Assessment and treatment of mental health problems in primary care : The course and results of Internet-based CBT and physical exercise on psychological functioning, stress and sleep

Abstract: The present thesis comprises three studies carried out within REGASSA, a multicenter randomized controlled trial in primary care. In the REGASSA study a 12 week treatment of mild to moderate depression and stress-related mental Health problems using Internet-based cognitive behavioural therapy (ICBT) and physical exercise (PE) was compared with treatment as usual (TAU). The inclusion criteria were symptoms of depression based on score >9 on the Patient Health Questionnaire-9. The overall aim in this thesis was to examine the course and results of the REGASSA treatment on psychological functioning, perceived stress and sleep assessed repeatedly by an computerized telephone technology, Interactive Voice Response (IVR), during treatment and in follow-up. The first study aimed to examine the psychometric properties of Outcome Questionnaire-45 (OQ-45) and the way OQ-45 would contribute to the explained variance in depression (MADRS) and health-related quality of life (EQ-5D). OQ-45 is a broad measure for psychological functioning with a total score for overalldistress and three subscales, Symptom of distress, Interpersonal relations and Social role functioning. The aim in the second study was to compare the course and results of the treatment alternatives ICBT, PE and TAU, based on IVR data ofOQ-45, stress and sleep over a 12- month follow-up period. The hypothesis was that ICBT would be more effective than PE and ICBT and that PE would be more effective than TAU. In the third study we extended the analyses and examined whether hazardous alcohol consumption at baseline influenced the results on OQ-45, stress and sleep during treatment and in follow-up. REGASSA included 946 patients and at baseline 879 of them registered for IVR and these patients are the focus of this thesis. The IVR system was programmed to automatically call the patient twice during treatment, once at the end of treatment and three times during follow-up. The sample comprised 70 % women and the average age was 43. The comorbidity between depression and several anxiety disorders was high and the proportion of hazardous drinkers was higher compared to the general population. The main results were (1) OQ-45 showed good psychometric properties with regard to the total score but was weaker with regard to the subscales and the OQ-45 total score was found to predict depression and health related quality of lifebeyond demographics and perceived stress. (2) ICBT and physical exercise were more effective than treatment as usual on psychological functioning and sleep but not on perceived stress with small to moderate effect sizes Cohen´s d = 0.20-0.56. (3) Hazardous alcohol drinking negatively influenced the course of perceived stress, but showed no effects on psychological functioning and sleep. In conclusion the OQ-45 total score is a comprehensive tool with good psychometric properties which seems useful for clinicians and researchers in the field. However, the subscales cannot be recommended for use on the basis of these results and further research is needed. Treatment of depression also affected psychological functioning, and sleep, but the effect on stress was less clear. The comparison between treatments showed similar results i.e. that ICBT and PE were both superior to TAU and could be implemented as treatments in primary care for mental health problems. It could however be of interest with further research on tailored treatment for patients with various mental health problems. With regard to hazardous alcohol consumption the results emphasized the need for screening for alcohol habits in routine care.