ABSTRACT Forty consecutive participants in a comprehensive, behaviourally oriented coronary rehab... more ABSTRACT Forty consecutive participants in a comprehensive, behaviourally oriented coronary rehabilitation and secondary prevention program were followed for three years. Changes in depression (as measured with the Beck Depression Inventory) as well as the influence of baseline levels of depression on achieved changes in lifestyle behaviour and on rehabilitation and secondary prevention effects were analyzed. Subjects with moderate levels of baseline depression experienced short-term reductions of depression, which was maintained at the 12-month follow-up. Clinically depressed subjects experienced less positive results, with smaller immediate reductions as well as relapse to baseline levels after 12 months, specifically in non-physical, cognitive-affective depression symptoms. There were, however, no differences in lifestyle changes or in hospital treatment between groups with different pre-treatment depression levels. These results are discussed in relation to earlier research on the detrimental effects of depression on the prognosis of coronary artery disease.
Current research indicates that stress problems primarily could be conceptualized as deficiencies... more Current research indicates that stress problems primarily could be conceptualized as deficiencies in recovery and recuperation between stress periods. Accordingly, interventions should put more emphasis on this aspect. A group based intervention program focusing exclusively on recovery behavior in everyday life was evaluated in this quasi-experimental, waiting-list control group study, where the control group was also treated in a second phase. Thirty-two self-referred female subjects, considering themselves in need of treatment for stress related health problems, were available for analyzes. Fifteen of these constituted the first phase treatment group (INT), while the remaining 17 subjects were placed on waiting list (WLC). Adding a few late applicants leaved 20 subjects later treated in the second intervention phase. Significant and clinically meaningful positive effects emerged in the INT-compared to the WLC-group on recovery behaviors, stress-and recovery experiences, as well as on burn-out symptoms, worry, anxiety and depression. Secondary analyzes of all treated subjects indicated that the positive change the primary clinical endpoint was predicted by the increase in frequency of recovery behaviors and by the decrease in the worry level. Thus, the present intervention model merits further research with more rigorous experimental design as well as with follow-up assessments.
International Journal of Psychological Studies, 2015
The effects of computer-based Working Memory (WM) training using two training procedures were exa... more The effects of computer-based Working Memory (WM) training using two training procedures were examined among sixty-four primary-school children with Special Educational Needs (SEN). Measures of general cognitive ability, auditory and visuospatial working memory, arithmetic ability, and reading and writing skills were gathered and analysed. The referred group of SEN children predominantly had lower performance in auditory WM, arithmetics and reading and writing skills. The SEN children within respective school were randomized into either an active WM training group or a control group and ten schools participating in the WM training study were randomized into one of two different training conditions. At five schools the SEN children received regular WM training and at the other five schools the children received WM training with the addition of metacognitive strategy training. Results showed a significant difference in WM performance during training in favor of the metacognitive intervention. Furthermore, transfer effects occurred on visuospatial WM measures at posttest and at 6-month follow-up. Post-hoc tests showed that the effects pertained only to the metacognitive intervention. No transfer to arithmetic or reading and writing skills occurred after training in the two training conditions. Results were discussed in terms of metacognitive factors being important in optimizing performance in WM training, and that such factors should be taken into consideration when designing interventions for children with SEN. It is also suggested that in referral of children with SEN to remediation with WM training the WM profiles should be taken into consideration to a greater degree.
In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance ... more In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance of achieved behaviour and risk factor-related changes. Out of a consecutive population of 151 patients treated with percutaneous transluminal angioplasty under 65 years of age, 87 were randomly allocated to an intervention group (n=46) or to a control group (n=41). The programme started with a 4 week residential stay, which was focused on health education and the achievement of behaviour change. During the first year of follow-up, a maintenance programme included regular contacts with a nurse, while no further rehabilitative efforts were offered during the second year. One patient died (control). During the second year the proportion of hospitalized patients was lower in the intervention group (4% vs 20%;P<0.05). Patients in the intervention group improved several lifestyle dependent behaviours: diet (index at 0, 12 and 24 months): 10.5+/-3. 4, 12.9+/-2.5 and 12.4+/-2.6 in the intervention group (I) vs 10. 1+/-3.2, 10.7+/-3.0 and 11.8+/-3.2 in the control group (C);P<0.05, exercise sessions per week: 2.5+/-2.3, 4.5+/-1.9 and 4.4+/-2.1 (I) vs 3.1+/-2.2, 3.5+/-2.3 and 3.7+/-2.7 (C);P<0.05, and smoking; 18%, 6% and 9% (I) vs 12%, 21% and 18% (C);P<0.05. This corresponded to improvement in exercise capacity (0, 12 and 24 months): 156+/-42, 174+/-49 and 165+/-47 W (I) vs 164+/-40, 163+/-49 and 156+/-48 watts (C);P<0.05. There were no significant differences between the two groups with regard to serum cholesterol levels at 0 and 24 months: 5. 4+/-0.8 and 5.2+/-0.9 mmol. l(-1)(I) vs 5.4+/-1.0 and 4.9+/-0.9 mmol. l(-1)(C); ns, low density lipoprotein cholesterol level: 3.6+/-0.8 and 3.4+/-0.8 mmol. l(-1)(I) vs 3.7+/-0.9 and 3.3+/-0.7 mmol. l(-1)(C); ns, triglyceride level: 2.2+/-1.6 and 1.8+/-1.3 mmol. l(-1)(I) vs 2.2+/-1.4 and 1.6+/-0.6 mmol. l(-1)(C); ns, body mass index (0, 12 and 24 months): 27.5+/-4.5, 27.0+/-4.3 and 27.4+/- 4.5 kg. m(-2)(I) vs 26.8+/-2.8, 26.9+/-2.7 and 26.9+/- 3.2 kg. m(-2)(C); ns, waist/hip ratio or blood pressure. The two groups did not differ in quality of life, or psychological factors. Return to work after 12 and 24 months was 74% and 78% (I) vs 68% and 61% (C); ns. This rehabilitation programme influenced important lifestyle behaviour and reduced some, but not all, important risk factors
To examine the impact of a Cognitive Behavior Therapy (CBT)-based intervention on HbA(1c), self-c... more To examine the impact of a Cognitive Behavior Therapy (CBT)-based intervention on HbA(1c), self-care behaviors and psychosocial factors among poorly controlled adult type 1 diabetes patients. Ninety-four type 1 diabetes patients were randomly assigned to either an intervention group or a control group. The intervention was based on CBT and was mainly delivered in group format, but individual sessions were also included. All subjects were provided with a continuous glucose monitoring system (CGMS) during two 3-day periods. HbA(1c), self-care behaviors and psychosocial factors were measured up to 48 weeks. Significant differences were observed with respect to HbA(1c) (P<0.05), well-being (P<0.05), diabetes-related distress (P<0.01), frequency of blood glucose testing (P<0.05), avoidance of hypoglycemia (P<0.01), perceived stress (P<0.05), anxiety (P<0.05) and depression (P<0.05), all of which showed greater improvement in the intervention group compared with the control group. A significant difference (P<0.05) was registered with respect to non-severe hypoglycemia, which yielded a higher score in the intervention group. This CBT-based intervention appears to be a promising approach to diabetes self-management. Diabetes care may benefit from applying tools commonly used in CBT. For further scientific evaluation in clinical practice, there is a need for specially educated diabetes care teams, trained in the current approach, as well as cooperation between diabetes care teams and psychologists trained in CBT.
Focuses on diversities among women and men are rare, and few studies have focused on gender diffe... more Focuses on diversities among women and men are rare, and few studies have focused on gender differences in psychosocial factors and coronary heart disease. The present study is one of a series in which a wide range of psychosocial factors will be analysed with a focus on women. We compared women with men as regards the impact of educational level and occupational position on differences in perceived external stress. A questionnaire (The Stress Profile) was answered by 538 rehabilitation participants (97 women, 441 men), and a reference group (5308 women, 5177 men), aged 40-65 years. Generally, women reported a higher value of perceived external stress than men. Most interesting, however, are the patterns of differences that emerged when women and men were compared in different subgroups. Women with upper secondary school education and women in white-collar positions reported significantly higher levels of perceived external stress than men in the respective groups. When using common multivariate methods and adjusting for gender a great deal of information can be lost, and adjusting for gender makes it more difficult to find the true effect of exposures. It is only by regarding women and men separately that it is possible to link their very different working conditions and experience of stress to different health effects and vice versa.
The importance of depression in coronary artery disease (CAD) outcomes is being increasingly reco... more The importance of depression in coronary artery disease (CAD) outcomes is being increasingly recognized. The aim of this study was to investigate the power of depression as a predictor of return to work, both at full time and at reduced working hours, within 12 months of participation in a behaviorally oriented rehabilitation program in Sweden. The sample comprised 198 employed patients who had recently experienced an acute myocardial infarction (AMI, n=85), or had been treated with coronary by-pass surgery (CABG, n=73) or coronary angioplasty (PTCA, n=40). The results showed that clinical depression before intervention (>or=16 as measured by the Beck Depression Inventory) exerted a great influence on work resumption both at full-time (odds ratio 9.43, CI=3.15-28.21) and at reduced working-hours (odds ratio 5.44, CI=1.60-18.53), while mild depression (BDI 10-15) influenced only work resumption at full-time (odds ratio 2.89, CI=1.08-7.70). Education and, at full-time hours, age also predicted work resumption. This highlights the importance of depressive symptoms in relation to return to work after a CAD event. More research is needed in order to elaborate the degree to which treatment of depression enhances work resumption rates.
OBJECTIVE: The objective of this study was to evaluate the psychometric properties of the Swedish... more OBJECTIVE: The objective of this study was to evaluate the psychometric properties of the Swedish version of the Hypoglycaemia Fear Survey (Swe-HFS) for use among Swedish-speaking patients with type 1 diabetes. METHODS: The HFS was translated using the ...
A group of 93 coronary patients recently treated with percutaneous transluminal coronary angiopla... more A group of 93 coronary patients recently treated with percutaneous transluminal coronary angioplasty (PTCA) were randomly assigned to either an intervention or a control group. Subjects in the intervention group participated in a comprehensive behaviorally oriented program aimed at achieving significant long-term changes in risk factor-related lifestyle behavior. Assessments of lifestyle behaviors, psychological factors, biological risk factors, and rehabilitation as well as secondary prevention endpoints were carried out, at inclusion and after 12 months. Results showed that the intervention patients, as compared with controls, improved significantly on measures assessing smoking, exercise, and diet habits. These self-rated changes were confirmed by weight reductions and improved exercise capacity, as well as by between-group differences in subclinical chest pain during an exercise test. However, few effects were found on the different psychological variables, as well as on morbidity or return to work.
Stress is becoming more significant for women, along with the increasing number of women in the w... more Stress is becoming more significant for women, along with the increasing number of women in the workforce. The present study compared women with respect to burnout and coping abilities, and related to the impact of educational level on differences in coping strategies. Women with coronary heart disease reported a higher level of burnout and had the highest scores demonstrating lack of coping, which indicates lesser coping abilities. Differences concerning strain reduction, self-control and emotional distancing are discussed in terms of living conditions. We also discuss that in order to optimize the outcome of rehabilitation and prevention we need more research on women, of women and especially from women's point of view.
International Journal of Behavioral Medicine, 2003
The aim of this study was to compare the effects of residential multifactorial cardiac rehabilita... more The aim of this study was to compare the effects of residential multifactorial cardiac rehabilitation, outpatient multifactorial rehabilitation, stress management, and standard coronary rehabilitation, on cardiac risk reduction. Out of 144 eligible male patients recently treated with percantaneous transluminal coronary angiography (PTCA), coronary artery bypass graft (CABG), or acute myocardial infarction (AMI), 132 were randomized into this study. All interventions covered a 12-month active intervention, intense during the first months and subsequently leveled out. Main assessments were performed before randomization and after the intervention. Patients offered behavioral rehabilitation showed improved selfreported healthy diet habits and exercise frequency, and higher internal locus of control. Although blood lipids, exercise capacity, body mass, anxiety, depression, and Type A scores were changed in the expected direction, no significant difference emerged between active intervention and the standard care condition. Standard care of today appears to have great potential in particular if supplemented with some kind of stress management.
European Journal of Cardiovascular Prevention & Rehabilitation, 2001
Few studies have focused on risk factors in women's lives concerning psychosocial factors... more Few studies have focused on risk factors in women's lives concerning psychosocial factors and coronary heart disease (CHD). The present study is one of a series in which a wide range of psychosocial factors will be analysed with a focus on women. Women and men have been compared with respect to sensitivity to psychosocial risk factors regarding CHD. The importance of psychosocial risk factors for women, compared with biomedical risk factors has also been studied. A questionnaire (The Stress Profile) was answered by 538 rehabilitation participants (97 women, 441 men) and a reference group (5308 women, 5177 men), aged 40-65 years. Psychosocial factors were investigated using means and b-coefficients. Comparisons between psychosocial and biomedical risk factors were made, with respect to the product of the beta-coefficient and the standard deviation for each compared risk factor. Significant differences appeared concerning five areas: work content, workload and control, physical stress reactions, emotional stress reactions and burnout. All showed that the relative sensitivity was larger for women than for men. Predictive psychosocial risk factors for women with respect to CHD were physical stress reactions, emotional stress reactions, burnout, family relationships and daily hassles/satisfactions, and they were on approximately the same level as biomedical risk factors. Women appear to be more sensitive than men with respect to psychosocial risk factors for CHD, and the predictive ability of psychosocial risk factors shows great importance. Actions against unhealthy psychosocial conditions are recommended. Both presumptive CHD patients and others might benefit from preventive actions, and since women are more sensitive they will probably gain more than men.
In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance ... more In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance of achieved behaviour and risk factor-related changes. Out of a consecutive population of 151 patients treated with percutaneous transluminal angioplasty under 65 years of age, 87 were randomly allocated to an intervention group (n=46) or to a control group (n=41). The programme started with a 4 week residential stay, which was focused on health education and the achievement of behaviour change. During the first year of follow-up, a maintenance programme included regular contacts with a nurse, while no further rehabilitative efforts were offered during the second year. One patient died (control). During the second year the proportion of hospitalized patients was lower in the intervention group (4% vs 20%;P<0.05). Patients in the intervention group improved several lifestyle dependent behaviours: diet (index at 0, 12 and 24 months): 10.5+/-3. 4, 12.9+/-2.5 and 12.4+/-2.6 in the intervention group (I) vs 10. 1+/-3.2, 10.7+/-3.0 and 11.8+/-3.2 in the control group (C);P<0.05, exercise sessions per week: 2.5+/-2.3, 4.5+/-1.9 and 4.4+/-2.1 (I) vs 3.1+/-2.2, 3.5+/-2.3 and 3.7+/-2.7 (C);P<0.05, and smoking; 18%, 6% and 9% (I) vs 12%, 21% and 18% (C);P<0.05. This corresponded to improvement in exercise capacity (0, 12 and 24 months): 156+/-42, 174+/-49 and 165+/-47 W (I) vs 164+/-40, 163+/-49 and 156+/-48 watts (C);P<0.05. There were no significant differences between the two groups with regard to serum cholesterol levels at 0 and 24 months: 5. 4+/-0.8 and 5.2+/-0.9 mmol. l(-1)(I) vs 5.4+/-1.0 and 4.9+/-0.9 mmol. l(-1)(C); ns, low density lipoprotein cholesterol level: 3.6+/-0.8 and 3.4+/-0.8 mmol. l(-1)(I) vs 3.7+/-0.9 and 3.3+/-0.7 mmol. l(-1)(C); ns, triglyceride level: 2.2+/-1.6 and 1.8+/-1.3 mmol. l(-1)(I) vs 2.2+/-1.4 and 1.6+/-0.6 mmol. l(-1)(C); ns, body mass index (0, 12 and 24 months): 27.5+/-4.5, 27.0+/-4.3 and 27.4+/- 4.5 kg. m(-2)(I) vs 26.8+/-2.8, 26.9+/-2.7 and 26.9+/- 3.2 kg. m(-2)(C); ns, waist/hip ratio or blood pressure. The two groups did not differ in quality of life, or psychological factors. Return to work after 12 and 24 months was 74% and 78% (I) vs 68% and 61% (C); ns. This rehabilitation programme influenced important lifestyle behaviour and reduced some, but not all, important risk factors
The aim of this study was to examine the fear of hypoglycaemia and its association with demograph... more The aim of this study was to examine the fear of hypoglycaemia and its association with demographic and disease-specific variables in a large and unselective population of adult patients with Type 1 diabetes. Questionnaires were sent by post to all patients with Type 1 diabetes who were identified in the local diabetes registries of two hospitals in Stockholm, Sweden (n=1387). Fear of hypoglycaemia was measured using the Swedish Hypoglycaemia Fear Survey, the Worry subscale and the Aloneness subscale. Demographic variables and disease-specific factors were collected from patients' self reports and medical records. Univariate analysis and multiple stepwise linear regression analysis were used in the statistical analyses of the data. Seven hundred and sixty-four (55%) patients participated in the study (mean age 43.3 years and mean HbA(1c) 7.0%, normal <5.0%). The Hypoglycaemia Fear Survey - Worry subscale was significantly associated with frequency of severe hypoglycaemia, number of symptoms during mild hypoglycaemia, gender, hypoglycaemic symptoms during hyperglycaemia and hypoglycaemic unawareness. The Hypoglycaemia Fear Survey - Aloneness subscale was significantly associated with frequency of severe hypoglycaemia, number of symptoms during mild hypoglycaemia, gender, frequency of mild hypoglycaemia, HbA(1c) , hypoglycaemic unawareness and visits to the emergency room because of severe hypoglycaemia. Fear of hypoglycaemia proved to be more prevalent in females and indicated a different pattern between genders in relation to factors associated with fear of hypoglycaemia. This study identifies the frequency of severe hypoglycaemia as the most important factor associated with fear of hypoglycaemia. Moreover, for the first time, we document gender differences in fear of hypoglycaemia, suggesting that females are more affected by fear of hypoglycaemia than men.
To describe experience from a behavioural medicine intervention among poorly controlled adult typ... more To describe experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients, in terms of feasibility, predictors and associations of improved glycaemic control. Data were collected on 94 poorly controlled adult type 1 diabetes patients who were randomised to a study evaluating the effects of a behavioural medicine intervention. Statistics covered descriptive and comparison analysis. Backward stepwise regression models were used for predictive and agreement analyses involving socio-demographic and medical factors, as well as measures of diabetes self-efficacy (DES), diabetes locus of control (DLOC), self-care activities (SDSCA), diabetes-related distress (Swe-PAID-20), fear of hypoglycaemia (HFS), well-being (WBQ), depression (HAD) and perceived stress (PSS). The participation rate in the study was 41% and attrition was 24%. Of those patients actually participating in the behavioural medicine intervention, 13% withdrew. From the regression models no predictors or associations of improvement in HbA(1c) were found. The programme proved to be feasible in terms of design and methods. However, no clear pattern was found regarding predictors or associations of improved metabolic control as the response to the intervention. Further research in this area is called for.
HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997: 96: 281-286. 0 Munk... more HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997: 96: 281-286. 0 Munksgaard 1997.
Objective: The aims of this study were to investigate the time-course of depressive mood in patie... more Objective: The aims of this study were to investigate the time-course of depressive mood in patients with coronary artery disease during a secondary prevention rehabilitation program, and to analyse how different pre-treatment levels of depressive mood during a treatment phase were related to the degree of lifestyle change at 36 months follow-up. Subjects: The study group comprised 109 of the original 183 consecutive coronary artery disease patients (91 male and 18 female) of whom 48 recently had experienced an acute myocardial infarction, 36 had been treated with coronary bypass surgery, 13 with percutaneous transluminal coronary angioplasty, and 12 had angina pectoris that had not been invasively treated. The subjects were divided into 3 subgroups based on their pre-treatment level of depressive mood.
ABSTRACT Forty consecutive participants in a comprehensive, behaviourally oriented coronary rehab... more ABSTRACT Forty consecutive participants in a comprehensive, behaviourally oriented coronary rehabilitation and secondary prevention program were followed for three years. Changes in depression (as measured with the Beck Depression Inventory) as well as the influence of baseline levels of depression on achieved changes in lifestyle behaviour and on rehabilitation and secondary prevention effects were analyzed. Subjects with moderate levels of baseline depression experienced short-term reductions of depression, which was maintained at the 12-month follow-up. Clinically depressed subjects experienced less positive results, with smaller immediate reductions as well as relapse to baseline levels after 12 months, specifically in non-physical, cognitive-affective depression symptoms. There were, however, no differences in lifestyle changes or in hospital treatment between groups with different pre-treatment depression levels. These results are discussed in relation to earlier research on the detrimental effects of depression on the prognosis of coronary artery disease.
Current research indicates that stress problems primarily could be conceptualized as deficiencies... more Current research indicates that stress problems primarily could be conceptualized as deficiencies in recovery and recuperation between stress periods. Accordingly, interventions should put more emphasis on this aspect. A group based intervention program focusing exclusively on recovery behavior in everyday life was evaluated in this quasi-experimental, waiting-list control group study, where the control group was also treated in a second phase. Thirty-two self-referred female subjects, considering themselves in need of treatment for stress related health problems, were available for analyzes. Fifteen of these constituted the first phase treatment group (INT), while the remaining 17 subjects were placed on waiting list (WLC). Adding a few late applicants leaved 20 subjects later treated in the second intervention phase. Significant and clinically meaningful positive effects emerged in the INT-compared to the WLC-group on recovery behaviors, stress-and recovery experiences, as well as on burn-out symptoms, worry, anxiety and depression. Secondary analyzes of all treated subjects indicated that the positive change the primary clinical endpoint was predicted by the increase in frequency of recovery behaviors and by the decrease in the worry level. Thus, the present intervention model merits further research with more rigorous experimental design as well as with follow-up assessments.
International Journal of Psychological Studies, 2015
The effects of computer-based Working Memory (WM) training using two training procedures were exa... more The effects of computer-based Working Memory (WM) training using two training procedures were examined among sixty-four primary-school children with Special Educational Needs (SEN). Measures of general cognitive ability, auditory and visuospatial working memory, arithmetic ability, and reading and writing skills were gathered and analysed. The referred group of SEN children predominantly had lower performance in auditory WM, arithmetics and reading and writing skills. The SEN children within respective school were randomized into either an active WM training group or a control group and ten schools participating in the WM training study were randomized into one of two different training conditions. At five schools the SEN children received regular WM training and at the other five schools the children received WM training with the addition of metacognitive strategy training. Results showed a significant difference in WM performance during training in favor of the metacognitive intervention. Furthermore, transfer effects occurred on visuospatial WM measures at posttest and at 6-month follow-up. Post-hoc tests showed that the effects pertained only to the metacognitive intervention. No transfer to arithmetic or reading and writing skills occurred after training in the two training conditions. Results were discussed in terms of metacognitive factors being important in optimizing performance in WM training, and that such factors should be taken into consideration when designing interventions for children with SEN. It is also suggested that in referral of children with SEN to remediation with WM training the WM profiles should be taken into consideration to a greater degree.
In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance ... more In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance of achieved behaviour and risk factor-related changes. Out of a consecutive population of 151 patients treated with percutaneous transluminal angioplasty under 65 years of age, 87 were randomly allocated to an intervention group (n=46) or to a control group (n=41). The programme started with a 4 week residential stay, which was focused on health education and the achievement of behaviour change. During the first year of follow-up, a maintenance programme included regular contacts with a nurse, while no further rehabilitative efforts were offered during the second year. One patient died (control). During the second year the proportion of hospitalized patients was lower in the intervention group (4% vs 20%;P<0.05). Patients in the intervention group improved several lifestyle dependent behaviours: diet (index at 0, 12 and 24 months): 10.5+/-3. 4, 12.9+/-2.5 and 12.4+/-2.6 in the intervention group (I) vs 10. 1+/-3.2, 10.7+/-3.0 and 11.8+/-3.2 in the control group (C);P<0.05, exercise sessions per week: 2.5+/-2.3, 4.5+/-1.9 and 4.4+/-2.1 (I) vs 3.1+/-2.2, 3.5+/-2.3 and 3.7+/-2.7 (C);P<0.05, and smoking; 18%, 6% and 9% (I) vs 12%, 21% and 18% (C);P<0.05. This corresponded to improvement in exercise capacity (0, 12 and 24 months): 156+/-42, 174+/-49 and 165+/-47 W (I) vs 164+/-40, 163+/-49 and 156+/-48 watts (C);P<0.05. There were no significant differences between the two groups with regard to serum cholesterol levels at 0 and 24 months: 5. 4+/-0.8 and 5.2+/-0.9 mmol. l(-1)(I) vs 5.4+/-1.0 and 4.9+/-0.9 mmol. l(-1)(C); ns, low density lipoprotein cholesterol level: 3.6+/-0.8 and 3.4+/-0.8 mmol. l(-1)(I) vs 3.7+/-0.9 and 3.3+/-0.7 mmol. l(-1)(C); ns, triglyceride level: 2.2+/-1.6 and 1.8+/-1.3 mmol. l(-1)(I) vs 2.2+/-1.4 and 1.6+/-0.6 mmol. l(-1)(C); ns, body mass index (0, 12 and 24 months): 27.5+/-4.5, 27.0+/-4.3 and 27.4+/- 4.5 kg. m(-2)(I) vs 26.8+/-2.8, 26.9+/-2.7 and 26.9+/- 3.2 kg. m(-2)(C); ns, waist/hip ratio or blood pressure. The two groups did not differ in quality of life, or psychological factors. Return to work after 12 and 24 months was 74% and 78% (I) vs 68% and 61% (C); ns. This rehabilitation programme influenced important lifestyle behaviour and reduced some, but not all, important risk factors
To examine the impact of a Cognitive Behavior Therapy (CBT)-based intervention on HbA(1c), self-c... more To examine the impact of a Cognitive Behavior Therapy (CBT)-based intervention on HbA(1c), self-care behaviors and psychosocial factors among poorly controlled adult type 1 diabetes patients. Ninety-four type 1 diabetes patients were randomly assigned to either an intervention group or a control group. The intervention was based on CBT and was mainly delivered in group format, but individual sessions were also included. All subjects were provided with a continuous glucose monitoring system (CGMS) during two 3-day periods. HbA(1c), self-care behaviors and psychosocial factors were measured up to 48 weeks. Significant differences were observed with respect to HbA(1c) (P<0.05), well-being (P<0.05), diabetes-related distress (P<0.01), frequency of blood glucose testing (P<0.05), avoidance of hypoglycemia (P<0.01), perceived stress (P<0.05), anxiety (P<0.05) and depression (P<0.05), all of which showed greater improvement in the intervention group compared with the control group. A significant difference (P<0.05) was registered with respect to non-severe hypoglycemia, which yielded a higher score in the intervention group. This CBT-based intervention appears to be a promising approach to diabetes self-management. Diabetes care may benefit from applying tools commonly used in CBT. For further scientific evaluation in clinical practice, there is a need for specially educated diabetes care teams, trained in the current approach, as well as cooperation between diabetes care teams and psychologists trained in CBT.
Focuses on diversities among women and men are rare, and few studies have focused on gender diffe... more Focuses on diversities among women and men are rare, and few studies have focused on gender differences in psychosocial factors and coronary heart disease. The present study is one of a series in which a wide range of psychosocial factors will be analysed with a focus on women. We compared women with men as regards the impact of educational level and occupational position on differences in perceived external stress. A questionnaire (The Stress Profile) was answered by 538 rehabilitation participants (97 women, 441 men), and a reference group (5308 women, 5177 men), aged 40-65 years. Generally, women reported a higher value of perceived external stress than men. Most interesting, however, are the patterns of differences that emerged when women and men were compared in different subgroups. Women with upper secondary school education and women in white-collar positions reported significantly higher levels of perceived external stress than men in the respective groups. When using common multivariate methods and adjusting for gender a great deal of information can be lost, and adjusting for gender makes it more difficult to find the true effect of exposures. It is only by regarding women and men separately that it is possible to link their very different working conditions and experience of stress to different health effects and vice versa.
The importance of depression in coronary artery disease (CAD) outcomes is being increasingly reco... more The importance of depression in coronary artery disease (CAD) outcomes is being increasingly recognized. The aim of this study was to investigate the power of depression as a predictor of return to work, both at full time and at reduced working hours, within 12 months of participation in a behaviorally oriented rehabilitation program in Sweden. The sample comprised 198 employed patients who had recently experienced an acute myocardial infarction (AMI, n=85), or had been treated with coronary by-pass surgery (CABG, n=73) or coronary angioplasty (PTCA, n=40). The results showed that clinical depression before intervention (>or=16 as measured by the Beck Depression Inventory) exerted a great influence on work resumption both at full-time (odds ratio 9.43, CI=3.15-28.21) and at reduced working-hours (odds ratio 5.44, CI=1.60-18.53), while mild depression (BDI 10-15) influenced only work resumption at full-time (odds ratio 2.89, CI=1.08-7.70). Education and, at full-time hours, age also predicted work resumption. This highlights the importance of depressive symptoms in relation to return to work after a CAD event. More research is needed in order to elaborate the degree to which treatment of depression enhances work resumption rates.
OBJECTIVE: The objective of this study was to evaluate the psychometric properties of the Swedish... more OBJECTIVE: The objective of this study was to evaluate the psychometric properties of the Swedish version of the Hypoglycaemia Fear Survey (Swe-HFS) for use among Swedish-speaking patients with type 1 diabetes. METHODS: The HFS was translated using the ...
A group of 93 coronary patients recently treated with percutaneous transluminal coronary angiopla... more A group of 93 coronary patients recently treated with percutaneous transluminal coronary angioplasty (PTCA) were randomly assigned to either an intervention or a control group. Subjects in the intervention group participated in a comprehensive behaviorally oriented program aimed at achieving significant long-term changes in risk factor-related lifestyle behavior. Assessments of lifestyle behaviors, psychological factors, biological risk factors, and rehabilitation as well as secondary prevention endpoints were carried out, at inclusion and after 12 months. Results showed that the intervention patients, as compared with controls, improved significantly on measures assessing smoking, exercise, and diet habits. These self-rated changes were confirmed by weight reductions and improved exercise capacity, as well as by between-group differences in subclinical chest pain during an exercise test. However, few effects were found on the different psychological variables, as well as on morbidity or return to work.
Stress is becoming more significant for women, along with the increasing number of women in the w... more Stress is becoming more significant for women, along with the increasing number of women in the workforce. The present study compared women with respect to burnout and coping abilities, and related to the impact of educational level on differences in coping strategies. Women with coronary heart disease reported a higher level of burnout and had the highest scores demonstrating lack of coping, which indicates lesser coping abilities. Differences concerning strain reduction, self-control and emotional distancing are discussed in terms of living conditions. We also discuss that in order to optimize the outcome of rehabilitation and prevention we need more research on women, of women and especially from women's point of view.
International Journal of Behavioral Medicine, 2003
The aim of this study was to compare the effects of residential multifactorial cardiac rehabilita... more The aim of this study was to compare the effects of residential multifactorial cardiac rehabilitation, outpatient multifactorial rehabilitation, stress management, and standard coronary rehabilitation, on cardiac risk reduction. Out of 144 eligible male patients recently treated with percantaneous transluminal coronary angiography (PTCA), coronary artery bypass graft (CABG), or acute myocardial infarction (AMI), 132 were randomized into this study. All interventions covered a 12-month active intervention, intense during the first months and subsequently leveled out. Main assessments were performed before randomization and after the intervention. Patients offered behavioral rehabilitation showed improved selfreported healthy diet habits and exercise frequency, and higher internal locus of control. Although blood lipids, exercise capacity, body mass, anxiety, depression, and Type A scores were changed in the expected direction, no significant difference emerged between active intervention and the standard care condition. Standard care of today appears to have great potential in particular if supplemented with some kind of stress management.
European Journal of Cardiovascular Prevention & Rehabilitation, 2001
Few studies have focused on risk factors in women's lives concerning psychosocial factors... more Few studies have focused on risk factors in women's lives concerning psychosocial factors and coronary heart disease (CHD). The present study is one of a series in which a wide range of psychosocial factors will be analysed with a focus on women. Women and men have been compared with respect to sensitivity to psychosocial risk factors regarding CHD. The importance of psychosocial risk factors for women, compared with biomedical risk factors has also been studied. A questionnaire (The Stress Profile) was answered by 538 rehabilitation participants (97 women, 441 men) and a reference group (5308 women, 5177 men), aged 40-65 years. Psychosocial factors were investigated using means and b-coefficients. Comparisons between psychosocial and biomedical risk factors were made, with respect to the product of the beta-coefficient and the standard deviation for each compared risk factor. Significant differences appeared concerning five areas: work content, workload and control, physical stress reactions, emotional stress reactions and burnout. All showed that the relative sensitivity was larger for women than for men. Predictive psychosocial risk factors for women with respect to CHD were physical stress reactions, emotional stress reactions, burnout, family relationships and daily hassles/satisfactions, and they were on approximately the same level as biomedical risk factors. Women appear to be more sensitive than men with respect to psychosocial risk factors for CHD, and the predictive ability of psychosocial risk factors shows great importance. Actions against unhealthy psychosocial conditions are recommended. Both presumptive CHD patients and others might benefit from preventive actions, and since women are more sensitive they will probably gain more than men.
In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance ... more In a multifactorial lifestyle behaviour programme, of 2 years duration, to study the maintenance of achieved behaviour and risk factor-related changes. Out of a consecutive population of 151 patients treated with percutaneous transluminal angioplasty under 65 years of age, 87 were randomly allocated to an intervention group (n=46) or to a control group (n=41). The programme started with a 4 week residential stay, which was focused on health education and the achievement of behaviour change. During the first year of follow-up, a maintenance programme included regular contacts with a nurse, while no further rehabilitative efforts were offered during the second year. One patient died (control). During the second year the proportion of hospitalized patients was lower in the intervention group (4% vs 20%;P<0.05). Patients in the intervention group improved several lifestyle dependent behaviours: diet (index at 0, 12 and 24 months): 10.5+/-3. 4, 12.9+/-2.5 and 12.4+/-2.6 in the intervention group (I) vs 10. 1+/-3.2, 10.7+/-3.0 and 11.8+/-3.2 in the control group (C);P<0.05, exercise sessions per week: 2.5+/-2.3, 4.5+/-1.9 and 4.4+/-2.1 (I) vs 3.1+/-2.2, 3.5+/-2.3 and 3.7+/-2.7 (C);P<0.05, and smoking; 18%, 6% and 9% (I) vs 12%, 21% and 18% (C);P<0.05. This corresponded to improvement in exercise capacity (0, 12 and 24 months): 156+/-42, 174+/-49 and 165+/-47 W (I) vs 164+/-40, 163+/-49 and 156+/-48 watts (C);P<0.05. There were no significant differences between the two groups with regard to serum cholesterol levels at 0 and 24 months: 5. 4+/-0.8 and 5.2+/-0.9 mmol. l(-1)(I) vs 5.4+/-1.0 and 4.9+/-0.9 mmol. l(-1)(C); ns, low density lipoprotein cholesterol level: 3.6+/-0.8 and 3.4+/-0.8 mmol. l(-1)(I) vs 3.7+/-0.9 and 3.3+/-0.7 mmol. l(-1)(C); ns, triglyceride level: 2.2+/-1.6 and 1.8+/-1.3 mmol. l(-1)(I) vs 2.2+/-1.4 and 1.6+/-0.6 mmol. l(-1)(C); ns, body mass index (0, 12 and 24 months): 27.5+/-4.5, 27.0+/-4.3 and 27.4+/- 4.5 kg. m(-2)(I) vs 26.8+/-2.8, 26.9+/-2.7 and 26.9+/- 3.2 kg. m(-2)(C); ns, waist/hip ratio or blood pressure. The two groups did not differ in quality of life, or psychological factors. Return to work after 12 and 24 months was 74% and 78% (I) vs 68% and 61% (C); ns. This rehabilitation programme influenced important lifestyle behaviour and reduced some, but not all, important risk factors
The aim of this study was to examine the fear of hypoglycaemia and its association with demograph... more The aim of this study was to examine the fear of hypoglycaemia and its association with demographic and disease-specific variables in a large and unselective population of adult patients with Type 1 diabetes. Questionnaires were sent by post to all patients with Type 1 diabetes who were identified in the local diabetes registries of two hospitals in Stockholm, Sweden (n=1387). Fear of hypoglycaemia was measured using the Swedish Hypoglycaemia Fear Survey, the Worry subscale and the Aloneness subscale. Demographic variables and disease-specific factors were collected from patients' self reports and medical records. Univariate analysis and multiple stepwise linear regression analysis were used in the statistical analyses of the data. Seven hundred and sixty-four (55%) patients participated in the study (mean age 43.3 years and mean HbA(1c) 7.0%, normal <5.0%). The Hypoglycaemia Fear Survey - Worry subscale was significantly associated with frequency of severe hypoglycaemia, number of symptoms during mild hypoglycaemia, gender, hypoglycaemic symptoms during hyperglycaemia and hypoglycaemic unawareness. The Hypoglycaemia Fear Survey - Aloneness subscale was significantly associated with frequency of severe hypoglycaemia, number of symptoms during mild hypoglycaemia, gender, frequency of mild hypoglycaemia, HbA(1c) , hypoglycaemic unawareness and visits to the emergency room because of severe hypoglycaemia. Fear of hypoglycaemia proved to be more prevalent in females and indicated a different pattern between genders in relation to factors associated with fear of hypoglycaemia. This study identifies the frequency of severe hypoglycaemia as the most important factor associated with fear of hypoglycaemia. Moreover, for the first time, we document gender differences in fear of hypoglycaemia, suggesting that females are more affected by fear of hypoglycaemia than men.
To describe experience from a behavioural medicine intervention among poorly controlled adult typ... more To describe experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients, in terms of feasibility, predictors and associations of improved glycaemic control. Data were collected on 94 poorly controlled adult type 1 diabetes patients who were randomised to a study evaluating the effects of a behavioural medicine intervention. Statistics covered descriptive and comparison analysis. Backward stepwise regression models were used for predictive and agreement analyses involving socio-demographic and medical factors, as well as measures of diabetes self-efficacy (DES), diabetes locus of control (DLOC), self-care activities (SDSCA), diabetes-related distress (Swe-PAID-20), fear of hypoglycaemia (HFS), well-being (WBQ), depression (HAD) and perceived stress (PSS). The participation rate in the study was 41% and attrition was 24%. Of those patients actually participating in the behavioural medicine intervention, 13% withdrew. From the regression models no predictors or associations of improvement in HbA(1c) were found. The programme proved to be feasible in terms of design and methods. However, no clear pattern was found regarding predictors or associations of improved metabolic control as the response to the intervention. Further research in this area is called for.
HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997: 96: 281-286. 0 Munk... more HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997: 96: 281-286. 0 Munksgaard 1997.
Objective: The aims of this study were to investigate the time-course of depressive mood in patie... more Objective: The aims of this study were to investigate the time-course of depressive mood in patients with coronary artery disease during a secondary prevention rehabilitation program, and to analyse how different pre-treatment levels of depressive mood during a treatment phase were related to the degree of lifestyle change at 36 months follow-up. Subjects: The study group comprised 109 of the original 183 consecutive coronary artery disease patients (91 male and 18 female) of whom 48 recently had experienced an acute myocardial infarction, 36 had been treated with coronary bypass surgery, 13 with percutaneous transluminal coronary angioplasty, and 12 had angina pectoris that had not been invasively treated. The subjects were divided into 3 subgroups based on their pre-treatment level of depressive mood.
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Papers by Jan Lisspers