This article was downloaded by: [Selcuk Universitesi] On: 23 December 2014, At: 20:24 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Cognitive Behaviour Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/sbeh20
State-of-the-Art Treatment via the Internet: An Optimistic Vision of the Future a
b
Per Carlbring , Gerhard Andersson & Viktor Kaldo a
Umeå University
b
Linköping University and Karolinska Institutet
c
c
Karolinska Institutet Published online: 24 Jun 2011.
To cite this article: Per Carlbring , Gerhard Andersson & Viktor Kaldo (2011) State-of-the-Art Treatment via the Internet: An Optimistic Vision of the Future, Cognitive Behaviour Therapy, 40:2, 79-81, DOI: 10.1080/16506073.2011.575591 To link to this article: http://dx.doi.org/10.1080/16506073.2011.575591
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Cognitive Behaviour Therapy Vol 40, No 2, pp. 79–81, 2011
Downloaded by [Selcuk Universitesi] at 20:24 23 December 2014
EDITORIAL State-of-the-Art Treatment via the Internet: An Optimistic Vision of the Future The Swedish National Board of Health and Welfare (2010) recently issued guidelines on the diagnosis and treatment of anxiety and depression. This government agency, part of the Ministry of Health and Social Affairs, recommended three approaches of equal merit in the treatment of moderate depression: Internet-based cognitive behavioural therapy (CBT), standard CBT, and selective serotonin reuptake inhibitor (SSRI) medication. Internet-based CBT (iCBT) was also advocated for several other psychiatric conditions, although usually after SSRI treatment or standard CBT. For social phobia, which was listed among these conditions, iCBT was ranked third among the treatments of choice. However, the evidence base for this conclusion includes only two studies from a single research group. This field of research is increasingly productive, and a recent metaanalysis found that the positive results of the Swedish research trials have been replicated by three other independent groups (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). It is clear that Internet-based treatment is here to stay. However, a number of issues need to be considered before optimal treatment can be provided for the ordinary patient. In Sweden, almost all clinical studies have been carried out in a university setting. There are exceptions: For instance, the Internet Psychiatry Department within the regular care in Stockholm City Council, in close cooperation with Karolinska Institute, has been the site for iCBT trials on depression, panic disorder, social phobia, irritable bowel syndrome, health anxiety, and insomnia (see, e.g., Bergstro¨m et al., 2010). However, one problem remains largely unresolved: Evidence-based treatment platforms and complementary quality systems suitable for regular primary care or psychiatric care are not readily available to local care providers. This
is mainly due to technical, legal, and organizational issues and makes care providers prone to start looking for help from commercial companies to provide this type of programs. There are several program development issues that these companies need to consider. In addition to specific content and the way it is presented, we need to establish the best way for patients to enter the program and the best type of guidance. Research has shown that professional support improves treatment outcomes and reduces dropout rates (Spek et al., 2007). However, there is no clear evidence as to who should give this support or how much should be given. Palmqvist, Carlbring, and Andersson (2007) have shown that there seems to be a linear correlation between therapist time and efficacy. However, increasing therapist time for each individual reduces the number of individuals with access to treatment. There is, therefore, a clear need for studies that look at not only the amount of allocated therapist time but also the type of contact and the type of health care professional that this support person should be (Robinson et al., 2010). In addition, we have not established the importance of feedback content. Therefore, studies examining the exact content of feedback messages are needed, possibly developing checklists as used in the quality assessment of personal therapy, in order to achieve the operationalisation of Internet-based feedback. Internet-based treatment has several risks, including the danger of patients failing to understand the instructions or, even worse, misinterpreting key concepts, thereby carrying out the exercises incorrectly, with the treatment ending in failure and discouragement. This would obviously raise dropout rates or, worse still, reinforce the patient’s low selfesteem and could, hypothetically, increase the
q 2011 Swedish Association for Behaviour Therapy ISSN 1650-6073 DOI: 10.1080/16506073.2011.575591
Downloaded by [Selcuk Universitesi] at 20:24 23 December 2014
80
Editorial
risk of acts of desperation, such as suicide. There is also a potential risk that clinical skills can suffer if clinicians perform only Internetbased treatment (Andersson, 2010). We suggest that the delivery of Internetbased treatment should start with making a proper diagnosis (cf. Nordin, Carlbring, Cuijpers, & Andersson, 2010). This must be done in order to exclude underlying somatic disease, such as hyperthyroidism masquerading as panic disorder. Also, and in many cases more importantly, the strength of iCBT is its focus on a specific diagnose or problem, and because the flexibility to shift focus during treatment is very limited, an accurate initial diagnosis seems essential to reach large effect sizes. An assessment of suitability must also be made at this initial consultation. However, we believe that Internet-based treatment should not be regarded as a third-rate alternative. The general practitioner should not present Internet-based therapy as a fall-back option when standard CBT is costly or subject to delay or merely as a means of avoiding the side effects of SSRI medication. On the contrary, Internet-based treatment can be positively promoted as one alternative to choose from among others, because there is clear evidence that this type of treatment does, in fact, produce good results (cf. Mataix-Cols, Cameron, Gega, Kenwright, & Marks, 2006). Our clinical observations suggest that individual outcomes are sometimes better if the professional doing the initial screening remains as the patient’s guide throughout the treatment. Homework assignments and professional support are usually required if patients are to achieve good results. However, it is still unclear whether increasing professional support represents the best use of resources. Some trials have shown that additional telephone contact or even additional live sessions do not necessarily improve overall treatment outcomes (Tillfors et al., 2008). Our clinical experience, however, suggests that patients stay in a program for longer if telephone contact is included (cf. Carlbring et al., 2006). However, this does not necessarily mean improved treatment outcomes. We recommend that one short call be scheduled for the end of the first treatment module and another at follow-up. Our intention with the second call is to provide a
COGNITIVE BEHAVIOUR THERAPY
deadline effect (i.e. an end-of-treatment goal toward which the patient can work) and to provide the comfort and reassurance of another human being who cares about the patient’s progress. At the Internet Psychiatry Department previously described, a followup visit is always scheduled as an important way to complement the otherwise self-rated outcome and to be able to refer patients in need of additional help to other parts of the health care system. Ideally, a discussion forum should form an integral part of the program. Progress must, of course, be monitored, especially in relation to home assignments. There should preferably be weekly selfratings by the patient so that the guiding professional can follow progress and detect sudden changes. In a psychiatric setting, special attention to indications of suicidal ideation is very important, and systems to monitor this should be included. Finally, possibly the two most important issues of the day are the tailoring of the treatment and the prediction of response. Regarding the first issue, most Internet-based treatment programs that have been tested are specific to one diagnosis, and a patient presenting with panic disorder would, therefore, be offered the panic disorder program. Trials have included patients with comorbidities, but in trials of panic disorder, for example, that diagnosis had to be the primary problem. However, patients typically have multiple problems. These could be panic disorder combined with subthreshold social phobia and depression along with insomnia. Such patients would usually be offered the panic disorder treatment program only. Tools from that targeted program often, but not always, have a crossover effect on the other problems. One solution to this one-size-fits-all approach would be to tailor the treatment program to the unique set of problems of a particular patient. A tailored treatment could start with some common psychoeducation on thoughts and perceptions, move on to treatment modules targeting panic syndrome, and then focus on supplementary modules on social phobia and sleep disorders. Individual patient programs could be of similar length but contain a variety of different modules. Initial testing of this type of tailored treatment is achieving promising results.
Downloaded by [Selcuk Universitesi] at 20:24 23 December 2014
VOL 40, NO 2, 2011
State-of-the-art treatment via the Internet
The second most pressing issue is to find reliable predictors of which patients are most likely to benefit from Internet-based treatment. This would enable us to offer unsuitable patients another treatment option immediately instead of allowing them to try and then fail with Internet-based therapy, leaving them with a sense of worthlessness and hopelessness. Being able to reliably select the most effective initial treatment would be far preferable to the stepped-care approach. However, little research has been done on the prediction of response. Another area in need of expansion is the testing of mediator and moderator effects. Even though there are step-by-step guides (Frazier, Tix, & Barron, 2004), there still is much confusion regarding this. Essentially, it means that we should move beyond the testing of only direct effects and also include the analysis of indirect effects. All this, however, demands a common ground. In this issue, Judy Proudfoot, Britt Klein, Azy Barak, and co-workers take a first step and propose guidelines for executing and reporting Internet intervention research. That is a giant leap for Internet research. Per Carlbring Umea˚ University Gerhard Andersson Linko¨ping University and Karolinska Institutet Viktor Kaldo Karolinska Institutet
References Andersson, G. (2010). The promise and pitfalls of the Internet for cognitive behavioural therapy. BMC Medicine, 8, 82. Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective,
81
acceptable and practical health care: A metaanalysis. PLoS ONE, 5(10), e13196. Bergstro¨m, J., Andersson, G., Ljo´tsson, B., Ruck, C., Andre´ewitch, S., Karlsson, A., . . . Lindefors, N. (2010). Internet- versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial. BMC Psychiatry, 10(54). Carlbring, P., Bohman, S., Brunt, S., Buhrman, M., Westling, B. E., Ekselius, L., & Andersson, G. (2006). Remote treatment of panic disorder: A randomized trial of Internet-based cognitive behavior therapy supplemented with telephone calls. American Journal of Psychiatry, 163(12), 2119– 2125. Frazier, P. A., Tix, A. P., & Barron, K. E. (2004). Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology, 51(1), 115– 134. Mataix-Cols, D., Cameron, R., Gega, L., Kenwright, M., & Marks, I. M. (2006). Effect of referral source on outcome with cognitivebehavior therapy self-help. Comprehensive Psychiatry, 47(4), 241– 245. Nordin, S., Carlbring, P., Cuijpers, P., & Andersson, G. (2010). Expanding the limits of bibliotherapy for panic disorder: Randomized trial of self-help without support but with a clear deadline. Behavior Therapy, 41(3), 267–276. Palmqvist, B., Carlbring, P., & Andersson, G. (2007). Internet-delivered treatments with or without therapist input: Does the therapist factor have implications for efficacy and cost? Expert Review of Pharmacoeconomics and Outcomes Research, 7(3), 291– 297. Robinson, E., Titov, N., Andrews, G., McIntyre, K., Schwencke, G., & Solley, K. (2010). Internet treatment for generalized anxiety disorder: A randomized controlled trial comparing clinician vs. technician assistance. PLoS ONE, 5(6), e10942. Spek, V., Cuijpers, P., Nyklı´ cek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychological Medicine, 37(3), 319– 328. Swedish National Board of Health and Welfare (Socialstyrelsen) (2010). Nationella riktlinjer fo¨r va˚rd vid depression och a˚ngestsyndrom [National guidelines for depression and anxiety]. Retrieved from http://www.socialstyrelsen.se/ nationellariktlinjerfordepressionochangest. Tillfors, M., Carlbring, P., Furmark, T., Lewenhaupt, S., Spak, M., Eriksson, A., & Andersson, G. (2008). Treating university students with social phobia and public speaking fears: Internet delivered self-help with or without live group exposure sessions. Depression and Anxiety, 25(8), 708– 717.
Cognitive Behaviour Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/sbeh20
State-of-the-Art Treatment via the Internet: An Optimistic Vision of the Future a
b
Per Carlbring , Gerhard Andersson & Viktor Kaldo a
Umeå University
b
Linköping University and Karolinska Institutet
c
c
Karolinska Institutet Published online: 24 Jun 2011.
To cite this article: Per Carlbring , Gerhard Andersson & Viktor Kaldo (2011) State-of-the-Art Treatment via the Internet: An Optimistic Vision of the Future, Cognitive Behaviour Therapy, 40:2, 79-81, DOI: 10.1080/16506073.2011.575591 To link to this article: http://dx.doi.org/10.1080/16506073.2011.575591
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Cognitive Behaviour Therapy Vol 40, No 2, pp. 79–81, 2011
Downloaded by [Selcuk Universitesi] at 20:24 23 December 2014
EDITORIAL State-of-the-Art Treatment via the Internet: An Optimistic Vision of the Future The Swedish National Board of Health and Welfare (2010) recently issued guidelines on the diagnosis and treatment of anxiety and depression. This government agency, part of the Ministry of Health and Social Affairs, recommended three approaches of equal merit in the treatment of moderate depression: Internet-based cognitive behavioural therapy (CBT), standard CBT, and selective serotonin reuptake inhibitor (SSRI) medication. Internet-based CBT (iCBT) was also advocated for several other psychiatric conditions, although usually after SSRI treatment or standard CBT. For social phobia, which was listed among these conditions, iCBT was ranked third among the treatments of choice. However, the evidence base for this conclusion includes only two studies from a single research group. This field of research is increasingly productive, and a recent metaanalysis found that the positive results of the Swedish research trials have been replicated by three other independent groups (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). It is clear that Internet-based treatment is here to stay. However, a number of issues need to be considered before optimal treatment can be provided for the ordinary patient. In Sweden, almost all clinical studies have been carried out in a university setting. There are exceptions: For instance, the Internet Psychiatry Department within the regular care in Stockholm City Council, in close cooperation with Karolinska Institute, has been the site for iCBT trials on depression, panic disorder, social phobia, irritable bowel syndrome, health anxiety, and insomnia (see, e.g., Bergstro¨m et al., 2010). However, one problem remains largely unresolved: Evidence-based treatment platforms and complementary quality systems suitable for regular primary care or psychiatric care are not readily available to local care providers. This
is mainly due to technical, legal, and organizational issues and makes care providers prone to start looking for help from commercial companies to provide this type of programs. There are several program development issues that these companies need to consider. In addition to specific content and the way it is presented, we need to establish the best way for patients to enter the program and the best type of guidance. Research has shown that professional support improves treatment outcomes and reduces dropout rates (Spek et al., 2007). However, there is no clear evidence as to who should give this support or how much should be given. Palmqvist, Carlbring, and Andersson (2007) have shown that there seems to be a linear correlation between therapist time and efficacy. However, increasing therapist time for each individual reduces the number of individuals with access to treatment. There is, therefore, a clear need for studies that look at not only the amount of allocated therapist time but also the type of contact and the type of health care professional that this support person should be (Robinson et al., 2010). In addition, we have not established the importance of feedback content. Therefore, studies examining the exact content of feedback messages are needed, possibly developing checklists as used in the quality assessment of personal therapy, in order to achieve the operationalisation of Internet-based feedback. Internet-based treatment has several risks, including the danger of patients failing to understand the instructions or, even worse, misinterpreting key concepts, thereby carrying out the exercises incorrectly, with the treatment ending in failure and discouragement. This would obviously raise dropout rates or, worse still, reinforce the patient’s low selfesteem and could, hypothetically, increase the
q 2011 Swedish Association for Behaviour Therapy ISSN 1650-6073 DOI: 10.1080/16506073.2011.575591
Downloaded by [Selcuk Universitesi] at 20:24 23 December 2014
80
Editorial
risk of acts of desperation, such as suicide. There is also a potential risk that clinical skills can suffer if clinicians perform only Internetbased treatment (Andersson, 2010). We suggest that the delivery of Internetbased treatment should start with making a proper diagnosis (cf. Nordin, Carlbring, Cuijpers, & Andersson, 2010). This must be done in order to exclude underlying somatic disease, such as hyperthyroidism masquerading as panic disorder. Also, and in many cases more importantly, the strength of iCBT is its focus on a specific diagnose or problem, and because the flexibility to shift focus during treatment is very limited, an accurate initial diagnosis seems essential to reach large effect sizes. An assessment of suitability must also be made at this initial consultation. However, we believe that Internet-based treatment should not be regarded as a third-rate alternative. The general practitioner should not present Internet-based therapy as a fall-back option when standard CBT is costly or subject to delay or merely as a means of avoiding the side effects of SSRI medication. On the contrary, Internet-based treatment can be positively promoted as one alternative to choose from among others, because there is clear evidence that this type of treatment does, in fact, produce good results (cf. Mataix-Cols, Cameron, Gega, Kenwright, & Marks, 2006). Our clinical observations suggest that individual outcomes are sometimes better if the professional doing the initial screening remains as the patient’s guide throughout the treatment. Homework assignments and professional support are usually required if patients are to achieve good results. However, it is still unclear whether increasing professional support represents the best use of resources. Some trials have shown that additional telephone contact or even additional live sessions do not necessarily improve overall treatment outcomes (Tillfors et al., 2008). Our clinical experience, however, suggests that patients stay in a program for longer if telephone contact is included (cf. Carlbring et al., 2006). However, this does not necessarily mean improved treatment outcomes. We recommend that one short call be scheduled for the end of the first treatment module and another at follow-up. Our intention with the second call is to provide a
COGNITIVE BEHAVIOUR THERAPY
deadline effect (i.e. an end-of-treatment goal toward which the patient can work) and to provide the comfort and reassurance of another human being who cares about the patient’s progress. At the Internet Psychiatry Department previously described, a followup visit is always scheduled as an important way to complement the otherwise self-rated outcome and to be able to refer patients in need of additional help to other parts of the health care system. Ideally, a discussion forum should form an integral part of the program. Progress must, of course, be monitored, especially in relation to home assignments. There should preferably be weekly selfratings by the patient so that the guiding professional can follow progress and detect sudden changes. In a psychiatric setting, special attention to indications of suicidal ideation is very important, and systems to monitor this should be included. Finally, possibly the two most important issues of the day are the tailoring of the treatment and the prediction of response. Regarding the first issue, most Internet-based treatment programs that have been tested are specific to one diagnosis, and a patient presenting with panic disorder would, therefore, be offered the panic disorder program. Trials have included patients with comorbidities, but in trials of panic disorder, for example, that diagnosis had to be the primary problem. However, patients typically have multiple problems. These could be panic disorder combined with subthreshold social phobia and depression along with insomnia. Such patients would usually be offered the panic disorder treatment program only. Tools from that targeted program often, but not always, have a crossover effect on the other problems. One solution to this one-size-fits-all approach would be to tailor the treatment program to the unique set of problems of a particular patient. A tailored treatment could start with some common psychoeducation on thoughts and perceptions, move on to treatment modules targeting panic syndrome, and then focus on supplementary modules on social phobia and sleep disorders. Individual patient programs could be of similar length but contain a variety of different modules. Initial testing of this type of tailored treatment is achieving promising results.
Downloaded by [Selcuk Universitesi] at 20:24 23 December 2014
VOL 40, NO 2, 2011
State-of-the-art treatment via the Internet
The second most pressing issue is to find reliable predictors of which patients are most likely to benefit from Internet-based treatment. This would enable us to offer unsuitable patients another treatment option immediately instead of allowing them to try and then fail with Internet-based therapy, leaving them with a sense of worthlessness and hopelessness. Being able to reliably select the most effective initial treatment would be far preferable to the stepped-care approach. However, little research has been done on the prediction of response. Another area in need of expansion is the testing of mediator and moderator effects. Even though there are step-by-step guides (Frazier, Tix, & Barron, 2004), there still is much confusion regarding this. Essentially, it means that we should move beyond the testing of only direct effects and also include the analysis of indirect effects. All this, however, demands a common ground. In this issue, Judy Proudfoot, Britt Klein, Azy Barak, and co-workers take a first step and propose guidelines for executing and reporting Internet intervention research. That is a giant leap for Internet research. Per Carlbring Umea˚ University Gerhard Andersson Linko¨ping University and Karolinska Institutet Viktor Kaldo Karolinska Institutet
References Andersson, G. (2010). The promise and pitfalls of the Internet for cognitive behavioural therapy. BMC Medicine, 8, 82. Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective,
81
acceptable and practical health care: A metaanalysis. PLoS ONE, 5(10), e13196. Bergstro¨m, J., Andersson, G., Ljo´tsson, B., Ruck, C., Andre´ewitch, S., Karlsson, A., . . . Lindefors, N. (2010). Internet- versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial. BMC Psychiatry, 10(54). Carlbring, P., Bohman, S., Brunt, S., Buhrman, M., Westling, B. E., Ekselius, L., & Andersson, G. (2006). Remote treatment of panic disorder: A randomized trial of Internet-based cognitive behavior therapy supplemented with telephone calls. American Journal of Psychiatry, 163(12), 2119– 2125. Frazier, P. A., Tix, A. P., & Barron, K. E. (2004). Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology, 51(1), 115– 134. Mataix-Cols, D., Cameron, R., Gega, L., Kenwright, M., & Marks, I. M. (2006). Effect of referral source on outcome with cognitivebehavior therapy self-help. Comprehensive Psychiatry, 47(4), 241– 245. Nordin, S., Carlbring, P., Cuijpers, P., & Andersson, G. (2010). Expanding the limits of bibliotherapy for panic disorder: Randomized trial of self-help without support but with a clear deadline. Behavior Therapy, 41(3), 267–276. Palmqvist, B., Carlbring, P., & Andersson, G. (2007). Internet-delivered treatments with or without therapist input: Does the therapist factor have implications for efficacy and cost? Expert Review of Pharmacoeconomics and Outcomes Research, 7(3), 291– 297. Robinson, E., Titov, N., Andrews, G., McIntyre, K., Schwencke, G., & Solley, K. (2010). Internet treatment for generalized anxiety disorder: A randomized controlled trial comparing clinician vs. technician assistance. PLoS ONE, 5(6), e10942. Spek, V., Cuijpers, P., Nyklı´ cek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychological Medicine, 37(3), 319– 328. Swedish National Board of Health and Welfare (Socialstyrelsen) (2010). Nationella riktlinjer fo¨r va˚rd vid depression och a˚ngestsyndrom [National guidelines for depression and anxiety]. Retrieved from http://www.socialstyrelsen.se/ nationellariktlinjerfordepressionochangest. Tillfors, M., Carlbring, P., Furmark, T., Lewenhaupt, S., Spak, M., Eriksson, A., & Andersson, G. (2008). Treating university students with social phobia and public speaking fears: Internet delivered self-help with or without live group exposure sessions. Depression and Anxiety, 25(8), 708– 717.
