Mr. Jones – a review for healthcare staff

(See also what the International Movie Database says about Mr. Jones)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

MR. JONES – existential problems in a patient-doctor relationship

Mr. Jones tells the story of a manic depressive man (played by Richard Gere) and his relationship with a female psychiatrist (Lena Olin) with whom he happens to cross paths. A lot of what happens in Hollywood's takes on life ends up being bigger than life itself. Sometimes it can be too much, sometimes it works seductively well, and sometimes, as is the case with Mr. Jones, it walks a fine line between extremes. This is the result of director Mike Figgis' tendency to wrap reality up in melodrama. But if you can come to terms with this, it's much easier to see how much the film has to offer. A critical view brings certain things out more clearly.

By Dr Göran Nordström, Senior Physician

Along with the depiction of the relationship at the centre of the film, Mr. Jones offers a nuanced picture of bipolar illness. The film succeeds throughout in maintaining a respectful tone. It can easily become the case that the unusual behaviour a person might demonstrate in a manic phase is given a glossed description in film. It is also easy to miss the larger problems arising from the fact that desire, happiness, and richness of thought can make the disorder's hypomanic phases so cherished by the patient. Mr. Jones makes it clear that the main character does not always look on lithium as his friend. It may be true that Richard Gere is not completely convincing as a depressive. But the depiction of the lust for the vitality, charm, and even intellectual capacity that characterise the depressive phase of a bipolar illness is fully acceptable.

The first time Mr. Jones and Dr. Elizabeth Bowen (Lena Olin) meet, he is manic and psychotic. Something about the woman psychiatrist drives him to seek contact with her outside the hospital. He is an individual with a strongly developed intuitive empathetic capacity. At the time they meet, she is under the influence of a recent separation.

Proximity, authenticity, and professional empathy

There is also something about Mr. Jones that stirs Dr. Elizabeth's interest. She lets herself be talked into letting Mr. Jones accompany her on the car ride from the legal hearings on his compulsory care - which she advocates, but loses. Elizabeth is a recognised and skilled psychiatrist. What gets her to go slightly outside the usual boundaries of the patient-doctor relationship is her willingness to help. Mr. Jones' case interests her. She is personally moved by his vulnerability during the depressive phase. Nonetheless, she maintains an entirely professional demeanour throughout. On one occasion, when the depressed Mr. Jones is admitted to hospital, Elizabeth is attacked by another patient. Mr. Jones saves her, possibly because he is able to reach the other patient despite the dynamic situation. There are several occasions when Elizabeth points out that Mr. Jones "has a gift". He has a unique capacity to reach others, including Elizabeth herself.

Balancing authenticity, proximity, and empathy may be crystal clear in legal and ethical terms, but it can prove much more complex in practice. Mr. Jones reveals these difficulties. Many therapists will surely recognise something of this problem, even if things generally end up far from what happens in the film. (And here I am disregarding the final scene, most likely a concession to the film's financers.) The film's central development is set by Dr. Elizabeth Bowen's confession that she made a mistake in her treatment of Mr. Jones. Not a major mistake, but enough for him to take offence and drop out of touch. As a result, Dr. Elizabeth ends up in a dilemma with both professional and personal dimensions. How much are you willing to risk getting what you want? At one point, Mr. Jones asks this question to his psychiatrist. He sees himself as a person who is ready to take great risks. What is Dr. Elizabeth prepared to risk?

It turns out that she breaks the rules of the patient-doctor relationship. For private or professional reasons? Because she is attracted to Mr. Jones? Or to re-establish contact and help her patient after a mistake? Is her last card, her only chance, to let things get deeply personal?

"Balancing authenticity, proximity, and empathy may be crystal clear in legal and ethical terms, but it can prove much more complex in practice."

"I never lose control," says one of Dr. Bowen's female patients in a short snippet of conversation. Elizabeth Bowen is also someone who maintains control. Perhaps too much for her own good, on a personal level. Her encounter with Mr. Jones places her before the existential problem that Kierkegaard puts as follows: "To dare is to lose your footing. Not to dare is to lose yourself." In using the patient-doctor relationship as an arena for this existential question, Figgis fully charges the question.
This is a situation where one, as a doctor, must not lose self-control.

By Dr Göran Nordström, Senior Physician

The patient-doctor relationship in treatment of patients with affective disorder

Warmth, empathy, authenticity – these are dimensions that psychotherapy research has determined to be determining factors for successful therapeutic contact. They closely resemble the ingredients that most would want to see in a non-professional relationship. It is not as easy as it might sound, partly since it may be difficult in a treatment-based relationship to measure out one's empathy and to be sufficiently engaged. Difficult to help enough to make it work and still avoid mixing the patient's problems with your own person.

It is a well-known fact that the relationship between the treating doctor and the depressed patient is significant for treatment results. This is obvious if the patient's condition and access to therapeutic skill leads him or her to make the choice to undertake psychotherapeutic treatment. When it comes to treatment with antidepressant medication, it also makes a difference whether the patient is simply provided with medication or a real interest is demonstrated in him or her. Putting yourself in a life situation, actively listening, following up as regularly and with as many repeat visits as necessary and feasible. It is important to maintain rather frequent contact, especially in the beginning of a treatment programme, before the antidepressant effect has begun to take hold.

An individually designed and individually measured support contact should be maintained the entire way through to the remission that is the goal of the treatment programme (which the patient shall hopefully reach). If the patient regains a healthy condition, then the patient should also be helped with weaning off medication. There are patients who may benefit from very long-term antidepressant medication. But it is all too often the case that medication is not discontinued because it was not possible to manage the difficulty of weaning off the medication, or even because the issue was never addressed.

Meeting others where they are

When someone seeks help, it is not a given that a trusting relationship will develop. An often-cited passage by Kierkegaard emphasizes the significance of meeting others (such as patients) "where they are". An accepting attitude, open questions, and active listening are important elements in such a means of relating, which most Swedish doctors probably feel fairly used to. Stress and any distracting or disruptive elements may cause complications. It is not always possible for a person to have control over their working circumstances and stress levels.
But it is all even more critical to try to create a proper environment in the meeting with truly vulnerable patients. And a depressed patient is vulnerable.

With patients who are so depressed that they have difficulty giving their perspective or even offering complete answers, open questions alone are not enough. The patient's verbal and non-verbal behaviour offers information that should lead to a more active approach. By making it clear to the patient that you understand how he or she feels, you increase the possibility for the patient, in the midst of their confusion, to be able to anticipate some type of hope.

Communicating hope

One of the very most important things that can be achieved in the initial contact with a depressed patient is to realistically and empathetically communicate a sense of hope.

"It is a well-known fact that the relationship between the treating doctor and the depressed patient is significant for treatment results."

You cannot count on having this confirmed by the patient until perhaps much later, when the depression has receded. It often seems as though the patient is not able to accept being told that they will be feeling better in perhaps just a week or so.
But this should be said all the same. Simply, clearly, and without argument. Nothing is improved by trying to force out a hard-won optimistic response. On the contrary, trust will increase if the patient experiences that the doctor takes the time to listen to pessimistic statements and can nonetheless calmly and factually speak of a future improvement. An authoritative supporting attitude usually works best. If, after a careful review of the symptoms, it can be concluded that the diagnosis really is depression, then problem solving is generally not the right way to begin. There are always exceptions, but for most, this has to come later. Sometimes the patient will naturally have psychological or social problems that they need help with. But part of what seems problematic or insurmountable sometimes fades away as the condition improves.

Asking about suicidal thoughts

One thing that must always be borne in mind when treating depressed patients is the risk of suicidal actions. Weariness of life is common in depression. Questions should be asked about this, but in a factual and non-moralising manner. It is natural to begin with more open questions. How are you feeling right now? Does life feel meaningless? If the patient answers in the affirmative, then you should continue. Have you thought it would be nice to find a way out of life? Have you perhaps thought of taking your life? If the patient answers "no" convincingly, then you can leave the subject. If the patient answers in the affirmative, then you should continue. Is there something stopping you? Do you have plans to take your life? Have you thought how you might do it? Have you decided when you would do it? It is almost without exception that patients later state that they thought it was nice that someone asked them these questions directly. Suicidal thoughts are not aroused by asking questions about them. On the other hand, you cannot expect a depressed, reticent patient to spontaneously recount such thoughts. Questions need to be asked clearly and explicitly. Either until you feel convinced that there is no risk, or until you can assess the risk and how imminent it is.

This may sometimes mean that compulsory care (according to the law on compulsory psychiatric care) must be considered. Deep depression accompanied by suicidal thoughts also generally has a good prognosis, and there is no defendable alternative to compulsory care if the patient is clearly suicidal and will not willingly accept hospital care.

The manic patient

Treating manic patients presents the doctor with other types of challenge. To get a spirited, high-tempo person who is brimming with ideas, seldom irritable, and who believes himself or herself to feel better than ever before to accept treatment is far from easy. This is an issue for specialists. Compulsory care may become necessary.

You may also encounter problems when treating bipolar patients who are functioning well on the whole. It happens that the patient (such as Mr. Jones in the film) experiences that the mood-stabilising medication makes life too drawn out, existence too even and grey. A person comes to encounter issues in a border area between the medical and the existential. As a doctor, you may often look more to the risks of relapse if medication is discontinued. There are no ready answers as to how this type of situation should be handled. The possibility of having your perspectives heard as a doctor increases if you respect the fact that it is the patient's life and

"An authoritative supporting attitude usually works best."

that you do not lightly and authoritatively dismiss their thoughts and wishes. On this side of the law on compulsory psychiatric care, the decision for treatment is mainly that of the patient.

The boundaries of the professional relationship

To see your patient as both a human being and a patient. Sounds easy, right? But of course, it is not always so easy. With the restrictions that abound in the doctor's role in relation to the patient, comes the need to provide the conditions for the proximity and intimacy that work with patients entails. An inevitable aspect of work as a doctor consists of setting limits, especially to create a secure space for interaction with the patient. Mr. Jones depicts how unmanageable the situation will become if the framework of this relationship is broken. It does not help matters to have done so with good intentions.

It may happen that the patient "sees through" the professional attitude and demands that the doctor is genuine. Regardless of whether you think this demand is understandable or not, the only reasonable approach is to maintain the limitations of your own role and to explain that as a doctor, this is my way of being genuine. Otherwise you have failed the unspoken agreement that was itself the grounds for contact with the patient. The art lies in balancing personal aspects - warmth, authenticity – within the framework of this agreement.

By Dr Tord Andreasson, Corporate Physician

Importance of the workplace in relation to the depressed patient

Work is meaningful for most people, and the same applies for the depressed patient.
To be struck with depression entails a great degree of suffering. A new Swedish study, led by the health economist Patrick Sobocki at the Karolinska Institute in Stockholm, shows that the cost that depression places on society has doubled over the last eight years, from 16.1 to a dizzying 32.9 billion SEK per year. These increased costs are not treatment costs, but instead arise from the fact that the patient is not professionally productive. When considering the fact that depression is a widespread condition that may arise at an early age and then become chronic and impact a person's entire working life, it then becomes understandable how incredibly important it is to be able to assist depressed individuals early on, from both a humanistic and an economic perspective.

In the professional health world we often meet patients with depressive illness. We notice that the relationship between the patient and their workplace is very important, and that it can influence how the patient enters remission.

Bosses and colleagues

When patients have told us what they considered important for their return to work, they often mentioned the significance of their bosses. Some have expressed it by saying that their boss symbolised the entire workplace. Without feeling the support of the boss, it was also difficult to feel the support of colleagues. Having a good relationship with a boss from early on, before the onset of illness, makes this much easier. If there is a conflict between parties, then this needs to be addressed. Patients have also credited the importance of the workplace being aware of the illness. A person is fragile and vulnerable in depression. Feeling welcomed back is important. Several depressed patients have also stated that it was good for them to get back to work in stages. For some, it has been important to meet with a boss or a colleague outside the workplace before coming back to work. That people from the workplace get in touch with the patient on sick leave and do not forget them is also very important.

Corporate healthcare

It is of great importance to discover a patient's depression early and quickly initiate treatment. If you notice a change in a colleague, the company can then arrange assistance, such as through the corporate healthcare system, which can often take steps quickly. If there is also a trusting relationship not only between the patient and the workplace, but also with the corporate healthcare system, then the healthcare system can quickly provide feedback, and the company can consider whether or not they have the possibility to make changes in the workplace. If not established ahead of time, the company also needs to assess whether or not to assign the corporate healthcare system to initiate treatment for depression, since the corporate healthcare system is financed entirely by employers. Otherwise, the patient must be quickly referred to the general care system. Even serious depression or bipolar conditions need to be treated in general care. The corporate healthcare system may here have a role in the rehabilitation process instead.

Sick leave

Depending on how the depressive illness and the workplace look for the individual, need for sick leave may vary considerably. It is important to have awareness of and communication with the workplace to determine whether a patient’s professional duties are appropriate with respect to

"Without feeling the support of the boss, it was also difficult to feel the support of colleagues."

the condition the patient is experiencing. It is sometimes possible to entirely avoid sick leave. It is then often necessary to be able to adapt work duties for a time. Partial sick leave is another option. It is often the case, however, that the patient needs to be given full sick leave for a period of time before he or she improves through treatment. Many patients also need to be able to be away from the workplace when they are feeling at their worst. Full sick leave can in certain cases serve as an important signal that measures must be taken in the workplace. If a person is deeply depressed, then full sick leave is inevitable. The ability to function may be so impaired that it takes a long time to return. It may then be a question of a more serious exhaustive condition, but there may also be other simultaneous health matters.

"A good rehabilitation meeting advances the relationship between the patient and the workplace."

The rehabilitation meeting

A good rehabilitation meeting advances the relationship between the patient and the workplace. It is here that the patient and the people who are working together towards the patient's return to work come together. The rehabilitation meeting may be a forum where it is possible to gain an understanding of the patient's condition while at the same time planning the measures and adaptations that might be needed to advance the patient's remission and return.

For the depressed patient, the relationship to the workplace is therefore important for remission and return to work. In the workplace, it is possible to detect early on that a colleague has undergone changes. It is my experience that quickly initiated treatment leads to reduced personal suffering and shorter periods of incapacity to work. Communication with the workplace is important, and it is here that the corporate healthcare system, with its coordinated resources, has the opportunity to assist. Awareness of depression and exhaustive conditions has increased in many of today's workplaces. It is increasingly uncommon to stand by confused, and inert, without understanding. If this development continues, and if intervention with measures can be made early on, then many long periods of suffering and inability to work can be avoided.

By Dr Göran Nordström, Senior Physician

The doctor and those close to the patient

Those who are close to depressed patients often suffer more than we might think. To see a loved one, or at least someone important to us, sink into brooding, anxiety, self-reproach and weariness of life, while seemingly impossible to reach, is a heart-rending experience. Relatives and others close to the patient often need support. The most important part of this support lies in communicating that you understand what has taken hold of the patient and how it will be possible to help. Meeting a professional who can "take over" can come as an enormous relief. Relatives often need a sense of "vicarious hope" almost as much as the depressed patient themselves.

Education and support

Awareness of depression is greater among the majority of people today than it was a few decades ago. But it is a good thing if you can set some time aside to educate those close to the patient. In a number of psychiatric clinics, there are depression awareness programmes for both patients and relatives alike. Patient associations often offer a great deal of support. There is now also the opportunity to find information - and sometimes even ask questions - via the Internet. All the same, the opportunity to get personal information from the doctor treating a sick relative is of inestimable value.

This information should naturally be formulated on the basis of the individual. It often proves to be a great help for relatives to hear that changes in patterns of behaviour of depressed patients are well-known symptoms in depression. Questions concerning aetiology and prognosis should be handled matter-of-factly. Nobody is served by ungrounded speculation or unfounded expectations. But getting to know "how things are" almost always results in a sense of security, even if there are no precise answers for just that individual patient.

Those who are close to the patient can sometimes offer information of great significance relating to the onset of the condition, previous periods of illness, and the degree of severity of symptoms. When an improvement starts to become apparent, it is often those close to the patients who see the first signs, sometimes even before the patients begin to experience any improvement themselves.

Confidentiality

Information to and from relatives and loved ones should of course be handled within the framework of confidentiality guidelines. Mr. Jones gives a good example of how this can go wrong – when Dr. Elizabeth finds out facts about Mr. Jones' girlfriend in younger years. Breaking a patient's wish for confidentiality is both formally wrong and something that may jeopardise the possibility for a continued trusting patient-doctor relationship.

In the worst-case scenario, damage may also be done to the relationship between the patient and their family and loved ones. If you have participated in an exchange of information that may be considered to breach confidentiality, it is generally best to have a frank discussion about this with the patient as soon as possible. If you can explain your thinking and make it clear to the patient that you were acting in the patient's best interests, then it will generally be possible to manage the situation without any further serious problems resulting.

The manic patient and loved ones

The problems faced by those who are close to a manic patient are usually of an entirely different character. For the person who recognises the signs of an upcoming manic period, the main problem may be in figuring out a way for the patient to get medical help. It is different when this is not seen as a symptom of illness. It will eventually become unbearable to stay with a person who breaks agreements, disregards rules and boundaries, who is easily irritated, sleeps only a few hours a night, and talks endlessly.

Or one who interrupts concerts, steals motorcycles, thinks himself or herself able to fly, and is generally unreliable just as in the film. This is not even to mention the sometimes catastrophic financial consequences of brilliant business ideas. The manic patient's loved ones largely need a form of concrete help in the form of proper care given to the patient. But of course, both education and individually designed support – and sometimes social initiatives – are also needed.

By Mats Frederikson, Brain researcher and Professor of clinical psycology

Internet treatment of anxiety and mood disorders

Mood and anxiety disorders; depression and anxiety syndrome; they result in great personal suffering as well as major social expense.
These conditions are common. Anxiety conditions affect up to a third of the population at some point in life. This problem is roughly twice as common among women. Depression affects one in two Swedish women and one in four Swedish men at some point in their lives. A depressed Swedish patient in treatment costs approximately 360,000 SEK per year, and these costs go down significantly for those who respond to treatment.

American estimates show that the direct and indirect costs of anxiety disorders amount to 60 billion dollars. Aside from reducing individual suffering, successful treatment of both depression and anxiety disorders leads to reduced social costs. Availability of drug treatment for depression and anxiety varies both between countries and within countries. The variation is greater still when it comes to psychotherapeutic treatment.

Both conditions respond well to SSRI treatment and treatment with cognitive behavioural therapy (CBT). In recently published studies, the Swedish Council on Technology Assessment in Health Care (SBU) has shown through systematic reviews of treatment literature that there is strong scientific support that both depression and anxiety disorders can be treated with CBT and SSRI. Depression also responds to interpersonal therapy, even if the supporting evidence for this is somewhat weaker.

CBT is a research-based, systematic, and empirically proven means of approaching a number of problems associated with negative feelings such as anxiety, dejection, and fear. CBT is based in learning theory, and there is much to suggest that principles such as classical and operant conditioning, as well as model learning, function in similar ways across several species. These are powerful principles that originate in natural selection, and there is ample research in the field both on humans and on other animals. 

CBT uses what has been shown to work in research studies. The methods focus on the situation here and now, and analyse which factors trigger and initiate behaviour, as well as the events that follow after these behaviour patterns and maintain these. Individual treatment plans are developed through so-called behavioural analyses, where triggering and reinforcing factors are charted. The training component is important, and the patient often trains independently between sessions.

Most methods for treatment of depression and discomfort build on documentation where the number of treatment sessions is predetermined and the content in each therapy session, although with a certain degree of flexibility, is also given. This treatment is based on replacing irrational and destructive, negative thoughts with rational and constructive, positive thoughts in order to then influence behaviour. Training also includes behaviour reversal tactics of various types. This may entail behavioural activation in depression and relaxation training for anxiety and fear. The patient learns techniques for emotional control and practises facing their negative thoughts, which are often wholly automatic. Of course, it is first a matter of being able to identify them.

Obviously, it is positive that there are effective and successful treatments for depression and anxiety problems. But not all patients in need of treatment receive it. It has been shown in a Swedish study that within open healthcare systems, only ¼ of all patients with anxiety problems are identified, and only 1/3 of these receive adequate treatment. Depression is undertreated in the

"Depression affects one in two Swedish women and one in four Swedish men at some point in their lives."

same way. While pharmacotherapy is relatively easily available, the same cannot be said of CBT. Of the 4,500 psychotherapists authorised by the Swedish National Board of Health and Welfare, only about 8% concentrate on cognitive therapy or cognitive behavioural therapy. In an ideal world, all patients would be given information on the effects and side-effects of both pharmacotherapy and psychotherapy, and then be able to make a choice on the basis of their own preferences. This does not happen because of practical limitations. The need to offer alternatives other than personal contact to deliver effective treatment is therefore great. The Internet offers this possibility.

CBT builds on a series of different techniques that often lead to successful treatment. Over the past few years it has proven possible to train and teach these techniques via the Internet so that they can be used successfully by patients with depression, anxiety, and other conditions. Self-help programmes can be used by most people with access to a computer and a minimum of computer skills. This has been confirmed by several research studies, both in Sweden and in other countries.

These methods usually combine existing effective techniques to approach different problems. There are programmes in Swedish for treatment of anxiety and fear, depression, sleeping disorders, and pain management. Stress management is also taught via the Internet by the company Livanda, which is a serious research company that collaborates with professional CBT psychologists and county councils in Swedish. For anxiety and fear, for example, treatment is based on eight steps. The first segment offers factual information on fear, fundamental self-evaluation, and tools to discover what you see as enjoyable and meaningful in life. It is then possible to set new life goals, which are difficult to equate with anxiety and mood disorders.

The overall purpose is to increase the motivation to truly work with the programme. Clear life goals make it easier to expose yourself to the fear that new learning situations often entail. The second segment focuses mainly on breathing, since most anxiety patients have a dysfunctional and shallow way of breathing that can be helped through breath training. The most important stage in treatment of anxiety is what is known as habituation or exposure. This is introduced early on. As soon as the third segment, it teaches how to use various techniques to remain calm in situations where you previously felt anxiety and discomfort. This is done by systematically practising getting closer to increasingly difficult situations without recoursing to different safety and security behaviour.

The fourth, fifth, and sixth modules teach how we as humans think, what steers negative and positive thoughts, and how we can handle them by remaining focused on the present. This is called mindfulness. Since anxiety and fear are important elements in both anxiety disorders and depression, it is important to avoid thinking of everything that can possibly go wrong, and instead just focusing on what is good right at this moment. It is also important to be able to say no and to assert your will, and this is also taught in the programme.

The programme available against depression and dejection encompasses eleven segments. Before the programme even starts, a self-evaluation is carried out and the participant is given feedback. Since the evaluations that have been done indicate that the programme has less effect in cases of deep depression, it is recommended that participants with excessively deep depression or suicidal tendencies first contact their doctor. The focus of the programme itself is the CBT methods that have proven to be most effective, namely behavioural activation and treatment of negative automatic thoughts. Depression often means avoiding activities and relationships. Through information on what depression is and how it may arise, participants gain an understanding of the vicious circle that avoidance creates.

"The overall purpose is to increase the motivation to truly work with the programme."

Behavioural activation can be a logical means of breaking dysfunctional behaviour, despite the fact that it sometimes goes against a persons "feelings". Behavioural activation is started as early as the first segment, and then follows throughout the entire programme. Treatment of negative automatic thoughts is taken up beginning in segment four, and together with mindfulness training, it contributes to increasing the ability to be present, while at the same time creating a distance from a person's own thoughts and feelings. This increased distance makes it easier to work towards the desired goals and improve the ability for impulse control. It concludes with a relaxation programme geared towards mindfulness. This is mainly intended as a support for behavioural changes, as research has shown that this is significant for minimising the risk for relapse.

All programmes include an interactive function with the possibility of asking questions to CBT therapists with extensive experience. Replies are given within a day's time. One advantage of Internet treatment is that it is flexible. The patient can personally choose when training will take place. You are not controlled by schedules or the need to go to a particular place to meet someone, but can instead train at a self-determined pace. These programmes are sometimes used by professional psychologists and psychiatrists with a view to treating multiple patients and thereby increase efficiency at work. The patients are then given support and reminders of the activities that should be performed between treatment sessions. These can then be made shorter and more loosely spaced out.

In my opinion, there is much to suggest that an individual should have a so-called "stepped care" approach, similar to what is done in blood pressure treatment in the USA and elsewhere. This could begin with an Internet-based programme on your own and then increase therapeutic support and perhaps combine this with pharmacological treatment. No formal evaluation has been made to assess whether Internet-based treatment of depression and anxiety increases sensitivity to drug treatment, but it would not be unreasonable to assume that this is the case. The issue is definitely worth studying.

People, including doctors, are creatures of habit, and habits are hard to break. Therefore it always takes time from the moment a substance has been shown effective in studies to the time it reaches everyday clinical practice. Estimates state that it takes about ten years before a drug is established as a clinical routine in treatment after having been shown to be effective through clinical trials. There are no studies showing how long it takes before a psychotherapeutically proven method reaches routine clinical use. This time is not likely to be any shorter.

The first Internet-based treatment programme was published in 2000 by Swedish researchers. It would be good if this information could contribute to expanding the use of inexpensive, flexible, and cost-effective treatment alternatives rapidly. This would reduce individual suffering and cut down social costs. The results of Internet-based treatment of anxiety and mild depression are equal to those seen in treatment with SSRI substances and traditional cognitive behavioural therapy, where patients meet therapists over the course of 10-12 weeks. My conclusion is that the methods used are effective and that they can be taught through both personal contact and other media formats such as the Internet.

Potential conflicts of interest: Mats Fredrikson is a minority shareholder and board member of Livanda AB, but has not participated in research studies on self-help.

"One advantage of Internet treatment is that it is flexible."