MATHILDA BEN SALEM: Internet-based Cognitive Behavioral Therapy in Primary Care

Project description

Background 
Mental ill health constitutes a substantial proportion of the global burden of disease and is a prioritized area within Swedish primary care. Despite national guidelines recommending psychological treatment for depression and anxiety, healthcare services have limited resources to meet the demand. Internet-based cognitive behavioral therapy (iCBT) has proven to be a cost-effective treatment modality with effects comparable to traditional face-to-face CBT and is currently used in routine primary care.

At the same time, there is a need for clinical evaluation of how iCBT is implemented and functions in real-world healthcare settings. Older adults, over the age of 65, have historically been underrepresented in iCBT studies, despite a high prevalence of depression, increased suicide risk, and rising internet use within this age group. There is therefore a need to examine both treatment outcomes and experiences of iCBT among older adults in primary care. 

Aim 
The overall aim of this doctoral thesis is to study the implementation of iCBT in routine primary care and to identify organizational factors influencing its delivery and outcomes. Furthermore, the thesis aims to investigate the effectiveness of iCBT for mild to moderate depression in individuals aged over 65 years, including symptom reduction, health-related quality of life, and self-efficacy. The thesis also seeks to explore older patients’ and healthcare professionals experiences and attitudes toward iCBT, as well as how changes in self-efficacy relate to treatment outcomes. 

Method 
The thesis comprises four sub-studies using a mixed methods approach. The implementation of iCBT is examined using the RE-AIM framework through quantitative registry data, surveys, and qualitative interviews with patients, therapists, and managers. Treatment effectiveness in older adults is investigated in a pragmatic randomized controlled trial comparing iCBT with treatment as usual, with follow-ups up to 12 months. Qualitative interviews and focus groups are used to analyse experiences of the treatment among both patients and healthcare professionals. The relationship between treatment effects and self-efficacy is analysed using covariance analyses based on self-report measures. Both statistical analyses and qualitative analytical methods, such as thematic analysis and systematic text condensation, are employed.

Relevance 
The study provides important knowledge on how iCBT can be sustainably implemented in primary care and how organizational structures influence outcomes. It addresses a knowledge gap regarding the use of iCBT among older adults and may contribute to more equitable access to evidence-based psychological treatment. The findings may strengthen decision-making within healthcare organizations, reduce prejudices regarding older adults’ digital capabilities, and support the development of person-centered care with improved quality of life for a growing patient population.