CBT in primary care : effects on symptoms and sick leave, implementation of stepped care and predictors of outcome

Background: Common mental disorders (CMDs) cause great individual suffering and high societal costs including long-term sick leave. Cognitive behavioural therapy (CBT) can effectively treat CMDs, but access to treatment is insufficient. Moreover, sick leave is not reduced to the same extent as psychiatric symptoms after CBT. Little is known about predictors of outcome after CBT, especially concerning guided self-help.

Aims: The aim of the present thesis was to systematically review the effects and evidence of psychological treatments on sick leave and assess the effects in a meta-analysis of published treatment trials (Study I), evaluate the effect of CBT and a novel return-to-work intervention (RTW-I) on sick leave and psychiatric symptoms for patients with CMDs (Study II), test a stepped care CBT model for CMDs in primary care (Study III), and investigate predictors of outcome for guided self-help CBT (Study IV).

Methods: In Study I, a systematic review and meta-analysis (45 studies) was conducted regarding effects of psychological interventions on sick leave and symptoms. In Study II (N = 211) and III (N = 396) patients from four primary care centres in Stockholm were treated with disorder specific CBT for CMDs. In Study II, patients on sick leave were randomised to CBT, RTW-I, or a combination of the two, and were followed up one year after treatment regarding sick leave and symptoms. In Study III all patients received disorder specific guided self-help CBT for nine weeks. Non-responders were then randomised to face-to-face CBT or continued guided self-help. In Study IV predictors of outcome for guided self-help CBT in Study III were investigated.

Results: Study I showed that psychological interventions were more effective than care as usual in reducing sick leave and psychiatric symptoms but the effect sizes were small (g = 0.15 and 0.20, respectively). There was no significant difference in effect between work focused interventions, problem solving therapy, CBT or collaborative care. In Study II, there was no significant difference between treatments regarding days on sick leave one year after treatment start; CBT however led to larger reduction of symptoms post-treatment than RTW-I. In Study III, 40% of patients were in remission after nine weeks of guided self-help CBT. After Step II, 39% of the non-remitted patients who had been randomised to face-to-face CBT were in remission compared to 19% of patients who received continued guided self-help (p < 0.05). Study IV showed that patients across all disorders benefitted from guided self-help CBT, but those with social anxiety disorder and depression reached remission to a lower extent. Higher educational level predicted remission, higher quality of life ratings predicted remission and post treatment depression ratings, and higher age at onset predicted reliable change. All investigated therapy related variables, e.g., adherence to treatment and expectancy of outcome, were positively associated to outcome.

Conclusions: Psychological interventions can reduce sick leave compared to treatment as usual, but effects are small. Adding RTW-I as investigated in the present thesis to CBT seems to have little effect on sick leave. This could be due to lack of power or that CBT also had an effect on sick leave. Disorder specific CBT can effectively treat CMDs in primary care and using stepped care with guided self-help CBT as the initial step seem to be a resource efficient way to treat CMDs. Patients with higher education, higher ratings of quality of life and later age of onset appear to have a better outcome of guided self-help. Patients who rate treatment as credible and actively participate in therapy have a greater chance of recovering. This knowledge can be of value when making treatment recommendations.

List of scientific papers

I. Salomonsson, S., Hedman-Lagerlöf, E., & Öst, L-G. Sickness absence: A Systematic Review and Meta-Analysis of Psychological Treatments for Individuals on Sick leave due to Common Mental Disorders. Psychological Medicine. [Accepted]
https://doi.org/10.1017/S0033291718000065

II. Salomonsson, S., Santoft, F., Lindsäter, E., Ejeby, K., Ljótsson, B., Öst, L-G., Ingvar, M., Lekander, M., Hedman-Lagerlöf, E. (2017). Cognitive-behavioural therapy and return-to-work intervention for patients on sick leave due to common mental disorders: a randomised controlled trial. Occupational and Environmental Medicine. 74(12), 905-912.
https://doi.org/10.1136/oemed-2017-104342

III. Salomonsson, S., Santoft, F., Lindsäter, E., Ejeby, K., Ljótsson, B., Öst, L-G., Ingvar, M., Lekander, M., Hedman-Lagerlöf, E. (2017). Stepped care in primary care - guided self-help and face-to-face cognitive behavioural therapy for common mental disorders: a randomised controlled trial. Psychological Medicine. 1-11.
https://doi.org/10.1017/S0033291717003129

IV. Salomonsson, S., Santoft, F., Lindsater, E., Ejeby, K., Öst, L-G., Lekander, M., Ljótsson, B., & Hedman-Lagerlöf, E. Predictors of outcome in Guided self-help Cognitive Behavioural Therapy for Common Mental Disorders in Primary Care. [Manuscript]