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      Internet-Based Treatment for Adults with Depressive Symptoms: Randomized Controlled Trial

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          Abstract

          Background

          Many depressed people do not receive help for their symptoms, and there are various barriers that impede help-seeking. The Internet may offer interesting alternatives for reaching and helping people with depression. Depression can be treated effectively with Internet-based cognitive behavioral therapy (CBT), but a short intervention based on problem solving therapy (PST) could constitute a worthwhile alternative to CBT.

          Objective

          In this study we evaluated the effectiveness of Internet-based CBT and Internet-based PST in comparison to a waiting list control group (WL), and we determined the differences between the two treatments.

          Methods

          We conducted a 3-arm randomized controlled trial to compare CBT, PST, and WL. The main inclusion criterion was presence of depressive symptoms (≥ 16 on the Center for Epidemiological Studies Depression scale). CBT and PST consisted of eight and five weekly lessons respectively. Participants were supported by email. Self-report measures of depression, anxiety, and quality of life were completed at pretest and after 5, 8, and 12 weeks.

          Results

          A total of 263 participants were randomized to the three conditions (CBT: n=88; PST: n=88; WL: n=87). Of the 263 participants, 184 (70%) completed questionnaires after 5 weeks, 173 (66%) after 8 weeks, and 151 (57%) after 12 weeks. Between-group effect sizes for depressive symptoms were 0.54 for CBT after 8 weeks (95% confidence interval (CI): 0.25 - 0.84) and 0.47 for PST after 5 weeks (95% CI: 0.17 - 0.77). These effects were further improved at 12 weeks (CBT: 0.69, 95% CI: 0.41 - 0.98; PST: 0.65, 95% CI: 0.36 - 0.95). For anxiety, effect sizes were also at a medium level. Effect sizes for quality of life were low. The number of participants showing clinically significant change at 12 weeks was significantly higher for CBT (n = 34, 38.6%) and PST (n = 30, 34.1%), compared to WL (n = 0).

          Conclusions

          Both Internet-based treatments are effective in reducing depressive symptoms, although the effect of PST is realized more quickly.

          Trial Registration

          International Standard Randomized Controlled Trial Number (ISRCTN): 16823487; http://www.controlled-trials.com/ISRCTN16823487/16823487 (Archived by WebCite at http://www.webcitation.org/5cQsOj7xf).

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          Most cited references28

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          EuroQol: the current state of play.

          R. Brooks (1996)
          The EuroQol Group first met in 1987 to test the feasibility of jointly developing a standardised non-disease-specific instrument for describing and valuing health-related quality of life. From the outset the Group has been multi-country, multi-centre, and multi-disciplinary. The EuroQol instrument is intended to complement other forms of quality of life measures, and it has been purposefully developed to generate a cardinal index of health, thus giving it considerable potential for use in economic evaluation. Considerable effort has been invested by the Group in the development and valuation aspects of health status measurement. Earlier work was reported upon in 1990; this paper is a second 'corporate' effort detailing subsequent developments. The concepts underlying the EuroQol framework are explored with particular reference to the generic nature of the instrument. The valuation task is reviewed and some evidence on the methodological requirements for measurement is presented. A number of special issues of considerable interest and concern to the Group are discussed: the modelling of data, the duration of health states and the problems surrounding the state 'dead'. An outline of some of the applications of the EuroQol instrument is presented and a brief commentary on the Group's ongoing programme of work concludes the paper.
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            Delivering interventions for depression by using the internet: randomised controlled trial.

            Helen Christensen, Kathleen Griffiths, Anthony F. Jorm (2004)
            To evaluate the efficacy of two internet interventions for community-dwelling individuals with symptoms of depression--a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy. Randomised controlled trial. Internet users in the community, in Canberra, Australia. 525 individuals with increased depressive symptoms recruited by survey and randomly allocated to a website offering information about depression (n = 166) or a cognitive behaviour therapy website (n = 182), or a control intervention using an attention placebo (n = 178). Change in depression, dysfunctional thoughts; knowledge of medical, psychological, and lifestyle treatments; and knowledge of cognitive behaviour therapy. Intention to treat analyses indicated that information about depression and interventions that used cognitive behaviour therapy and were delivered via the internet were more effective than a credible control intervention in reducing symptoms of depression in a community sample. For the intervention that delivered cognitive behaviour therapy the reduction in score on the depression scale of the Center for Epidemiologic Studies was 3.2 (95% confidence interval 0.9 to 5.4). For the "depression literacy" site (BluePages), the reduction was 3.0 (95% confidence interval 0.6 to 5.2). Cognitive behaviour therapy (MoodGYM) reduced dysfunctional thinking and increased knowledge of cognitive behaviour therapy. Depression literacy (BluePages) significantly improved participants' understanding of effective evidence based treatments for depression (P < 0.05). Both cognitive behaviour therapy and psychoeducation delivered via the internet are effective in reducing symptoms of depression.
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              Internet-based self-help for depression: randomised controlled trial.

              Gerhard Andersson, Jan Bergström, Fredrik Holländare … (2005)
              Major depression can be treated by means of cognitive-behavioural therapy, but as skilled therapists are in short supply there is a need for self-help approaches. Many individuals with depression use the internet for discussion of symptoms and to share their experience. To investigate the effects of an internet-administered self-help programme including participation in a monitored, web-based discussion group, compared with participation in web-based discussion group only. A randomised controlled trial was conducted to compare the effects of internet-based cognitive-behavioural therapy with minimal therapist contact (plus participation in a discussion group) with the effects of participation in a discussion group only. Internet-based therapy with minimal therapist contact, combined with activity in a discussion group, resulted in greater reductions of depressive symptoms compared with activity in a discussion group only (waiting-list control group). At 6 months' follow-up, improvement was maintained to a large extent. Internet-delivered cognitive cognitive-behavioural therapy should be pursued further as a complement or treatment alternative for mild-to-moderate depression.
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                Author and article information

                Contributors
                :
                VU University AmsterdamFPP, Dept. Clinical PsychologyVan der Boechorststraat 11081 BT AmsterdamThe Netherlands+ 31 20 59 88959+ 31 20 59 88758eh.warmerdam@psy.vu.nl
                Journal
                Journal ID (nlm-ta): J Med Internet Res
                Journal ID (publisher-id): JMIR
                Title: Journal of Medical Internet Research
                Publisher: Gunther Eysenbach (Centre for Global eHealth Innovation, Toronto, Canada )
                ISSN (Electronic): 1438-8871
                Publication date Collection: Oct-Dec 2008
                Publication date (Electronic): 20 November 2008
                Volume: 10
                Issue: 4
                Electronic Location Identifier: e44
                Affiliations
                [3] 3simpleTrimbos Institute simpleNetherlands Institute of Mental Health and Addiction UtrechtThe Netherlands
                [2] 2simpleDepartment of Clinical Epidemiology and Applied Biostatistics simpleVU University AmsterdamThe Netherlands
                [1] 1simpleDepartment of Clinical Psychology simpleInstitute for Research in Extramural Medicine simpleVU University AmsterdamThe Netherlands
                Article
                Publisher ID: v10i4e44
                DOI: 10.2196/jmir.1094
                PMC ID: 2629364
                PubMed ID: 19033149
                SO-VID: 41df5707-f241-4719-ab4b-4462fbeb7818
                Copyright © © Lisanne Warmerdam, Annemieke van Straten, Jos Twisk, Heleen Riper, Pim Cuijpers. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 20.11.2008.  
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

                History
                Date received : 08 May 2008
                Date revision requested : 18 June 2008
                Date revision received : 21 July 2008
                Date accepted : 01 October 2008
                Categories
                Subject: Original Paper

                ScienceOpen disciplines: Medicine
                Keywords: internet,depression,self-help,cognitive therapy,problem solving,randomized trial
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: internet, depression, self-help, cognitive therapy, problem solving, randomized trial

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