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      Tailored vs. Standardized Internet-Based Cognitive Behavior Therapy for Depression and Comorbid Symptoms: A Randomized Controlled Trial

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          Abstract

          Background and Aims

          Major depression can be treated by means of cognitive behavior therapy, delivered via the Internet as guided self-help. Individually tailored guided self-help treatments have shown promising results in the treatment of anxiety disorders. This randomized controlled trial tested the efficacy of an Internet-based individually tailored guided self-help treatment which specifically targeted depression with comorbid symptoms. The treatment was compared both to standardized (non-tailored) Internet-based treatment and to an active control group in the form of a monitored online discussion group. Both guided self-help treatments were based on cognitive behavior therapy and lasted for 10 weeks. The discussion group consisted of weekly discussion themes related to depression and the treatment of depression.

          Methods

          A total of 121 participants with diagnosed major depressive disorder and with a range of comorbid symptoms were randomized to three groups. The tailored treatment consisted of a prescribed set of modules targeting depression as well as comorbid problems. The standardized treatment was a previously tested guided self-help program for depression.

          Results

          From pre-treatment to post-treatment, both treatment groups improved on measures of depression, anxiety and quality of life. The results were maintained at a 6-month follow-up. Subgroup analyses showed that the tailored treatment was more effective than the standardized treatment among participants with higher levels of depression at baseline and more comorbidity, both in terms of reduction of depressive symptoms and on recovery rates. In the subgroup with lower baseline scores of depression, few differences were seen between treatments and the discussion group.

          Conclusions

          This study shows that tailored Internet-based treatment for depression is effective and that addressing comorbidity by tailoring may be one way of making guided self-help treatments more effective than standardized approaches in the treatment of more severe depression.

          Trial Registration

          Clinicaltrials.gov NCT01181583

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          Most cited references32

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          Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry.

          Ralitza Gueorguieva, John Krystal (2004)
          The analysis of repeated-measures data presents challenges to investigators and is a topic for ongoing discussion in the Archives of General Psychiatry. Traditional methods of statistical analysis (end-point analysis and univariate and multivariate repeated-measures analysis of variance [rANOVA and rMANOVA, respectively]) have known disadvantages. More sophisticated mixed-effects models provide flexibility, and recently developed software makes them available to researchers. To review methods for repeated-measures analysis and discuss advantages and potential misuses of mixed-effects models. Also, to assess the extent of the shift from traditional to mixed-effects approaches in published reports in the Archives of General Psychiatry. The Archives of General Psychiatry from 1989 through 2001, and the Department of Veterans Affairs Cooperative Study 425. Studies with a repeated-measures design, at least 2 groups, and a continuous response variable. The first author ranked the studies according to the most advanced statistical method used in the following order: mixed-effects model, rMANOVA, rANOVA, and end-point analysis. The use of mixed-effects models has substantially increased during the last 10 years. In 2001, 30% of clinical trials reported in the Archives of General Psychiatry used mixed-effects analysis. Repeated-measures ANOVAs continue to be used widely for the analysis of repeated-measures data, despite risks to interpretation. Mixed-effects models use all available data, can properly account for correlation between repeated measurements on the same subject, have greater flexibility to model time effects, and can handle missing data more appropriately. Their flexibility makes them the preferred choice for the analysis of repeated-measures data.
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            Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study.

            R L Spitzer, J. Williams, K Kroenke … (1994)
            To assess the validity and utility of PRIME-MD (Primary Care Evaluation of Mental Disorders), a new rapid procedure for diagnosing mental disorders by primary care physicians. Survey; criterion standard. Four primary care clinics. A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians. PRIME-MD diagnoses, independent diagnoses made by mental health professionals, functional status measures (Short-Form General Health Survey), disability days, health care utilization, and treatment/referral decisions. Twenty-six percent of the patients had a PRIME-MD diagnosis that met full criteria for a specific disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. The average time required of the primary care physician to complete the PRIME-MD evaluation was 8.4 minutes. There was good agreement between PRIME-MD diagnoses and those of independent mental health professionals (for the diagnosis of any PRIME-MD disorder, kappa = 0.71; overall accuracy rate = 88%). Patients with PRIME-MD diagnoses had lower functioning, more disability days, and higher rates of health care utilization than did patients without PRIME-MD diagnoses (for all measures, P < .005). Nearly half (48%) of 287 patients with a PRIME-MD diagnosis who were somewhat or fairly well-known to their physicians had not been recognized to have that diagnosis before the PRIME-MD evaluation. A new treatment or referral was initiated for 62% of the 125 patients with a PRIME-MD diagnosis who were not already being treated. PRIME-MD appears to be a useful tool for identifying mental disorders in primary care practice and research.
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              Toward a unified treatment for emotional disorders

              David Barlow, Laura Allen, Molly L Choate-Summers (2005)
              Article 0 comments Cited 205 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 15 May 2012
                Volume: 7
                Issue: 5
                Electronic Location Identifier: e36905
                Affiliations
                [1 ]Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
                [2 ]Department of Psychology, Umeå University, Umeå, Sweden
                [3 ]Psychiatric Clinic, University Hospital of Linköping, Linköping, Sweden
                [4 ]Swedish Institute for Disability Research, Linköping University, Linköping, Sweden
                [5 ]Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden
                University of Missouri-Kansas City, United States of America
                Author notes

                Conceived and designed the experiments: RJ ES MS EJ PC TA AR GA. Analyzed the data: RJ PC GA. Wrote the paper: RJ ES MS EJ PC TA AR GA.

                Article
                Publisher ID: PONE-D-11-23293
                DOI: 10.1371/journal.pone.0036905
                PMC ID: 3352859
                PubMed ID: 22615841
                SO-VID: 2bab1b53-c14a-4920-9e02-a26229cf9fc3
                Copyright © Johansson et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 9 November 2011
                Date accepted : 5 April 2012
                Page count
                Pages: 9
                Categories
                Subject: Research Article
                Subject: Medicine
                Subject: Mental Health
                Subject: Psychiatry
                Subject: Anxiety Disorders
                Subject: Mood Disorders
                Subject: Psychology
                Subject: Clinical Psychology
                Subject: Therapies
                Subject: Psychotherapy
                Subject: Social and Behavioral Sciences
                Subject: Psychology
                Subject: Therapies
                Subject: Psychotherapy
                Subject: Clinical Psychology

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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