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1.  Communication and mental health in general practice: physicians' self-perceived learning needs and self-efficacy 
Mental Health in Family Medicine  2012;9(3):201-209.
Background General practitioners (GPs) often see patients presenting with mental health problems, but their training regarding mental health treatment varies. GPs' communication skills are of particular importance in these consultations, and communication skills training of GPs has been found to improve patients' mental health. To tailor a communication skills training by basing it on GPs' learning needs and self-efficacy, thereby maximising learning, we conducted a questionnaire study.
Objective To measure GPs' self-perceived needs regarding communication with and treatment of mental health patients.
Methods GPs in training for specialist general practice were given a questionnaire on communication and mental health in general practice. The questionnaire measured prevalence, referring practices, self-efficacy and self-perceived learning need regarding mental health treatment and communication skills, as well as interest in attending training.
Results A majority of GPs in our sample was interested in training on communication skills and mental health treatment. However, they reported moderate learning needs and high confidence on the different measures. GPs reported highest learning needs regarding specific communication skills and treatment of the most common mental health problems. At the same time, they reported highest self-efficacy in treating the same disorders. They also reported high confidence in communication skills.
Conclusion Despite being confident, GPs in this sample recognise the need for specific skills in consultations with patients with mental health problems, but may underestimate the importance of general communication skills. These results are informative when designing training for GPs in communication and mental health.
PMCID: PMC3622912  PMID: 23997826
communication; general practice; mental health
2.  A Smartphone-Based Intervention With Diaries and Therapist Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain. Part 2: 11-month Follow-up Results of a Randomized Trial 
Internet-based interventions are increasingly used to support self-management of individuals with chronic illnesses. Web-based interventions may also be effective in enhancing self-management for individuals with chronic pain, but little is known about long-term effects. Research on Web-based interventions to support self-management following participation in pain management programs is limited.
The aim is to examine the long-term effects of a 4-week smartphone-intervention with diaries and therapist-written feedback following an inpatient chronic pain rehabilitation program, previously found to be effective at short-term and 5-month follow-ups.
140 women with chronic widespread pain, participating in a 4-week inpatient rehabilitation program, were randomized into two groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of one face-to-face individual session and 4 weeks of written communication via a smartphone, consisting of three diaries daily to elicit pain-related thoughts, feelings, and activities, as well as daily personalized written feedback based on cognitive behavioral principles from a therapist. Both groups were given access to an informational website to promote constructive self-management. Outcomes were measured with self-reported paper-and-pencil format questionnaires with catastrophizing as the primary outcome measure. Secondary outcomes included daily functioning and symptom levels, acceptance of pain, and emotional distress.
By the 11-month follow-up, the favorable between-group differences previously reported post-intervention and at 5-month follow-up on catastrophizing, acceptance, functioning, and symptom level were no longer evident (P>.10). However, there was more improvement in catastrophizing scores during the follow-up period in the intervention group (M=-2.36, SD 8.41) compared to the control group (M=.40, SD 7.20), P=.045. Also, per protocol within-group analysis showed a small positive effect (Cohen’s d=.33) on catastrophizing in the intervention group (P=.04) and no change in the control group from the smartphone intervention baseline to 11-month follow-up. A positive effect (Cohen’s d=.73) on acceptance was found within the intervention group (P<.001) but not in the control group. Small to large negative effects were found within the control group on functioning and symptom levels, emotional distress, and fatigue (P=.05) from the intervention baseline to the 11-month follow-up.
The long-term results of this randomized trial are ambiguous. No significant between-group effect was found on the study variables at 11-month follow-up. However, the within-group analyses, comparing the baseline for the smartphone intervention to the 11-month data, indicated changes in the desired direction in catastrophizing and acceptance in the intervention group but not within the control group. This study provides modest evidence supporting the long-term effect of the intervention.
Trial Registration NCT01236209; (Archived by WebCite at
PMCID: PMC3636011  PMID: 23538392
Internet-based personalized feedback; widespread chronic pain; fibromyalgia; pain management; eHealth; smartphone; Internet; cognitive therapy; catastrophization
3.  Cancer patients’ experiences of using an Interactive Health Communication Application (IHCA) 
Interactive Health Communication Applications (IHCAs) are increasingly used in health care. Studies document that IHCAs provide patients with knowledge and social support, enhance self- efficacy and can improve behavioural and clinical outcomes. However, research exploring patients’ experiences of using IHCAs has been scarce. The aim of this study was to explore cancer patients’ perspectives and experiences related to the use of an IHCA called WebChoice in their homes. Qualitative interviews were conducted with infrequent, medium and frequent IHCA users—six women and four men with breast and prostate cancer. The interviews were transcribed and analyzed inspired by interactionistic perspectives. We found that some patients’ perceived WebChoice as a “friend,” others as a “stranger.” Access to WebChoice stimulated particularly high frequency users to position themselves as “information seeking agents,” assuming an active patient role. However, to position oneself as an “active patient” was ambiguous and emotional. Feelings of “calmness”, “normalization of symptoms”, feelings of “being part of a community”, feeling “upset” and “vulnerable”, as well as “feeling supported” were identified. Interaction with WebChoice implied for some users an increased focus on illness. Our findings indicate that the interaction between patients and an IHCA such as WebChoice occurs in a variety of ways, some of which are ambivalent or conflicting. Particularly for frequent and medium frequency users, it offers support, but may at the same time reinforce an element of uncertainty in their life. Such insights should be taken into consideration in the future development of IHCAs in healthcare in general and in particular for implementation into patients’ private sphere.
PMCID: PMC3349955  PMID: 22582085
Cancer; IHCA (Interactive Health Communication Applications); interactionism; the active patient's role
4.  The Course of Fatigue during the First 18 Months after First-Ever Stroke: A Longitudinal Study 
Stroke Research and Treatment  2011;2012:126275.
Background. Little is known about the course of poststroke fatigue. Objectives. To describe the course of poststroke fatigue in relation to the patient's level of physical functioning, depressive symptoms, and self-reported history of prestroke fatigue. Methods. A longitudinal study using structured face-to-face interviews, questionnaires, and patients' medical records. Data were collected from 95 patients in Norway with first-ever stroke. Fatigue was measured with the Fatigue Severity Scale 7 item version and assessed for change between the acute phase, six, 12, and 18 months after stroke using 2-way ANOVA repeated-measures analyses. Results. The patients' level of fatigue did not change over time. However, those who reported prestroke fatigue showed a relatively high level of fatigue over time in the poststroke period, while patients with no history of pre-stroke fatigue showed a stable course of relatively low fatigue over time. Conclusion. Studies on poststroke fatigue should control for the patient's pre-stroke fatigue level.
PMCID: PMC3189618  PMID: 22007350
5.  Sleep-Wake Patterns during the Acute Phase after First-Ever Stroke 
Stroke Research and Treatment  2011;2011:936298.
This study describes the pattern of day and night sleep and explores relationships between these patterns and sociodemographic and clinical factors as well as sleep environmental context and the patient's subjective sleep quality. Data from 110 patients with first-ever stroke was collected by structured interview surveys, medical record, and objective estimated sleep data from wrist actigraphy. The variability in estimated sleep is large. Half the patients slept either <6 hours or >8 hours per night, and 78% had more than nine awakenings per night. Men slept less than women, and patients sleeping at home had fewer awakenings than those who slept in hospital. It was estimated sleep during daytime in all, except 4, patients. Longer stay in hospital was related to more daytime sleep, and the subjective sleep quality correlated with estimated sleep time, wake time, and wake percentage.
PMCID: PMC3138134  PMID: 21776369
6.  Written online situational feedback via mobile phone to support self-management of chronic widespread pain: a usability study of a Web-based intervention 
This pretrial study aimed to develop and test the usability of a four-week Internet intervention delivered by a Web-enabled mobile phone to support self-management of chronic widespread pain.
The intervention included daily online entries and individualized written feedback, grounded in a mindfulness-based cognitive behavioral approach. The participants registered activities, emotions and pain cognitions three times daily using the mobile device. The therapist had immediate access to this information through a secure Web site. The situational information was used to formulate and send a personalized text message to the participant with the aim of stimulating effective self-management of the current situation. Six women participated and evaluated the experience.
The intervention was rated as supportive, meaningful and user-friendly by the majority of the women. The response rate to the daily registration entries was high and technical problems were few.
The results indicate a feasible intervention. Web-applications are fast becoming standard features of mobile phones and interventions of this kind can therefore be more available than before.
Trial registration number NCT01236209
PMCID: PMC3050782  PMID: 21352516
7.  Pain and psychological health status over a 10‐year period in patients with recent onset rheumatoid arthritis 
Annals of the Rheumatic Diseases  2007;66(9):1195-1201.
To examine rheumatoid arthritis (RA) with short disease duration over 10 years, and to identify factors that are associated with the course of pain, depression and anxiety.
A cohort of 238 patients with RA (age 20–70 years, mean disease duration 2.3 years, 68% rheumatoid factor positive) was followed with assessments at baseline and after 1, 2, 5 and 10 years. Self‐reported health status was assessed by pain on a 100 mm visual analogue scale, the Arthritis Impact Measurement Scales (AIMS), the 28‐item version of General Health Questionnaires, and the Health Assessment Questionnaire. We also examined the erythrocyte sedimentation ratio, grip strength (kg) and radiographic progression of the hands (van der Heijde modified Sharp score). Repeated measures analyses of variance were used to explore the effect of time on measures of outcome among completers, whereas repeated measures analyses using a mixed model were applied to identify factors that were longitudinally associated with pain, depression and anxiety.
At the various assessment points 30% had a visual analogue scale pain score of ⩾40 mm, 5–13% had an AIMS depression score of ⩾4.0 and 20–30% had an AIMS anxiety score of ⩾4.0. The perceived level of pain was explained longitudinally by anxiety, disease activity, physical function and female gender, depression by high disease activity and anxiety, whereas anxiety was explained by low disease activity and depression.
More patients had increased levels of anxiety (20–30%) than increased levels of depression (5–13%). Several factors, including anxiety, but not depression, were associated with the course of pain.
PMCID: PMC1955161  PMID: 17392351
8.  A cross-sectional prospective study of seclusion, restraint and involuntary medication in acute psychiatric wards: patient, staff and ward characteristics 
Previous research on mental health care has shown considerable differences in use of seclusion, restraint and involuntary medication among different wards and geographical areas. This study investigates to what extent use of seclusion, restraint and involuntary medication for involuntary admitted patients in Norwegian acute psychiatric wards is associated with patient, staff and ward characteristics. The study includes data from 32 acute psychiatric wards.
Multilevel logistic regression using Stata was applied with data from 1016 involuntary admitted patients that were linked to data about wards. The sample comprised two hierarchical levels (patients and wards) and the dependent variables had two values (0 = no use and 1 = use). Coercive measures were defined as use of seclusion, restraint and involuntary depot medication during hospitalization.
The total number of involuntary admitted patients was 1214 (35% of total sample). The percentage of patients who were exposed to coercive measures ranged from 0-88% across wards. Of the involuntary admitted patients, 424 (35%) had been secluded, 117 (10%) had been restrained and 113 (9%) had received involuntary depot medication at discharge. Data from 1016 patients could be linked in the multilevel analysis. There was a substantial between-ward variance in the use of coercive measures; however, this was influenced to some extent by compositional differences across wards, especially for the use of restraint.
The substantial between-ward variance, even when adjusting for patients' individual psychopathology, indicates that ward factors influence the use of seclusion, restraint and involuntary medication and that some wards have the potential for quality improvement. Hence, interventions to reduce the use of seclusion, restraint and involuntary medication should take into account organizational and environmental factors.
PMCID: PMC2858144  PMID: 20370928
10.  Emotion regulation in patients with rheumatic diseases: validity and responsiveness of the Emotional Approach Coping Scale (EAC) 
Chronic rheumatic diseases are painful conditions which are not entirely controllable and can place high emotional demands on individuals. Increasing evidence has shown that emotion regulation in terms of actively processing and expressing disease-related emotions are likely to promote positive adjustment in patients with chronic diseases. The Emotional Approach Coping Scale (EAC) measures active attempts to acknowledge, understand, and express emotions. Although tested in other clinical samples, the EAC has not been validated for patients with rheumatic diseases. This study evaluated the data quality, internal consistency reliability, validity and responsiveness of the Norwegian version of the EAC for this group of patients.
220 patients with different rheumatic diseases were included in a cross-sectional study in which data quality and internal consistency were assessed. Construct validity was assessed through comparisons with the Brief Approach/Avoidance Coping Questionnaire (BACQ) and the General Health Questionnaire (GHQ-20). Responsiveness was tested in a longitudinal pretest-posttest study of two different coping interventions, the Vitality Training Program (VTP) and a Self-Management Program (SMP).
The EAC had low levels of missing data. Results from principal component analysis supported two subscales, Emotional Expression and Emotional Processing, which had high Cronbach's alphas of 0.90 and 0.92, respectively. The EAC had correlations with approach-oriented items in the BACQ in the range 0.17-0.50. The EAC Expression scale had a significant negative correlation with the GHQ-20 of -0.13. As hypothesized, participation in the VTP significantly improved EAC scores, indicating responsiveness to change.
The EAC is an acceptable and valid instrument for measuring emotional processing and expression in patients with rheumatic diseases. The EAC scales were responsive to change in an intervention designed to promote emotion regulation. The instrument has not yet been tested for test-retest reliability, which is recommended in future studies.
PMCID: PMC2749806  PMID: 19728869
12.  Frequency of GP communication addressing the patient's resources and coping strategies in medical interviews: a video-based observational study 
BMC Family Practice  2009;10:49.
There is increasing focus on patient-centred communicative approaches in medical consultations, but few studies have shown the extent to which patients' positive coping strategies and psychological assets are addressed by general practitioners (GPs) on a regular day at the office. This study measures the frequency of GPs' use of questions and comments addressing their patients' coping strategies or resources.
Twenty-four GPs were video-recorded in 145 consultations. The consultations were coded using a modified version of the Roter Interaction Analysis System. In this study, we also developed four additional coding categories based on cognitive therapy and solution-focused therapy: attribution, resources, coping, and solution-focused techniques.
The reliability between coders was established, a factor analysis was applied to test the relationship between the communication categories, and a tentative validating exercise was performed by reversed coding.
Cohen's kappa was 0.52 between coders. Only 2% of the utterances could be categorized as resource or coping oriented. Six GPs contributed 59% of these utterances. The factor analysis identified two factors, one task oriented and one patient oriented.
The frequency of communication about coping and resources was very low. Communication skills training for GPs in this field is required. Further validating studies of this kind of measurement tool are warranted.
PMCID: PMC2720936  PMID: 19570200
13.  Apathy is associated with executive functioning in first episode psychosis 
BMC Psychiatry  2009;9:1.
The underlying nature of negative symptoms in psychosis is poorly understood. Investigation of the relationship between the different negative subsymptoms and neurocognition is one approach to understand more of the underlying nature. Apathy, one of the subsymptoms, is also a common symptom in other brain disorders. Its association with neurocognition, in particular executive functioning, is well documented in other brain disorders, but only studied in one former study of chronic patients with schizophrenia. This study investigates the association between apathy and neurocognitive functioning in patients with first episode psychosis (FEP), with the hypothesis that apathy is more associated with tests representing executive function than tests representing other neurocognitive domains.
Seventy-one FEP patients were assessed with an extensive neuropsychological test battery. Level of apathy was assessed with the abridged Apathy Evaluation Scale (AES-C-Apathy).
AES-C-Apathy was only significantly associated with tests from the executive domain [Semantic fluency (r = .37, p < .01), Phonetic fluency (r = .25, p < .05)] and working memory [Letter Number Span (r = .26; p =< .05)]; the first two representing the initiation part of executive function. Confounding variables such as co-occuring depression, positive symptoms or use of antipsychotic medication did not significantly influence the results.
We replicated in FEP patients the relationship between apathy and executive functioning reported in another study for chronic patients with schizophrenia. We also found apathy in FEP to have the same relationship to executive functioning, as assessed with the Verbal fluency tests, as that reported in patients with other brain disorders, pointing to a common underlying nature of this symptom across disorders.
PMCID: PMC2640391  PMID: 19133132
14.  Observed communication skills: how do they relate to the consultation content? A nation-wide study of graduate medical students seeing a standardized patient for a first-time consultation in a general practice setting 
In this study, we wanted to investigate the relationship between background variables, communication skills, and the bio-psychosocial content of a medical consultation in a general practice setting with a standardized patient.
Final-year medical school students (N = 111) carried out a consultation with an actor playing the role of a patient with a specific somatic complaint, psychosocial stressors, and concerns about cancer. Based on videotapes, communication skills and consultation content were scored separately.
The mean level of overall communication skills had a significant impact upon the counts of psychosocial issues, the patient's concerns about cancer, and the information and planning parts of the consultation content being addressed. Gender and age had no influence upon the relationship between communication skills and consultation content.
Communication skills seem to be important for final-year students' competence in addressing sensitive psychosocial issues and patients' concerns as well as informing and planning with patients being representative for a fairly complex case in general practice. This result should be considered in the design and incorporation of communication skills training as part of the curriculum of medical schools.
PMCID: PMC2213643  PMID: 17996053
15.  Life satisfaction and resilience in medical school – a six-year longitudinal, nationwide and comparative study 
This study examined the relationship between life satisfaction among medical students and a basic model of personality, stress and coping. Previous studies have shown relatively high levels of distress, such as symptoms of depression and suicidal thoughts in medical undergraduates. However despite the increased focus on positive psychological health and well-being during the past decades, only a few studies have focused on life satisfaction and coping in medical students. This is the first longitudinal study which has identified predictors of sustained high levels of life satisfaction among medical students.
This longitudinal, nationwide questionnaire study examined the course of life satisfaction during medical school, compared the level of satisfaction of medical students with that of other university students, and identified resilience factors. T-tests were used to compare means of life satisfaction between and within the population groups. K-means cluster analyses were applied to identify subgroups among the medical students. Analysis of Variance (ANOVA) and logistic regression analyses were used to compare the subgroups.
Life satisfaction decreased during medical school. Medical students were as satisfied as other students in the first year of study, but reported less satisfaction in their graduation year. Medical students who sustained high levels of life satisfaction perceived medical school as interfering less with their social and personal life, and were less likely to use emotion focused coping, such as wishful thinking, than their peers.
Medical schools should encourage students to spend adequate time on their social and personal lives and emphasise the importance of health-promoting coping strategies.
PMCID: PMC1592096  PMID: 16984638

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