Objective(s). An increasing demand exists for psychological interventions to increase recovery from depression and anxiety in people with long-term physical health conditions (LTCs). Guided self-help (GSH) may meet this need, however, there is limited evidence of GSH’s appropriateness for people with LTCs. Design. A mixed-methods study using qualitative interviews with people with stroke and Chronic Obstructive Pulmonary Disease (COPD), and a quantitative survey of professionals who support guided self-help, explored opinions about whether self-help is appropriate, and whether suggested adaptations varied across LTCs. Results. Opinions varied about the appropriateness of standard self-help and adaptations required. Illness beliefs may help explain differences between the two LTCs and individual interviewees. The majority of professionals surveyed felt competent supporting people with LTCs, and reported having access to appropriate self-help material. Conclusions. Recommendations for improving the appropriateness of contents of guided self-help for people with LTCs are provided. Supporting professionals need relevant knowledge and skills to integrate information about the LTC into the intervention, and offer flexible, personalised delivery to support participation.

Objectives. To see whether a cognitive behavioural guided self-help approach can reduce mental health symptoms, which patients might benefit most, and whether such a treatment increases self-efficacy and internal locus of control. Design. Repeated measures and correlational designs were used. Methods. 173 patients were recruited at a cognitive behavioural guided self-help clinic in Edinburgh, of which 97 completed the three-session intervention. Verbal IQ was estimated with the National Adult Reading Test (NART). Measures of emotional symptoms, self-efficacy and locus of control were taken before and after treatment, with follow-up at one month and six months. Results. Patients completing the intervention made favourable gains, which were maintained at six months. Self-efficacy and locus of control measures were not robustly correlated with mental health improvement, but did show pre- to posttreatment changes in themselves. Conclusions. Guided self-help appears to be a useful treatment option for those with depression, anxiety and stress. The implications of the findings, the strengths and limitations of the study, and areas for future research are discussed.

Background: The prevalence of mental disorder in children and young people in the UK is estimated at 10-20% (Meltzer et al. 2003). The World Health Organisation advocates urgent preventive measures to reduce the impact of a predicted steep rise in global rates of depression (World Health Organization 2008 ). The mental health of young people is therefore a public health issue, nationally and globally. The UK children's policy agenda proposes that promoting emotional wellbeing is a shared responsibility between children's agencies at the Tier 1 level of Child and Adolescent Mental Health Services (DCSF 2008), but further research is required to develop low intensity, evidence based interventions to promote emotional and mental health. Schools have a remit to address emotional problems in students and evidence exists to support school based interventions to promote emotional wellbeing. However young people encounter barriers to help-seeking in primary care, which need to be understood in order to deliver appropriate support. There is an emerging evidence base for using guided self-help (GSH) to deliver cognitive behaviour therapy-based interventions to adults in primary mental health care (Gellatly et al. 2007). It is not known whether using GSH in high schools to deliver emotional wellbeing interventions to young people would be feasible or acceptable. Aims: To develop an emotional wellbeing intervention for high schools using GSH, and evaluate it for feasibility and acceptability. Methods: The Medical Research Council (MRC) Framework for complex interventions (MRC 2000) provided the conceptual structure of the research. The methodological approach was also strongly influenced by standards for qualitative research proposed by Popay et al (1998), particularly the need to be responsive to the research context. There were three stages: Consultation, Development and Implementation. In the Consultation stage 54 young people aged 11-15 were consulted in 6 focus groups in 3 inner city high schools in the UK. The outcomes supported the development of a GSH intervention, named the 'Change Project', which was the focus of the Development Stage. Pastoral and Special Educational Needs staff in schools received brief training to deliver the intervention, followed by weekly supervision for the duration of the Project. In the Implementation Stage the Change Project was piloted in the same 3 high schools. The Project was evaluated for acceptability and feasibility using qualitative interview methods and a survey of students. Two instruments were incorporated: the PHQ-2 (Kroenke et al. 2003) was included to identify students who would benefit from a referral to the school nurse and the Rosenberg Self Esteem Scale (Rosenberg 1965) was used to explore its suitability as an outcome measure with the target population. Results: Eight Project workers delivered the Change Project. Twenty one students used it. They were aged 11-17 years and included male, female, white and non-white students. Self reported personal outcomes for students were generally positive. Nine sets of baseline and post-intervention RSES scores were collected. There was a general trend for improvement in scores. Presenting difficulties included potentially clinical disorders which were successfully addressed with support from school nurses. Interviews were conducted with 23 students, and 27 school staff and questionnaire data were collected from 140 students. Project worker reports of the Change Project's acceptability and feasibility were mixed, though also generally positive. The acceptability and feasibility of the RSES is discussed. The ethos of pastoral care, support of senior figures and other contextual factors affected implementation quality in each school. Help-seeking in the young people was driven by peer norms of hiding signs of vulnerability. Conclusions: The Change Project intervention was generally felt to be useful and relevant and overall it was welcomed by staff and students. The intervention has potential for further development. Its acceptability and feasibility were co-dependent and strongly influenced the implementation processes, indicating the value of investing time in understanding social and cultural factors in the research context. Understanding organisational and individual barriers and facilitators of help-seeking in young people may encourage use of emotional support in school.

Obesity is a serious public health issue within the U.S. and minimal long-term success is found with standard behavioral weight-loss treatments. Typical weight-loss interventions do not acknowledge psychological factors, such as weight-related stigma, which may play a role in the development and maintenance of poor coping behaviors, such as unhealthy eating patterns. Individuals who are obese may often experience weight-related stigma present in society and are ultimately at risk for weight self-stigma, which is related to poor health behaviors and increased psychological distress. Acceptance and commitment therapy (ACT), can be effective for treating numerous mental health presentations, might also be effective in decreasing weight self-stigma and improving health behaviors. Guided self-help may be particularly attractive to individuals struggling with weight self-stigma because it allows for greater flexibility and personal choice. There have been no previous randomized controlled trials evaluating guided self-help for weight self-stigma and health behavior change in obese populations. This study reports the results of a randomized controlled trial of ACT guided self-help for weight self-stigma comparing two versions of guided self-help with varying levels of support versus waitlist control. Each active condition provided unique levels of guided self-help to evaluate whether phone coaching enhanced the program. Results showed both active conditions were highly acceptable, although greater satisfaction with support and greater follow-through with book reading was found for those who received phone coaching. There were significant improvements at post in binge eating, physical activity, psychological distress, weight self-stigma, and weight-related psychological flexibility for both active conditions versus waitlist. Mediational analyses showed significant treatment effects, such that weight self-stigma and weight-related psychological flexibility fully and separately accounted for the relation between ACT guided self-help and binge eating behavior. The findings from this study provide the first randomized controlled trial data of an effective intervention for weight self-stigma. Clinical implications, limitations, and future directions are discussed.

Chronic pain is a one of the most common causes of disability and sick leave. Psychological factors play a central role in the experience of pain and are important in the management of pain. However, for many people with chronic pain CBT is not available. There is a need to develop alternative ways to deliver treatments that reach more individuals with chronic pain. Internet-based treatments have been shown to be effective for several disorders and recent research suggests that internet-based CBT for chronic pain can be effective. The present thesis included four randomized controlled studies with the aim of evaluating whether guided internet-based treatments based on CBT can help individuals with chronic pain regarding psychological variables. Study I investigated the effects of an internet-based CBT intervention with telephone support for chronic back pain. The study showed reductions in some variables assessed.      Study II investigated the effects of an internet-based CBT intervention for chronic back pain without telephone support and with a live structured interview before inclusion. It was found that the treatment can reduce some of the distress associated with chronic pain. Study III investigated the effects of a guided internet-delivered CBT as a secondary intervention. Participants were patients who had previously completed multidisciplinary treatment at a pain management unit. Results showed that the internet-based treatment can be a feasible option for persons with residual problems after completed pain rehabilitation. Effects remained at six-month follow-up.    Study IV focused on the effect of a guided internet-delivered acceptance and commitment therapy (ACT) for persons with chronic pain. Results suggest that an internet-delivered ACT treatment can help persons with chronic pain. Effects remained at six-month follow-up. In conclusion, guided internet-based CBT can decrease distress associated with chronic pain.

Socialstyrelsen menar att primärvården står inför en utmaning att tillgodose tillgänglig psykologisk behandling till ett växande behov. Ett möjligt tillvägagångssätt skulle kunna vara Integrerad beteendehälsa som eftersträvar att kunna erbjuda korta psykologiska interventioner med hög tillgänglighet. Syftet med föreliggande studie var att jämföra två varianter av Integrerad beteendehälsa; ett sedvanligt upplägg med Brief Interventions och ett upplägg med utökad bedömning och möjligheten till vägledd självhjälp för ett specifikt problem. Det här med avseende på generella symtom och symtom specifika för just det problem som patienter erhållit självhjälp för, alternativt bedömts skulle ha passat för självhjälp avseende ett specifikt problem. Resultaten visade att den generella symtomnivån förbättrades för gruppen som helhet, samt inom respektive grupp. Den problemspecifika symtomnivån sjönk för både patienter som erhållit vägledd självhjälp och för patienter som erhållit Brief Interventions men vars problemprofil visat att de hade passat för en specifik självhjälpsmanual. Någon signifikant skillnad i symtomförändring, oavsett generell eller problemspecifik, kunde inte hittas. I diskussionen problematiseras bland annat den interna validiteten och den naturalistiska miljön lyfts som en styrka. / The national board of health and wellfare are stating that primary care faces a major challenge in providing available psychological treatment to an increasing need. One possible approach is Integrated Behavioral Health, which strives towards offering brief psychological interventions with great access. The purpose of the following study was to compare two different methods of Integrated Behavioral Health; an ordinary set up with Brief Interventions and one set up with extended assesment and the possibility of guided self-help treatment for a particular problem. This regarding general as well as specific symptoms for the particular problem the patient has received guided self-help for, or considered to have been suited for. The results showed that the general level of symptoms improved for all patients, merged into one group, and within the respective group. The level of the problem-specific symptom decreased for patients who received guided self-help and for patients who received Brief Interventions, but whose problem profile showed that they had fit for a specific self-help manual. No significant difference in symptom change, regardless of general or problem- specific, could be found. In the discussion, the internal validity is discussed, and the naturalistic environment is described as a strength.

Primärvårdens uppdrag innefattar behandling av psykisk ohälsa och för närvarande överstiger behandlingsbehovet vårdnivåns resurser. Integrerad beteendehälsa (IBH) är en organisationsmodell för primärvård som tidseffektivt tillgängliggör psykologisk behandling. Föreliggande pilotstudie ägde rum under perioden januari till april 2019 på vårdcentralen Centrum, som arbetade enligt modellen för IBH. Syftet för studien var att utvärdera effekterna av behandling med Brief Interventions (BI) respektive vägledd självhjälp avseende patienternas vardagliga funktionsnivå, livskvalitet och symtom. Mätningar genomfördes innan behandling påbörjades, efter fyra veckor samt efter åtta veckor. Vidare undersöktes processfaktorer, så som hur stor andel av patienterna som skulle kunna tillgodogöra sig behandling med självhjälp, samt huruvida införande av en sådan behandling skulle kunna vara motiverad i primärvårdsmiljö utifrån tidseffektivitetsperspektiv. Totalt randomiserades 41 patienter mellan behandling med BI respektive en utökad bedömning följt av behandling med vägledd självhjälp. De patienter som vid den utökade bedömningen inte befanns lämpliga för vägledd självhjälp fick behandling med BI. Sammantaget fullföljde 29 patienter behandling inom ramen för studien. Resultaten visade att både BI och självhjälp förbättrade patienternas vardagliga funktionsnivå, livskvalitet och symtomnivå, samt att det fanns få skillnader i behandlingsutfall mellan grupperna. Tidsåtgången för personalen var större för behandling med självhjälp jämfört med BI. Vidare forskning behövs för att utvärdera psykologisk behandling anpassad till primärvården. / A commitment of primary care is mental health treatment. At present the need for treatment exceeds accessible resources. Primary Care Behavioral Health (PCBH) is a model of organization of primary care with the aim to make access to mental treatment from a time-efficiency perspective. The present study was conducted between January and April 2019 at Vårdcentralen Centrum, a primary care unit organized in accordance with PCBH. The aim of the present study was to evaluate the effects of treatment with Brief Interventions (BI) and guided self-help regarding daily functioning, quality of life and aggregate level of symptoms. Self-assessments were filled out by the patients before treatment, at FU4 and at FU8. Furthermore, proportion of patients suitable for self-help treatment was examined, and whether introduction of such a treatment might be justified in the context of primary care on basis of time effectiveness approach. In overall, 41 patients were randomized to two conditions: BI treatment and, respectively, extended assessment with subsequent self-help treatment. Participants, not found suitable for self-help at the extended assessment, got treatment with BI. Within the study, 29 patients went through treatment. The results showed that groups treated with BI and self-help had improved significantly between before treatment and FU8 regarding daily functioning, quality of life and level of symptoms. There were in general little differences in improvement between the two groups. Furthermore, timescale for the group that got extended assessment and subsequent self-help treatment, was significantly larger than timescale for the group that got BI treatment. For future research, evaluation of short-term forms of mental treatment in primary care ought to be relevant.

The overall aim of the present thesis was to examine long-term psychological distress following cancer during adolescence and to develop a tailored psychological intervention to reduce cancer-related distress experienced by young survivors of adolescent cancer that was feasible and acceptable. Study I adopted a longitudinal design, assessing health-related quality of life (HRQOL) and symptoms of anxiety and depression among adolescents diagnosed with cancer from shortly after diagnosis (n=61) up to 10 years after diagnosis (n=28). Findings suggest that development of HRQOL and anxiety and depression is not linear and whilst the majority adjust well, a subgroup report long-term elevated distress. In Study II, experiences of cancer-related psychological distress were explored using unstructured interviews. Participants described cancer treatment as a mental challenge, felt marked and hindered by the cancer experience, and struggled with feelings of inadequacy and insecurity, existential issues, and difficulties handling emotions. Study III was a preliminary investigation of individualised cognitive behavioural therapy (CBT), alongside the identification and conceptualisation of cancer-related concerns using cognitive-behavioural theory. Significant difficulties with recruitment were encountered. Participants reported cancer-related concerns conceptualised as social avoidance, fear and avoidance of emotions and bodily symptoms, imbalance in activity, and worry and rumination. In Study IV, the acceptability and feasibility of an internet-administered CBT based self-help intervention (ICBT) for young persons diagnosed with cancer during adolescence was examined using an uncontrolled design and embedded process evaluation. The study protocol for Study IV was included in this thesis along with preliminary findings demonstrating significant difficulties with recruitment. Overall, findings suggest that whilst the majority of survivors of adolescent cancer adjust well over time a subgroup report elevated levels of distress and a range of distressing cancer-related experiences. A number of cancer-related difficulties were identified in Study II and III, which may be used to inform the development of future psychological treatments for the population. Preliminary investigation of the psychological interventions examined within this thesis further highlights the need for future development work to enhance the feasibility and acceptability of psychological support for the population.

Primärvården står i dagsläget inför utmaningar gällande omhändertagandet av psykisk ohälsa. Integrerad beteendehälsa (IBH) är en organisatorisk modell med potential att underlätta för hur evidensbaserad psykologisk behandling kan bedrivas i en primärvårdskontext. Syftet med föreliggande studie var att utvärdera en sedvanlig IBH-vårdmodell, kontextuell bedömning följt av fokuserade insatser, med en utökad bedömningsprocedur följt av valet att inleda fokuserade insatser eller vägledd självhjälp, samt de två behandlingsuppläggen fokuserade insatser (oavsett bedömningsförfarande) och vägledd självhjälp efter utökad bedömning. Effekter på vardaglig funktionsnivå, betydelsen av antal behandlingskontakter samt den kontinuerliga upplevelsen av problemets svårighetsgrad, tilltro till den egna förmågan att förändras och besökens hjälpsamhet undersöktes. 69 primärvårdspatienter randomiserades mellan de två vårdmodellerna. Resultaten indikerade på en signifikant förbättring i vardaglig funktionsnivå för samtliga patienter oavsett vårdmodell och behandlingsupplägg. Inget samband mellan antal sessioner och förbättring upptäcktes. Skillnader i utfall och patienternas kontinuerliga upplevelser av behandlingsinterventionerna diskuteras. / The primary healthcare system faces challenges concerning the treatment of mental health. Integrated behavioral health (IBH) is an organizational model with the potential to implement evidence-based psychological treatment in a primary care setting. The aim of this study was to compare a standard IBH treatment model, contextual assessment followed by brief interventions, with an extended assessment procedure followed by brief interventions or guided self-help, as well as the two different treatment plans brief interventions (regardless of assessment procedure) and guided self-help post an extended assessment procedure. Effects on everyday functioning and correlations between number of sessions and treatment effect are evaluated along with the continuous patient experience regarding the severity of the problem, confidence in ability to change and session helpfulness. 69 primary care patients were randomized between the two treatment models. The results indicated a significant improvement in everyday functioning regardless of treatment model or treatment plan. No significant correlation between number of sessions and improvement was found. Differences in treatment outcome and patient experience are discussed.

Syftet för föreliggande studie var att undersöka olika sätt att organisera primärvårdens om- händertagande av patienter med psykisk ohälsa och hur det påverkar patienters nöjdhet med vården. Studiens frågeställningar syftade att undersöka 1) skillnader i nöjdhet mellan patienter som erbjuds sedvanlig Integrerad Beteendehälsa (IBH) med Brief Interventions (BI) och de som får utökad bedömning med vägledd självhjälp 2) om patienters vardagliga funktion förbättras och om förbättringen har ett samband med deras upplevelse av nöjdhet 3) hur vanligt negativa upplevelser är inom behandlingsmetoderna. Av 41 randomiserade primärvårdspatienter kunde 30 analyseras utifrån deras upplevda nöjdhet inom vården. Båda grupperna var i genomsnitt nöjda med vården och skattade besöken som hjälpsamma. Patienter som efter utökad bedömning fick vägledd självhjälp skattade tidigt i behandlingen högre grad av nöjdhet och den skillnaden kvarstod. Det fanns en signifikant förändring av vardaglig funktion till det bättre för patientgruppen som helhet, men förändringen korrelerade inte signifikant med nöjdhet. Det fanns en tydlig skillnad i antal rapporterade negativa upplevelser. 14 negativa upplevelser rapporterades av patienter som fått Brief Interventions, medan en negativ upplevelse rapporterades av patienterna som fått vägledd självhjälp. Slutsatser från föreliggande studie bekräftar tidigare forskning kring att nöjdhet går att uppfylla med kortare behandlingsinterventioner samt strukturerade behandlingar. / The purpose of the present study was to examine different ways of organizing primary care for patients with general mental disorders, and how the treatment affects the patient’s satisfaction with the care. The study aimed to examine 1) if there is a difference in patient satisfaction between patients offered brief interventions within the primary care behavior health model, and patients offered an extended assessment with guided self help 2) if the patients everyday function improves and correlates with their experience of satisfaction 3) how common adverse events are within the two treatment methods. Out of 41randomized primary care patients, 30 could be analyzed based on their perceived satisfaction in health care. The result showed that both treatment groups were overall satisfied with the care and estimated the care visits as helpful. Patients who received guided self-help estimated a higher degree of satisfaction earlier in the treatment, and the level of satisfaction remained high throughout the treatment. Regarding the patient group as a whole, there was a significant change in everyday function; the patients improved their everyday function although it did not correlate with satisfaction. There was a significant difference in the number of adverse events between the two treatment groups. 14 adverse events were reported from patients who received Brief Interventions and 1 adverse event was reported from a patient who received guided self-help. Conclusions from the present study confirm findings from previous research that it is possible to achieve patient satisfaction with brief treatment interventions and structured treatment plans.