 to −0.52; 13.3%) and HADS (b = −0.40; 95% CI −0.73 to −0.18; 29.2%), while BI-Z mediated minor changes. Conclusion Reductions in IIV in key sleep metrics mediate significant changes in insomnia severity and especially psychological distress when using dCBT-I. These findings offer important evidence regarding the therapeutic action of dCBT-I and may guide the future development of this intervention. Clinical trials Name: Overcoming Insomnia: Impact on Sleep, Health and Work of Online CBT-I Registration number: NCT02558647 URL: https://clinicaltrials.gov/ct2/show/NCT02558647?cond=NCT02558647&draw=2&rank=1

Pain and depression are episodic conditions that might take a chronic course. They are clearly related, but information on how they influence each other in the process of chronification is limited. Pain catastrophizing is hypothesized to play a role in the development of depression and chronic pain, but few longitudinal studies have investigated their association over a longer term. In this study, a random cohort from the general population (n = 4764) answered questions about pain, catastrophizing, and depression at 5 assessments in yearly intervals. Linear mixed models showed that within persons, increases in pain intensity and catastrophizing were independently associated with increases in depressive symptoms {mean change = -1.12, 95% confidence interval (CI) [-1.32 to -0.91] and -1.29, 95% CI [-1.52 to -1.05], respectively}. In prospective analyses restricted to individuals without depression above cutoff at baseline, chronic pain increased the risk of endorsing depression over the following 4 years (odds ratio = 2.01, 95% CI [1.71-2.37]). Seven percent showed a chronic course of depression, as indicated by scores above cutoff on at least 3 of 5 assessments. The number of years lived with chronic pain was associated with a chronic course of depression, with odds ratios increasing from 1.55 (95% CI [0.87-2.91]) to 14.19 (95% CI [8.99-22.41]) when reporting chronic pain on 2 vs 5 assessments compared with none. The results suggest that when pain intensity or catastrophizing change, depressive symptoms change in the same direction. When pain and catastrophizing become chronic, they seem to be mutually reinforcing determinants for chronic depression.

Metacognitive theory proposes that depression is caused by excessive rumination, which is in turn maintained by maladaptive positive and negative beliefs about rumination (“metacognitions”) and reduced executive control. Moreover, the metacognitive model asserts that metacognitions are maintained by prolonged depression symptoms. However, no studies have tested the metacognitive model of depression prospectively in a clinical population. Currently remitted adults with recurrent depressive disorder (N = 105) reported depression symptoms at five time points over a 12-month period. Based on this data, we used latent growth modelling to estimate depression levels and symptom trajectories. Positive metacognitions were associated with rumination, while negative metacognitions and rumination predicted higher depression levels, but not symptom recurrence. Moreover, depression levels and symptom recurrence predicted positive and negative metacognitions, as well as rumination. There was no association between metacognitions and reduced executive control. The present study lends partial support for the metacognitive model, but raises questions of the relevance of metacognitions as a proximal vulnerability marker for symptom recurrence.

That certain psychological factors are negatively associated with function in patients with chronic pain is well established. However, few studies have evaluated these factors in individuals with chronic pain from the general population. The aims of this study were to: 1) evaluate the unique associations between catastrophizing and perceived solicitous responses and psychological function, physical function, and insomnia severity in individuals with neuropathic pain, osteoarthritis, or spinal pain in the general population; and 2) determine if diagnosis moderates the associations found. Five hundred fifty-one individuals from the general population underwent examinations with a physician and physiotherapist, and a total of 334 individuals were diagnosed with either neuropathic pain (n = 34), osteoarthritis (n = 78), or spinal pain (n = 222). Results showed that catastrophizing was significantly associated with reduced psychological and physical function, explaining 24% and 2% of the variance respectively, whereas catastrophizing as well as perceived solicitous responding were significantly and uniquely associated with insomnia severity, explaining 8% of the variance. Perceived solicitous responding was significantly negatively associated with insomnia severity. Moderator analyses indicated that: 1) the association between catastrophizing and psychological function was greater among individuals with spinal pain and neuropathic pain than those with osteoarthritis, and 2) the association between catastrophizing and insomnia was greater among individuals with spinal pain and osteoarthritis than those with neuropathic pain. No statistically significant interactions including perceived solicitous responses were found. The findings support earlier findings of an association between catastrophizing and function among individuals with chronic pain in the general population, and suggest that diagnosis may serve a moderating role in some of these associations. Perspective When examining persons with pain in the general population, catastrophizing is associated with several aspects of function, and diagnosis serves as a moderator for these associations. The replication of these associations in the general population support their reliability and generalizability.

Acceptance and commitment therapy (ACT) has never been tested for patients with chronic fatigue. We aimed to test if a 3.5-week ACT rehabilitation program for patients with chronic fatigue improved quality of life (QoL), fatigue, and psychological flexibility. Further, to test if improvements in QoL and fatigue were associated with improvement in psychological flexibility, and if psychological flexibility explained variance above and beyond maladaptive cognitions typically targeted in CBT for fatigue. Patients (n = 140) who had been on sick leave > 8 weeks due to chronic fatigue received a 3.5-week non-controlled inpatient rehabilitation program based on ACT. A physician and a psychologist examined the patients, assessing medication use and SCID-I diagnoses. Patients completed questionnaires about somatic complaints, psychological complaints, and maladaptive cognitions before and after treatment. At post-treatment, patients reported improved QoL (p < 0.001; g = 1.07) and less fatigue (p < 0.001; g = 1.08), but not increased psychological flexibility (p = 0.6). Changes in psychological flexibility was associated with improved QoL, but not fatigue, in hierarchical regression analyses. When adjusting for other cognitions, changes in fear-avoidance cognitions and all-or-nothing thoughts, but not psychological flexibility, were associated with improved QoL and fatigue. The ACT-based treatment improved QoL and reduced fatigue for patients with chronic fatigue with large effect sizes. Improvement was associated with a reduction in fear-avoidance cognitions and all-or-nothing thoughts, but not psychological flexibility.

Background Although several large-scale randomised controlled trials have shown the efficacy of digital cognitive behavioural therapy for insomnia (dCBT-I), there is a need to validate widespread dissemination of dCBT-I using recommended key outcomes for insomnia. We investigated the effect of a fully automated dCBT-I programme on insomnia severity, sleep–wake patterns, sleep medication use, and daytime impairment. Methods We did a parallel-group superiority randomised controlled trial comparing dCBT-I with online patient education about sleep. The interventions were available through a free-to-access website, publicised throughout Norway, which incorporated automated screening, informed consent, and randomisation procedures, as well as outcome assessments. Adults (age ≥18 years) who had regular internet access and scored 12 or higher on the Insomnia Severity Index (ISI) were eligible for inclusion, and were allocated (1:1) to receive dCBT-I (consisting of six core interactive sessions to be completed over 9 weeks) or patient education (control group). Participants were masked to group assignment and had no contact with researchers during the intervention period. The primary outcome was the change in ISI score from baseline to 9-week follow-up, assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02558647) and is ongoing, with 2-year follow-up assessments planned. Findings Between Feb 26, 2016, and July 1, 2018, 5349 individuals commenced the online screening process, of which 1497 were ineligible or declined to participate, 2131 discontinued the screening process, and 1721 were randomly allocated (868 to receive dCBT-I and 853 to receive patient education). At 9-week follow-up, 584 (67%) participants in the dCBT-I group and 534 (63%) in the patient education group completed the ISI assessment. The latent growth model showed that participants in the dCBT-I group had a significantly greater reduction in ISI scores from baseline (mean score 19·2 [SD 3·9]) to 9-week follow-up (10·4 [6·2]) than those in the patient education group (from 19·6 [4·0] to 15·2 [5·3]; estimated mean difference −4·7 (95% CI −5·4 to −4·1; Cohen's d −1·21; p

Background: Digital CBT-I (dCBT-I) has demonstrated significant efficacy in reducing insomnia severity in self-referred and community samples. It is unknown, however, how dCBT-I compares to individual face-to-face (FtF) CBT-I for individuals referred to clinical secondary care services. Methods: Parallel-group non-inferiority randomized controlled trial of fully automated dCBT-I versus FtF CBT-I. Eligible participants were adults with insomnia referred to a sleep clinic via public mental health services in Norway. The primary outcome measure was the Insomnia Severity Index (ISI). The non-inferiority margin was defined a priori as 2-points on the ISI at week 33 post-randomization i.e. dCBT-I is non-inferior if the 95% Confidence Interval (CI) for the mean difference is between -2 and ∞, whilst individual FtF CBT-I is superior if the 95% CI is between -∞ and 0. Secondary outcomes were tested using superiority analyses. These were sleep-wake variables, psychological distress and fatigue. Findings: Between October 2014 and January 2016, 101 patients from 288 potential participants were recruited. Individuals were randomized to FtF CBT-I (n=52) or dCBT-I (n=49); mean baseline ISI scores were 18·4 (SD 3·7) and 19·4 (SD 4·1) respectively. At week 33, 48 (92%) in the FtF CBT-I group and 41 (85%) in the dCBT-I group completed the ISI; the mean scores were 8·9 (SD 6·0) and 12·3 (SD 6·9) respectively. There was a significant time effect for both interventions (p

Background: Although several large trials have demonstrated the efficacy of digital cognitive–behavioural therapy for insomnia (dCBT-I), there is a need to validate a far-reaching dissemination of dCBT-I on recommended key outcomes of insomnia. We aimed to investigate the effect of self-guided dCBT-I on insomnia severity, sleep-wake patterns, use of sleep medication, and daytime impairment. Methods: We did a parallel-group superiority randomised controlled trial (RCT) comparing digital CBT-I with online patient education about sleep (PE). Interventions were available from a free-to-access website with an online automated screening test. Primary outcome was ISI score at nine-week follow-up, and secondary outcomes included self-reported use of sleep medication, sleep diary measures, and measures of daytime impairment. Findings: A total of 1721 adults who scored ³12 on the Insomnia Severity Index (ISI) were randomized, 868 to dCBT-I and 853 to PE. At nine-week follow-up, 584 (67%) in the dCBT-I group and 534 (63%) in the PE group completed online self-report ratings. The dCBT-I group had a significantly greater reduction in the primary outcome of insomnia severity compared with the PE group (Cohen’s d = -1·21; 95% Confidence Interval [CI], -1·05 to -1·38; p < ·001). Compared with the PE intervention, the number needed to treat with dCBT-I was 2·7 (95% CI 2·4 to 3·2) for response and 3·2 (95% CI 2·8 to 3·8) for remission of insomnia. The dCBT-I group were significantly less likely to use sleep medication (secondary outcome) at follow-up, compared with the PE group (Odds ratio [OR] = 0·49; 95% CI, 0·23 to 0·74; p < ·001), and reported lower daytime impairment. Interpretation: A self-guided dCBT-I programme made widely accessible is effective in reducing both night-time and daytime impairments associated with the insomnia disorder, while also reducing the likelihood of using sleep medication. Trial Registration: This trial was registered with ClinicalTrials.gov, NCT02558647. Funding Statement: The Norwegian Research Council; grant number 239985 and the Liaison Committee for education, research and innovation in Central Norway; grant number 90061500. Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. BS, HK, OV, ORFS, GM, SP, AGH, PG, KL, and TCS report no conflicts of interest. FPT and LMR report having a financial and/or business interest in BeHealth Solutions and Pear Therapeutics, two companies that develop and disseminate digital therapeutics, including by licensing the therapeutic developed, based in part, on early versions of the software utilized in research reported in the enclosed paper. These companies had no role in preparing this manuscript. LMR is also a consultant to Mahana Therapeutics, a separate digital therapeutic company not affiliated with this research. Some of the research in this paper was conducted while FPT was a faculty member at the University of Virginia. At that time for FPT, and ongoing for LMR, the terms of these arrangements have been reviewed and approved by the University of Virginia in accordance with its policies. Ethical Approval Statement: The trial protocol was approved by the Regional Committees for Medical and Health Research Ethics in South East Norway (2015/134).

Epidemiological studies have to a little extent addressed the potential fluctuations of chronic pain over time, and there is a lack of information about the long-term course of pain using repeated measurements. We wanted to identify different trajectories of pain during 8 waves of follow-up over 4 years among individuals in the general population reporting pain lasting at least 6 months at baseline. Secondarily, we wanted to investigate whether biopsychosocial factors at baseline were associated with the different pain trajectories. Longitudinal Latent Class Analysis was performed to classify a random sample of 1905 participants from a larger population-based study (HUNT3) into groups based on their longitudinal pain severity reporting. A five-class solution gave the best fit. The terms chosen to describe the pain trajectories were: “fluctuating” (n = 586 [31%]), “persistent mild” (n = 449 [24%]), “persistent moderate” (n = 414 [22%]), “persistent severe” (n = 251 [13%]), and “gradual improvement” (n = 205 [11%]). In a multinomial logistic regression model using “gradual improvement” as the reference category, the “persistent moderate”, “persistent severe”, and “fluctuating” pain groups were associated with chronic widespread pain, elevated levels of catastrophizing, and poorer mental health. The “persistent mild” group was associated with sleep difficulties only. This study finds that although most individuals have a stable pain course, individuals in the largest distinct trajectory reports pain that fluctuate between mild and moderate levels, thus fluctuating under and above the chronic pain definition using moderate pain or more as a criterion. Perspective When examining the long-term course of chronic pain in the general population, 5 trajectories emerge. Although most individuals have stable pain, the largest distinct trajectory fluctuated under and above the chronic pain cut-off, using moderate pain or more as a criterion. A dichotomous categorization of chronic pain may be overly simplistic.

In this effectiveness trial we compared the long-term effects on hospitalizations of group psychoeducation (GP) versus individual psychoeducation (IP) for a heterogeneous sample of patients with BD recruited from general clinical settings.Eighty-five patients with BD were randomized to receive 10 weekly sessions of GP followed by 8 booster-sessions over the next two years, or three sessions of IP. Time to first admission over the course of GP was the primary outcome measure, with additional outcomes examining the use of psychiatric services over about 8 years.Patients allocated to GP had longer survival time compared to IP over 27 months (p0.05). There were also group differences in survival time over 8 years, but treatment allocation alone was no longer a significant predictor of survival time (p=0.07). There was an interaction between group (GP/IP) and harmful substance use (HSU), such that GP cases with comorbid HSU had the shortest survival time, whilst GP cases without HSU survived the longest (p=0.02). Also, GP cases had a small but significant reduction in hospital use compared with IP (p=0.04).We did not have a 'pure' treatment as usual group. Wide confidence intervals for some of the odds ratios suggest that the findings need to be treated with some caution. Insufficient sample size for more detailed subgroup analyses.GP is superior to IP in delaying hospitalizations in a clinically representative population. However, GP did not prevent or delay admissions in BD patients with HSU.

Using a computational network approach, we reanalyzed data from a randomized controlled trial of attention bias modification (ABM) tasks on residual depression symptoms. The main aim was to characterize the symptom-to-symptom changes following ABM. ABM was associated with improvements in interest, which was in turn associated with improvements in other depression symptoms. Although there were no changes in the global network strength following ABM, the comparison with symptom change in the ABM and control group suggests that ABM leads to a reduction of the association between anxiety, depressed mood, and guilt. Findings suggest that reduction in depression symptoms following ABM may have been set in motion by increased interest and involvement in everyday activities, leading to a reduction of the adverse impact of anxiety and negative cognition. ABM may be more effective in patients in whom these symptoms are prominent.

Background Group-based transdiagnostic occupational rehabilitation programs including participants with mental and somatic disorders have emerged in clinical practice. Knowledge is sparse on subsequent participation in competitive work. This study aimed to investigate trajectories for (re)entry to work for predefined subgroups in a diagnostically heterogeneous sample of sick-listed participants after completing occupational rehabilitation. Methods A cohort of 212 participants aged 18–69 on long-term sick leave (> 8 weeks) with chronic pain, chronic fatigue and/or common mental disorders was followed for one year after completing a 3½-week rehabilitation intervention based on Acceptance and Commitment Therapy. Self-reported, clinical and registry data were used to study the associations between predefined biopsychosocial predictors and trajectories for (re)entry to competitive work (≥ 1 day per week on average over 8 weeks). Generalized estimating equations analysis was used to investigate trajectories. Results For all biopsychosocial subgroups (re)entry to work increased over time. Baseline employment, partial sick leave and higher expectation of return to work (RTW) predicted higher probability of having (re)entered work at any given time after discharge. The odds of increasing reentry over time (statistical interaction with time) was weaker for the group receiving the benefit work assessment allowance compared with those receiving sickness benefit (OR = 0.92, p = 0.048) or for those on partial sick leave compared with full sick leave (OR 0.77, p

BackgroundFollowing treatment, many depressed patients have significant residual symptoms. However, large randomised controlled trials (RCT) in this population are lacking. When Attention bias modification training (ABM) leads to more positive emotional biases, associated changes in clinical symptoms have been reported. A broader and more transparent picture of the true advantage of ABM based on larger and more stringent clinical trials have been requested.AimsTo evaluate the early effect of two weeks ABM training on blinded clinician-rated and self-reported residual symptoms, and whether changes towards more positive attentional biases (AB) would be associated with symptom reduction.MethodA total of 321 patients with a history of depression were included in a preregistered randomized controlled double-blinded trial. Patients were randomised to an emotional ABM paradigm over fourteen days or a closely matched control condition. Symptoms based on the Hamilton Rating Scale for Depression (HRSD) and Beck Depression Inventory II (BDI-II) were obtained at baseline and after ABM training.ResultsABM training led to significantly greater decrease in clinician-rated symptoms of depression as compared to the control condition. No differences between ABM and placebo were found for self-reported symptoms. ABM induced a change of AB towards relatively more positive stimuli associated with greater symptom reduction.ConclusionThe current study demonstrates that ABM produces early changes in both AB and blinded clinician-rated depressive symptoms. ABM may have practical potential in the treatment of residual depression.ClinicalTrials.govID:NCT02658682

Depression is a common illness which tends to have a relapsing progression. Revealing vulnerability factors is an important step towards improved treatment and prevention. Previous studies of individuals in remission indicate that inhibitory control is more strongly impaired than other cognitive functions. Studies have mostly used Stroop tasks; it is unclear how this population performs on other measures of inhibition. Abnormal reactions to errors may also promote depression relapse, but this has rarely been studied in remitted depression. We used a Stop Signal task and Stroop inhibition task to investigate inhibitory function and post-error reaction time adjustments in 54 individuals with a history of depression and 185 never-depressed controls. Inhibitory processing was slower among the remitted depressed individuals on the Stop Signal task, but no difference was found in Stroop inhibition. The groups were not different on post-error adjustments. This finding extends the understanding of inhibitory deficiency in this population and offers insight into trait markers of depression.

Background: The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments. Methods: A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments. Results: CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group. Conclusions: CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone.

Objective There are reasons to suggest that the therapist effect lies at the intersection between psychotherapists' professional and personal functioning. The current study investigated if and how the interplay between therapists' (n = 70) professional self-reports (e.g., of their difficulties in practice in the form of ‘professional self-doubt’ and coping strategies when faced with difficulties) and presumably more global, personal self-concepts, not restricted to the professional treatment setting (i.e., the level of self-affiliation measured by the Structural Analysis of Social Behaviour (SASB) Intrex, Benjamin, 1996), relate to patient (n = 255) outcome in public outpatient care. Method Multilevel growth curve analyses were performed on patient interpersonal and symptomatic distress rated at pre-, post- and three times during follow-up to examine whether change in patient outcome was influenced by the interaction between their therapists' level of ‘professional self-doubt’ and self-affiliation as well as between their therapists' use of coping when faced with difficulties, and the interaction between type of coping strategies and self-affiliation. Results A significant interaction between therapist ‘professional self-doubt’ (PSD) and self-affiliation on change in interpersonal distress was observed. Therapists who reported higher PSD seemed to evoke more change if they also had a self-affiliative introject. Therapists' use of coping strategies also affected therapeutic outcome, but therapists' self-affiliation was not a moderator in the interplay between therapist coping and patient outcome. Conclusion A tentative take-home message from this study could be: ‘Love yourself as a person, doubt yourself as a therapist’. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner Messages The findings of this study suggest that the nature of therapists' self-concepts as a person and as a therapist influences their patients' change in psychotherapy. These self-concept states are presumably communicated through the therapists' in-session behaviour. The study noted that a combination of self-doubt as a therapist with a high degree of self-affiliation as a person is particularly fruitful, while the combination of little professional self-doubt and much positive self-affiliation is not. This finding, reflected in the study title, ‘Love yourself as a person, doubt yourself as a therapist’, indicates that exaggerated self-confidence does not create a healthy therapeutic attitude. Therapist way of coping with difficulties in practice seems to influence patient outcome. Constructive coping characterized by dealing actively with a clinical problem, in terms of exercising reflexive control, seeking consultation and problem-solving together with the patient seems to help patients while coping by avoiding the problem, withdrawing from therapeutic engagement or acting out one's frustrations in the therapeutic relationship is associated with less patient change.

The present study was specifically designed to investigate the prevalence of auditory verbal hallucinations (AVH) in the general population, and sought to compare similarities and differences regarding socio-demographics, mental health and severe life events between individuals who have never experienced AVH with those who had. The study also aimed to compare those who sought professional help for their experience of AVH with those who had not sought help. Through a postal questionnaire, 2,533 participants ages 18 and over from a national survey completed the Launay-Slade Hallucinations Scale and other measures examining AVH characteristics and other areas related to AVH. In total, 7.3% of the sample reported a life-time prevalence of AVH. Those with AVH were more likely to be single and unemployed, reported higher levels of depression and anxiety, and experienced a higher number of severe life events compared with those without AVH. Only 16% of those who experienced AVH in the general population sought professional help for these experiences. Compared to those who did not seek professional help, participants that had were more likely to experience AVH with a negative content, experience them on a daily basis, undergo negative reactions when experiencing AVH, and resist AVH. In conclusion, the prevalence of AVH was found to be relatively high. The results also revealed higher levels of reduced mental health for individuals who sought professional help, followed by those who did not, compared with those who had never experienced AVH. © 2015 The Authors. Scandinavian Journal of Psychology published by Scandinavian Psychological Associations and John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Background The definition of Chronic Fatigue Syndrome (CFS) overlaps with definitions of insomnia, but there is limited knowledge about the role of insomnia in the treatment of chronic fatigue. Aims To test if improvement of insomnia during treatment of chronic fatigue was associated with improved outcomes on 1) fatigue and 2) cortisol recovery span during a standardized stress exposure. Methods Patients (n = 122) with chronic fatigue received a 3.5-week inpatient return-to-work rehabilitation program based on Acceptance and Commitment Therapy, and had been on paid sick leave > 8 weeks due their condition. A physician and a psychologist examined the patients, assessed medication use, and SCID-I diagnoses. Patients completed self-report questionnaires measuring fatigue, pain, depression, anxiety, and insomnia before and after treatment. A subgroup (n = 25) also completed the Trier Social Stress Test for Groups (TSST-G) before and after treatment. Seven cortisol samples were collected during each test and cortisol spans for the TSST-G were calculated. Results A hierarchical regression analysis in nine steps showed that insomnia improvement predicted improvement in fatigue, independently of age, gender, improvement in pain intensity, depression and anxiety. A second hierarchical regression analysis showed that improvement in insomnia significantly predicted the cortisol recovery span after the TSST-G independently of improvement in fatigue. Conclusion Improvement in insomnia severity had a significant impact on both improvement in fatigue and the ability to recover from a stressful situation. Insomnia severity may be a maintaining factor in chronic fatigue and specifically targeting this in treatment could increase treatment response.

The current study tests possible transfer effects from NT 3D MOT training among elite athletes from dynamic sports on executive brain functions, such as alerting, orienting, executive control, inhibition, shifting and updating. Sixty athletes from different sports, such as martial arts (boxing and wrestling), handball, soccer, orienteering, biathlon, alpine skiing, and Paralympic sports (sled hockey, badminton and table tennis), participated in a cross-over experiment-control group design over a period of 10 weeks. The results in the current study show specific training effects on training measures used by the NT 3D MOT tool, but no significant transfer effects on the executive functioning tests. The results are discussed based on the importance of training specificity and the mental state at the moment of NT 3D MOT training. © 2018 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license.

Introduction Insomnia is a major public health concern. While cognitive behaviour therapy for insomnia (CBT-I) is acknowledged as the best available intervention, there are unanswered questions about its wider dissemination, socioeconomic benefits and its impact on health resource utilisation. The aim of this randomised controlled trial (RCT) is to investigate the effectiveness of a fully automated online version of CBT-I compared with online patient education about sleep (PE). Outcome measures comprise changes in symptoms of insomnia, time off work due to sick leave as well as medication and health resource utilisation. Also, we will examine (i) putative mediators of the effects of CBT-I on insomnia severity and (ii) selected potential psycho-bio-social moderators of the effects of the interventions. Methods and analysis A parallel-group RCT will be conducted in a target sample of about 1500 adults recruited across Norway. Participants will complete an online screening and consent process. Those who meet eligibility criteria will be randomised to receive direct access to fully automated online CBT-I or to an online PE programme. The primary outcome is change in insomnia severity immediately postintervention; secondary outcomes are change in daytime functioning and other sleep measures postintervention and at 6-month and 24-month follow-up. Objective data from national registries will be obtained at two time points (1 year and 2 years post-treatment), allowing a mirror image study of preintervention and postintervention rates of sick leave, and of medication and healthcare utilisation by condition. Ethics and dissemination The study protocol was approved by the Regional Committee for Medical and Health Research Ethics in South East Norway (2015/134). Findings from the RCT will be disseminated in peer-reviewed publications and conference presentations. Exploratory analyses of potential mediators and moderators will be reported separately. User-friendly outputs will be disseminated to patient advocacy and other relevant organisations. © Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/