Data from 20 patients, 11 men and 9 women, ranging in age from 34 to 79 years with an average age of 62 and most of the patients had a university degree n=11 (55%). The patients had completed five to seven modules out of seven possible modules included in the 9-week iCBT program. The patients lived in both rural and urban areas, and most of the patients (n=17) were in a relationship (Table 1).
Three main identified themes were (a) Taking control of the disease, (b) Not just a walk in the park, and (c) Feeling a personal engagement with the therapy program. Each of these three main themes has three corresponding sub-themes. Themes and sub-themes are presented in, Figure 1.
Taking control of the disease
This first main theme describes how the patients experience taking control of their health by working in the program. The patients described how the program gave them guidance through the different modules, which made them feel they were part of the treatment process. They also felt that they could make their own decisions in their treatment based on the new knowledge they had obtained from the program about their disease. The patients experienced a sense of control over the treatment due to the perceived freedom of being able to go back and forth in the program and work at their own pace.
Be one’s own guide
The patients noted that being involved in the treatment and making their own decisions in the program created a feeling of being in control. The feeling of being in control made it easier to take difficult steps forward in order to improve their health by changing their negative thinking and behavior.
“Realizing that it’s up to me how I deal with life. Perhaps you can get that out of such a program. Not believing that the healthcare service should help me with everything. I’m not a child who needs their mom and dad to help, I’m an adult and I have to take charge of my life, and it’s up to me what I make of it” participant no.14 Female.
The patients reported that learning about their disease helped them gain new insights. Working with the program was helpful to gain a new understanding of how to live with CVD and depression. This also helped them perceive their situation as less stressful and made it easier for them to make decisions in the program concerning the necessary steps to change their negative emotions, thoughts, and behaviors.
“Because there’s a fear linked to this issue of the heart not behaving. But the fear disappeared, and I learnt that the heart can cope with much more than you think. And I also learnt that this little leakage I have, that’s quite normal in old age” participant no.11 Female.
The patients experienced a feeling of freedom regarding the program. Having the possibility to influence the date and time to work with the program was perceived as flexible, but above all it contributed to a feeling that the program was constantly present during the whole treatment period and did not take breaks between the individual treatment sessions. The experienced freedom motivated the patients to continuously work with the treatment to achieve changes and take control of their own health.
“One advantage… In other words, in a physical meeting there is… It’s perhaps that you have a physical meeting today, and then you meet again in two weeks. The advantage here was that you worked with the program during this time” participant no.10 Male.
Not just a walk in the park
In this second main theme, the patients describe the work in the program as demanding and emotionally challenging but necessary to achieve a change in their negative emotions, thoughts, and behaviors. Not all the patients participating in the program were satisfied with the program and some of the content was experienced as demanding and difficult.
The program was in some parts perceived as demanding and the patients had to work harder than they expected. For some patients, the amount of work and the active participation needed made it hard to complete the treatment despite experiencing positive changes in their negative thinking.
“You have to read through, you have to reflect, you have to work for yourself. But you know that you’ll get an answer. Yes, it’s more… cognitive behavioral therapy is more work, but it also produces results” participant no.13 Male.
Working on the program evoked emotions and led to feelings of discomfort and stress. These emotions were a result of the increased insights about their health and the changes needed to achieve more positive thinking and behavior. Patients expressed these evoked emotions as a necessary part of the process towards improvement and recovery from depression.
“You try to repress things sometimes, unfortunately. Yes, it’s both good and bad, but eventually it re-emerges then, but no, I think what’s worth most is that you have to, err… think about it and above all look forward. That’s what has helped most, that there’s a change for the better in everything, both physically and mentally” participant no.3 Male.
Not my cup of tea
Not all the patients were satisfied with the program. The text in the program was sometimes experienced as difficult to read and to recognize, and not to be tailored to their own situation This made them find the program less credible and thereby less helpful.
“I perceived it almost as if perhaps it wasn’t designed for a… someone who works, like, and has a lot of different types of activities. It became very complex, filling in these weekly schedules based on the module” participant no.17 Male.
Feeling a personal engagement with the therapy program
In the third main theme, patients emphasized the importance of recognizing themselves in the program and relating the content of the program to their CVD and depression. The patients perceived the work structure in the program, including support and feedback from a trusted therapist, as an important factor in achieving changes in emotions, thoughts and behaviors.
Feeling acknowledged as a person
The patients felt that the tailored content of the program was personally directed towards patients with CVD and depression, creating a sense of being seen and listened to. Being able to relate the content of the program to their CVD and depression gave a feeling of safety and a realization of not being alone in their disease. This helped them to express their emotions and thoughts more openly about their disease, which in turn contributed to behavior changes, and thus improvements in their depression.
“Sometimes you talk about depression and then if you don’t recognize it, so perhaps you don’t read that much, but if you recognize yourself there then you look up why you’re depressed and what you can do” participant no.1 Male.
“And it can be good to have the chance to express your feelings and so on, even if it’s online in the form of… You still get an answer from somewhere. I think that can be a positive thing. Just being able to express yourself can be enough” Participant no.4 Male.
Getting support and structure for a personal health plan
Patients reported that the structure of the program helped them set individual goals, organize, and perform activities, which was experienced as helpful in order to achieve changes in emotions, thoughts, and behaviors. For example, the psychoeducation regarding the cardiovascular disease, and creating an individual activity plan, were experienced as important support in order to break the vicious circle including negative emotions, thoughts, and behaviors. New insights motivated them to increase their physical and social activities and learn to accept their cardiovascular disease.
“Ideas about how to activate yourself, too. Like, planning your day better. And that one thing leads to the other, as it were. That you, I mean, just by activating yourself it’s easier to get out of a vicious circle, in a manner of speaking” participant no.12 Male.
Feeling a connection with the therapist
The written feedback was experienced as trustworthy and made the patients perceive the therapist as credible, which also facilitated changes in emotions, thoughts, and behaviors. For most patients, the therapist was perceived as a close personal guide throughout the program, who made it possible to complete those parts of the program that were seen as difficult. The therapist also helped them become aware of and reflect upon, and thus change their negative emotions, thoughts, and behaviors.
“Otherwise, I think that the feedback has been adequate, and I’m sometimes surprised how much the person providing the feedback has understood about what I’ve actually thought, when I’ve done my exercises. So, it’s been good” participant no.17 Male.
“I felt that I was treated very personally then, and it was a bit like sitting next to the person. There was very close, direct contact” participant no.11 Female.