Background and AimsMajor depression can be treated by means of cognitive behavior therapy, delivered via the Internet as guided self-help. Individually tailored guided self-help treatments have shown promising results in the treatment of anxiety disorders. This randomized controlled trial tested the efficacy of an Internet-based individually tailored guided self-help treatment which specifically targeted depression with comorbid symptoms. The treatment was compared both to standardized (non-tailored) Internet-based treatment and to an active control group in the form of a monitored online discussion group. Both guided self-help treatments were based on cognitive behavior therapy and lasted for 10 weeks. The discussion group consisted of weekly discussion themes related to depression and the treatment of depression.MethodsA total of 121 participants with diagnosed major depressive disorder and with a range of comorbid symptoms were randomized to three groups. The tailored treatment consisted of a prescribed set of modules targeting depression as well as comorbid problems. The standardized treatment was a previously tested guided self-help program for depression.ResultsFrom pre-treatment to post-treatment, both treatment groups improved on measures of depression, anxiety and quality of life. The results were maintained at a 6-month follow-up. Subgroup analyses showed that the tailored treatment was more effective than the standardized treatment among participants with higher levels of depression at baseline and more comorbidity, both in terms of reduction of depressive symptoms and on recovery rates. In the subgroup with lower baseline scores of depression, few differences were seen between treatments and the discussion group.ConclusionsThis study shows that tailored Internet-based treatment for depression is effective and that addressing comorbidity by tailoring may be one way of making guided self-help treatments more effective than standardized approaches in the treatment of more severe depression.Trial RegistrationClinicaltrials.gov NCT01181583

BackgroundLong-term sick leave is rising and associated with reduced quality of life as well as high societal cost. Within longstanding pain of RMD and mental illness the overall direct cost is approximately 6000 EUR per patient and year in Stockholm County [1]. To improve return to work (RTW), new models with extended roles for health professionals are under development across Europe [2]. For instance with RTW coordination Schandelmaier [3] found moderate quality evidence on RTW and Bewley [4] showed good effects in trials but when the intervention was widely adopted results dropped. In Sweden several ongoing initiatives uses a well-educated health professional to coordinate the process of rehabilitation and patient coaching, however little is known on the total effects on RTW, costs and QoL [5].ObjectivesThe objective of the ongoing RCT is to develop an evidence-based model for RTW coordination and evaluate the effects for patients with high risk of long periods of sick leave within longstanding pain in RMD:s and mild/moderate mental illness.MethodsStudy design: Health professionals with specific competence as RTW coordinators were recruited and trained for the study. The extended role requiring indept knowledge and focus on work ability, function and rehabilitation and sick-leave regulations and processes.Patients with high risk for long-term sick-leave are identified within primary care. Included patients are randomized to two groups; A) standard care B) standard care + intervention.Intervention: RTW coordination (individually adapted patient coaching and coordination of rehabilitation activities, work place efforts and health care).Outcomes measured: RTW, cost of care and claims, QoL by SF36, interviews with patients, physicians and RTW coordinatorsResultsSick-leave consumption: Average sick-claim rates are reduced and intervention patients return to work faster, corresponding to 55 days less on sick-leave compared to standard careHealth-care consumption: Non-effects on total healthcare consumptionPatient reported quality of life and satisfaction: improved QoL (SF36), high patient satisfaction with intervention, coordination and coaching.Change in care delivery: physicians report increased adherence to treatment and reduced administrative work.ConclusionsRTW coordination is a promising new extended role. Preliminary results indicate faster RTW, improve QoL and reduced costs for sick-leave claims. More research is needed to evaluate long-term effects.To be effective the model needs to enable early identification of high-risk patients, thorough root-cause analysis, individual adjustments based on work ability, close cooperation with employer and primary care. The challenges for the RTW coordinators are mainly return to work focus, framework adherence, root-cause analysis and structured follow-ups of effects.At the conference, the new extended role will be elaborated and results from 30 months of study with approximately 500 patients will be presented.References(VAL2009-2010; OVR, SLV, ARV, KONVAL);Stamm T, Hill...