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Purpose: Repetitive transcranial magnetic stimulation (rTMS) is a treatment option for major depressive disorder (MDD). MDD is a heterogeneous condition with subtypes, including atypical depression (AD). The effectiveness of rTMS for AD remains unknown. In this study, we investigated the effects of rTMS in patients with AD compared to those with MDD in a clinical setting.

Materials and methods: A total of 103 patients with uni- or bipolar depressive episodes, treated with rTMS at the Uppsala Brain Stimulation Unit between April 2017 and October 2023, were included. Participants were categorized as AD (Quick Inventory of Depressive Symptomatology Self Report items 4, 7, and 9 ≥ 3) or MDD. The primary outcomes were response and remission rates based on the total score of Montgomery and Åsberg Depression Rating Scale self-report (MADRS-S). Response was defined as a 50% reduction of the total MADRS-S score and remission as MADRS-S < 10.

Results: Depressive symptoms significantly decreased after rTMS in the whole sample, with the mean MADRS-S score reduced from 34 to 25. The AD group had consistently lower scores on MADRS-S. No significant differences were observed in symptom reduction, response, or remission rates between AD and MDD groups. Response and remission rates were 12.6% and 2.9% for the whole sample, although reasons for treatment termination could not be assessed.

Conclusions: rTMS does not appear to yield specific benefits for AD. Observed response and remission rates were lower than previously reported, highlighting the need for more reports of the actual effectiveness of rTMS.

Introduction: Compassion-focused therapy (CFT) has shown promising outcomes for young people, but research on CFT for this population remains limited. This study aims to evaluate the feasibility and acceptability of a seven-session, therapist-led, internet-based group CFT for young people, and to investigate its preliminary effects.

Methods: A two-arm pilot randomized controlled trial (RCT) was conducted. The study included 42 participants (aged 15–20), experiencing mild to moderate stress, anxiety, or depression, most of whom (90%) were female. In the intervention group, 22 participants were included in the intention-to-treat (ITT) analysis. The trial was registered at ClinicalTrials.gov (NCT05448014).

Results: The intervention group had low attrition and moderate attendance, with 77% completing four or more modules. No adverse events were reported, and participants generally expressed satisfaction with the intervention. Linear regression models showed preliminary between-group differences in two variables. Depressive symptoms increased post-intervention for individuals in the intervention group compared to the waitlist (WL) group (p = 0.002). Self-compassion improved in the intervention group (p = 0.023). These patterns were consistent among participants who completed more than two sessions. Within-group analyses indicated moderate, significant improvements in stress, self-compassion and compassion from others.

Discussion: These preliminary results suggest that CFT is feasible and acceptable and may offer benefits for young people, particularly by enhancing self-compassion and compassion for others. The observed increase in depressive symptoms in the intervention group, despite improvements in self-compassion, warrants further investigation. Larger studies are needed to confirm these preliminary results and to better understand the underlying mechanisms.

Introduction: Online group compassion-focused therapy (CFT) has not been thoroughly studied in young people, and the participants' perspectives on the treatment are highly relevant.

Methods: A seven-session internet-based group CFT program was evaluated for young people aged 15–20 (n = 42, females = 37). A self-report evaluation questionnaire, specifically designed for this study, was administered post-intervention. The current study investigated: (1) Potential factors influencing the treatment program goals (increase self-compassion, reduce self-criticism and increase affect-regulation abilities) and the participants' overall experience of the treatment; and (2) The effect each intervention exercise had on the program goals according to the participants' ratings.

Results: Participants generally reported high satisfaction and had a high attendance rate. Only 2.4% of the participants completed less than half of the sessions and 71% of the participants attended at least six of the seven sessions. Exercises that integrated traditional cognitive-behavioral therapy (CBT) and Compassion-Focused Therapy (CFT) principles received high ratings, whereas breathing and mindfulness exercises were rated lower in many cases. Several compassion exercises were also highly rated, such as the Threat-drive and security system, based on CFT affect-regulation theory. The majority did not find home assignments helpful.

Discussion: The findings suggest that internet-based group CFT could be an easily accessible and acceptable intervention for young people in primary care, though further research is warranted.

Purpose: The objective of this study is to assess the psychometric properties and reliability of the Swedish Patient-Reported Outcomes Measurement Information System (PROMIS) item banks for anxiety and depressive symptoms with item response theory analysis and post-hoc computerized adaptive testing in a combined Swedish Child and Adolescent Psychiatry (CAP) and school sample.

Methods: Participants (n = 928, age 12–20) were recruited from junior and high schools and Child and Adolescent Psychiatry Clinics in the region of Västerbotten. Unidimensionality, local independence, and monotonicity was tested. We fitted a graded response model to the data and tested differential item functioning (DIF) for sex, age group, sample type, and language (Swedish vs. U.S.). Moreover, a post-hoc computer adaptive testing (CAT) simulation was performed. All analysis were made in R.

Results: Unidimensionality, local independence, and monotonicity were acceptable. The graded response model yielded acceptable item fit, discriminative, and threshold values for all items in both item banks. DIF for language (Swedish vs. U.S.) was found for two items from the anxiety and one item from the depressive symptoms item banks. A Stocking-lord transformation was used for the items displaying language DIF, and post-hoc CAT simulations were performed. The post-hoc CAT simulation showed reliability around 0.9 for both Swedish and official U.S. item parameters T-scores calibration from within normal limits to severe anxiety and depressive symptoms.

Conclusion: The Swedish pediatric PROMIS item banks of anxiety and depressive symptoms are appropriate to assess mild to severe symptoms of anxiety and depressive symptoms in Swedish school- and CAP samples.

Background: Depression in adolescence is a serious major global health problem with increasing rates of prevalence. Measures of depression that are valid for young people are clearly needed in clinical contexts.

Methods: The study included 577 patients from child and adolescent psychiatry (n = 471) and primary care (n = 106) aged 12–22 years in Sweden (Mage=16.7 years; 76% female). The reliability and validity for Montgomery–Åsberg Depression Rating Scale–Youth (MADRS-Y) were investigated. To confirm the latent structure, we used a single-factor confirmatory factor analysis (CFA). A Kruskal–Wallis test was performed to test total score differences between diagnostic groups. Using Spearman’s rho correlations, we examine whether single items in the MADRS-Y correlate with suicidal ideation measured by The Suicidal Ideation Questionnaire-JR (SIQ-JR).

Results: The internal consistency using McDonald’s coefficient omega was excellent. The CFA of the 12-item MADRS-Y supported a one factor structure. Evidence of convergent and discriminant validity was shown. There was a significant difference in MADRS-Y scores across diagnostic groups, with higher results for depressive disorders. A strong correlation with suicidal ideation was found for two items.

Conclusions: The results support MADRS-Y as a brief, reliable, and valid self-report questionnaire of depressive symptoms for young patients in a clinical setting.

Objective: Observed and predicted increases in the global burden of disease caused by major depressive disorder (MDD) highlight the need for psychometrically robust multi-dimensional measures to use for clinical and research purposes. Reynolds Adolescent Depression Scale second edition (RADS-2) is an internationally well-validated scale measuring different dimensions of adolescent depression. The Swedish version has previously only been evaluated in a normative sample.

Methods: We collected data from patients in child and adolescent psychiatry and primary care and performed: (1) Confirmatory factor analysis (CFA) to evaluate the established four-factor structure, (2) Analyses of reliability and measurement invariance, (3) Analyses of convergent and discriminant validity using the Montgomery–Asberg Depression Rating Scale, the depression subscales of the Beck Youth Inventories and the Revised Child Anxiety and Depression Scale, as well as the Patient Reported Outcome Measurements Information System, peer-relationships and physical activity item banks.

Results: Recruited participants (n = 536, 129 male and 407 female, mean age 16.45 years, SD = 2.47, range 12 − 22 years) had a variety of psychiatric diagnoses. We found support for the four-factor structure and acceptable to good reliability for the subscale and total scores. Convergent and discriminant validity were good. Measurement invariance was demonstrated for age, sex, and between the present sample and a previously published normative sample. The RADS-2-scores were significantly higher in the present sample than in the normative sample. In this clinical study, the Swedish RADS-2 demonstrated good validity and acceptable to good reliability. Our findings support the use of RADS-2 in Swedish clinical and research contexts.

Background: Studies of time trends of adolescent self-reported mental health suggest an increase of mental health symptoms globally. Unfortunately, several studies within the field have methodological problems, such as short time-period between measurements and different mental health measures over time. When estimating mental health through self-report measures, the measures need to be both valid and reliable. Reports from the Swedish National Board of Health and Welfare have shown that several self-report scales used in Child- and Adolescent Psychiatry lack validation in Swedish, and some are direct translations of adult self-report scales without proper age- adaption.

Aims: This thesis aims to add to previous knowledge regarding time trends of self-reported mental health among Swedish youth and to validate internationally used reliable self-report measures for use in Sweden.

Methods: In Study I, we investigated changes in self-reported mental health symptoms, both internalized and externalized, in two samples: The first sample in 1981 and the second in 2014, both samples including all grade 9 students of Luleå. The same composite self-report measures were used at both time points. In study II we translated and validated the Reynolds Adolescent Depression Scale second edition (RADS-2) with classical test theory. In study III, eight pediatric Patient-Reported Outcomes Measurement Information System (PROMIS®) item banks were translated to Swedish and culturally adapted using the Functional Assessment of Chronic Illness Therapy (FACIT) methodology. Study IV describes the item response theory (IRT) validation of two item banks, the PROMIS Pediatric Bank v2.0 – Anxiety and the PROMIS Pediatric Bank v2.0 - Depressive Symptoms, in a school- and Child- and Adolescent Psychiatry patient sample.

Results: Study I: There has been an increase in internalizing symptoms, especially among girls. Externalizing symptoms have decreased, especially among boys, and in 2014 compared to 1981; there is no significant difference between girls and boys. Study 2: The factor structure of the Swedish version of RADS-2 was confirmed and measurement invariance for sex and age-group. Reliability was acceptable to excellent for all subscales and the RADS-2 total scale. Concurrent, convergent, and discriminant validity was acceptable. Study III: All of the eight pediatric PROMIS item banks had translation issues to resolve. However, the translated and adapted versions were linguistically acceptable. Study IV: After removing a few items, the pediatric PROMIS item banks of anxiety and depressive symptoms showed good IRT fit statistics and no differential item functioning. A computer adaptive test (CAT) simulation supports the idea of the item banks to be appropriate to use with CAT.

Conclusion: This study supports the previous knowledge pointing to a rise in self-reported mental health, especially among girls. Valid and reliable diagnostic measures are needed in Child- and Adolescent Psychiatry. RADS-2 is an internationally established measure, and the Swedish version is now validated in a relatively large school sample. Item response theory has several advantages compared to classical test theory. We have translated eight PROMIS item banks to Swedish, and two of them, anxiety and depressive symptoms, have been validated with IRT in a school- and patient sample.

Depression in adolescents and young adults is an increasing global health concern. Available treatments are not sufficiently effective and relapse rates remain high. The novel group-treatment program “Training for Awareness, Resilience and Action” (TARA) targets specific mechanisms based on neuroscientific findings in adolescent depression. TARA is framed within the National Institute of Mental Health's Research Domain Criteria and has documented feasibility and preliminary efficacy in the treatment of adolescent depression. Since neurodevelopment continues well into the mid-twenties, age-adapted treatments are warranted also for young adults. Patients 15–22 years old, with either major depressive disorder (MDD) or persistent depressive disorder (PDD) according to the DSM-IV/5 or a rating >40 on the clinician rating scale Children's Depression Rating Scale—Revised (CDRS-R), will be recruited from specialized Child and Adolescent Psychiatry and local Youth-Clinics and randomized to either TARA or standard treatment, including but not limited to antidepressant medication and/or psychotherapy. Outcome measures will be obtained before randomization (T0), after 3 months of treatment (T1) and at 6-months- (T2) and 24-months- (T3) follow-up. Additionally, dose-response measures will be obtained weekly in the TARA-arm and measures for mediation-analysis will be obtained halfway through treatment (T0.5). Primary outcome measure is Reynolds Adolescent Depression Scale (RADS-2) score at T1. Secondary outcome measures include RADS-2 score at T2, Multidimensional Anxiety Scale for Children at T1 and T2, and CDRS-R at T1. Additional outcome measures include self-report measures of depression-associated symptoms, systemic bio-indicators of depression from blood and hair, heartrate variability, brain magnetic resonance imaging, as well as three-axial accelerometry for sleep-objectivization. Qualitative data will be gathered to reach a more comprehensive understanding of the factors affecting adolescents and young adults with depression and the extent to which the different treatments address these factors. In summary, this article describes the design, methods and statistical analysis plan for pragmatically evaluating the clinical effectiveness of TARA. This will be the first RCT to examine the effects of TARA compared to standard treatment for adolescents and young adults with MDD or PDD. We argue that this study will extend the current knowledgebase regarding the treatment of depression.

Background: This study is part of the Swedish initiative for the establishment of standardized, modern patient-reported measures for national use in Swedish healthcare. The goal was to translate and culturally adapt eight pediatric Patient-Reported Outcomes Measurement Information System (PROMIS®) item banks (anger, anxiety, depressive symptoms, family relationships, fatigue, pain interference, peer relationships and physical activity) into Swedish.

Methods: Authorization to translate all currently available pediatric PROMIS item banks (autumn, 2016) into Swedish was obtained from the PROMIS Health Organization. The translation followed the Functional Assessment of Chronic Illness Therapy translation recommendations with one major modification, which was the use of a bilingual multi-professional review workshop. The following steps were applied: translation, reconciliation, a two-day multi professional reviewer workshop, back translation, and cognitive debriefing with eleven children (8–17 years) before final review. The bilingual multi-professional review workshop provided a simultaneous, in-depth assessment from different professionals. The group consisted of questionnaire design experts, researchers experienced in using patient-reported measures in healthcare, linguists, and pediatric healthcare professionals.

Results: All item banks had translation issues that needed to be resolved. Twenty-four items (20.7%) needed resolution at the final review stage after cognitive debriefing. The issues with translations included 1. Lack of matching definitions with items across languages (6 items); 2. Problems related to language, vocabulary, and cultural differences (6 items); and 3. Difficulties in adaptation to age-appropriate language (12 items).

Conclusions: The translated and adapted versions of the eight Swedish pediatric PROMIS item banks are linguistically acceptable. The next stage will be cross-cultural validation studies in Sweden. Despite the fact that there are cultural differences between Sweden and the United States, our translation processes have successfully managed to address all issues. Expert review groups from already-established networks and processes regarding pediatric healthcare throughout the country will facilitate the future implementation of pediatric PROMIS item banks in Sweden.

Background: Due to the sharp global increase in prevalence of adolescent major depressive disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, we need internationally validated tools for multi-dimensional assessment. Reynolds Adolescent Depression Scale second edition (RADS-2) measures dysphoric mood, anhedonia/negative affect, negative self-evaluation and somatic complaints and is widely used internationally, but not yet available in Swedish.

Aim: The aim of this study is to test the psychometric characteristics of the Swedish version of RADS-2 in a normative sample.

Material and method: Data was gathered from junior and high school students in Northern Sweden (N = 637). We performed: 1. Confirmatory factor analysis to examine the 4-factor structure proposed by Reynolds, 2. Measurement invariance analysis for sex (girls, boys) and age group (12-15 years, 16-20 years). 3. Reliability testing and 4. Tests for concurrent, discriminant and convergent validity using Beck's Youth Inventories of Emotional and Social Impairment Depression and Anger subscales, the Patient Reported Outcome Measurements Information System, Anxiety and Friends subscales and the World Health Organization Wellness Index.

Results: The sample consisted of n = 637 students (n = 389 girls and n = 248 boys), mean age 15.73 (SD = 1.76); 12-20 years. The 4-factor structure was confirmed, as well as measurement invariance for sex and age group. Reliability was acceptable to excellent for all subscales and RADS-2 total scale. Concurrent, convergent and discriminant validity was good.

Conclusion: The Swedish version of RADS-2 showed acceptable reliability and validity in a Swedish normative sample.