Mindfulness is a way of managing chronic pain and its consequences as it fosters anaccepting approach to pain that can be beneficial in several aspects of life affected bypain. This study sought to examine whether an online mindfulness training programcould reduce the experience of pain, increase acceptance of pain, and increase qualityof life in a group of individuals suffering from chronic pain. The study was arandomized controlled trial with a partly active control group. Initially 52 participantswere randomized to the intervention group and 55 to the control group. The drop outrates were high, 21 participants from the intervention group and 40 participants fromthe control group completed post measurement. Increased levels of mindfulness,reduced pain related distress, and heightened pain acceptance, as well as increasedquality of life, was observed in the intervention group. A strong tendency towards aperceived reduction of pain intensity was also evident in the intervention group. Asthe mindfulness program had positive effects on the overall experience of pain it mayserve as a cost‐effective and useful method of dealing with chronic pain. / Mindfulness är ett sätt att hantera kronisk smärta och dess konsekvenser då det lär uten accepterande inställning till smärta som kan vara till hjälp i flera aspekter av livetpåverkade av smärta. Denna studie undersökte huruvida ett online‐baseratmindfulnessprogram kunde minska upplevelsen av smärta, öka acceptans av smärtaoch öka livskvaliteten hos en grupp individer med kronisk smärta. Studien varrandomiserad och kontrollerad med en delvis aktiv kontrollgrupp. Initialtrandomiserades 52 deltagare till experimentgruppen och 55 deltagare tillkontrollgruppen. Bortfallet var högt, 21 deltagare från experimentgruppen och 40deltagare från kontrollgruppen fullgjorde eftermätningarna. Ökade nivåer avmindfulness, reducerat smärtrelaterat lidande, ökad acceptans av smärta såväl somökad livskvalitet återfanns i experimentgruppen. En stark tendens till minskadupplevd smärtintensitet var också tydlig hos experimentgruppen. Dåmindfulnessprogrammet hade positiva effekter på den övergripande upplevelsen avsmärta kan det fungera som en kostnadseffektiv och användbar metod att hanterakronisk smärta.

Anxiety disorders share the feature of excessive fear, anxiety and related behavioural disturbances. Fear is defined as the emotional response to a real or a perceived imminent threat and anxiety is the anticipation of a future threat. The anxiety disorders covered in this thesis are panic disorder with or without agoraphobia, social phobia, post-traumatic stress disorder, generalized anxiety disorder and anxiety disorder not otherwise specified. Cognitive behavioural treatment protocols are typically designed to target one specific disorder and falls under the definition of disorder-specific cognitive behavioural therapy. It is however unclear if this is the most optimal approach in regards to the high comorbidity between anxiety disorders and depressive disorders. Internet-based cognitive behavioural therapy has in the past generally been disorder-specific and from above mentioned predicament two alternative treatment approaches emerged, the tailored and the transdiagnostic approach that aims to simultaneously treat both principal and comorbid disorders. Previous trials on internet-based cognitive behavioural therapy have targeted adults in general and relatively few target adolescents, young adults and older adults. The aims of this thesis were to further develop and test the effects of tailored internet-based cognitive behavioural therapy on the basis of age, for adolescents, young adults and older adults. Specifically by developing and testing the effects of individually tailored internet-based cognitive behavioural therapy for adolescents with anxiety and comorbid depressive symptoms and by adapting and testing the effects of individually tailored internet-based cognitive behavioural therapy for young adults and older adults with anxiety and comorbid depressive symptoms. These aims were tested in two pilot effectiveness studies (Paper I and III) and two efficacy randomised controlled trials (Paper II and IV). The results from these four trials showed significant results across all outcome measures with overall moderate to large effect sizes. The tentative conclusion based on these results is that tailoring internet-based cognitive behavioural therapy can be a feasible approach in the treatment of anxiety symptoms and comorbid depressive symptoms for adolescents, young adults and older adults. Despite the positive findings of the studies in this thesis, there is a need for more research examining the acceptability and effectiveness of internet-based cognitive behavioural therapy for adolescents, young adults and older adults with anxiety and depression before implementation on a larger scale.

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format. Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT. / Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities. Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Background: Depression is one of the most frequent and costly mental disorders. While there is increasing evidence for the efficacy of online self-help to improve depression or prevent relapse, there is little evidence in blended care settings, especially combined with inpatient face-to-face psychotherapy. Therefore, we evaluated whether an evidencebased online self-help program improves the efficacy of inpatient psychotherapy. Methods: A total of 229 depressed patients were randomly allocated either to an online selfhelp program (intervention group [IG]; Deprexis) or an active control group (CG; weekly online information on depression) in addition to inpatient psychodynamic psychotherapy. Both groups had access to their respective experimental intervention for 12 weeks, regardless of inpatient treatment duration. Reduction of depressive symptoms, as measured with the Beck Depression Inventory-II, was the primary outcome at the end of the intervention (T2). Results: Depressive symptoms were statistically significantly lower in the IG compared to the active CG at T2 with a moderate betweengroup effect size of d = 0.44. The same applied to anxiety ( d = 0.33), quality of life ( d = 0.34), and self-esteem ( d = 0.38) at discharge from inpatient treatment (T1). No statistically significant differences were found regarding dysfunctional attitudes ( d = 0.14) and work ability ( d = 0.08) at T1. Conclusions: This is the first evidence for blended treatment combining online self-help with inpatient psychotherapy. The study opens new and promising avenues for increasing the efficacy of inpatient psychotherapy. Future studies should determine how integration of online self-help into the therapeutic process can be developed further.