A randomized controlled trial of an internet-delivered treatment: Its potential as a low-intensity community intervention for adults with symptoms of depression

Highlights

• The study demonstrated the potential of an internet-delivered treatment with support in a community sample.

• It gives support to a model for delivering population-wide internet-interventions for depression using trained supporters.

• The volunteers' community of practice may be significant for the success of internet-interventions in the community.

• Dose and response in internet-delivered interventions is an area that requires further research.

Abstract

Background

Internet-delivered treatments for depression have proved successful, with supported programs offering the potential for improved adherence and outcomes. Internet interventions are particularly interesting in the context of increasing access to interventions, and delivering interventions population-wide.

Methods

The study was a randomized controlled trial of an 7-module internet-delivered cognitive behavioral therapy (iCBT) program for adults with depressive symptoms (n = 96) compared to a waiting-list control group (n = 92). Participants received weekly support from a trained supporter. The primary outcome was depressive symptoms as measured by the Beck Depression Inventory (BDI-II). The program was made available nationwide from an established and recognized charity for depression.

Results

For the treatment group, post-treatment effect sizes reported were large for the primary outcome measure (d = 0.91). The between-group effects were moderate to large and statistically significant for the primary outcomes (d = 0.50) favoring the treatment group. Gains were maintained at 6-month follow-up.

Conclusion

The study has demonstrated the efficacy of the internet-delivered Space from Depression treatment. Participants demonstrated reliable and statistically significant changes in symptoms from pre-to post-intervention. The study supports a model for delivering online depression interventions population-wide using trained supporters.

Trial registration number: Current Controlled Trials ISRCTN03704676. http://dx.doi.org/10.1186/ISRCTN03704676.

Introduction

Depression has been ranked among the leading causes of disease burden throughout the world (Mathers & Loncar, 2006), with high rates of lifetime incidence, early age onset, high chronicity, and role impairment (Richards, 2011). Twelve-month prevalence rates for depression have been estimated at 6.6% in the US (Kessler et al., 2003), 8.5% in Europe and 10.3% in Ireland (Ayuso-Mateos et al., 2001). Further, an overall 12-month prevalence rate of 12.3% for older adults (65+) in Europe has been reported and in Ireland the reported 12-month prevalence has been estimated at 11.9% (Copeland et al., 2004).

Epidemiological studies of the occurrence of depression have highlighted younger age groups, with 15–29 years identified as the peak age of onset (Craighead, Sheets, Brosse, & Ilardi, 2007), suggesting that lifetime prevalence will be higher among future cohorts (Craighead et al., 2007). Prevalence rates are higher for females than males (Ayuso-Mateos et al., 2001, Copeland et al., 2004, Ohayon, 2007) and depression exacts significant economic, personal, intra-personal and societal costs, and is associated with losses in quality of life and increased mortality rates (Cuijpers et al., 2007, Rapaport et al., 2005).

Antidepressants are commonly used to treat depression, however relapse is high following cessation, and many patients prefer psychological therapies (Van Schaik, Klijn, & van Hout, 2004), which have proved equally effective as antidepressants (Cuijpers, van Straten, van Oppen, & Andersson, 2008). Cognitive Behavior Therapy (CBT) is the most extensively researched psychological therapy for depression (National Institute for Health and Clinical Excellence, 2006), and has been shown to maintain post-treatment gains and reduce the risk of future relapses and recurrences of depression (Hollon & DeRubeis, 2006).

Accessing evidence-based treatments such as cognitive behavior therapy can be problematic. The worldwide treatment gap in depression has been estimated at 56.3% (Kohn, Saxena, Levav, & Saraceno, 2004). Several barriers such as waiting lists, cost and/or physical difficulties in accessing services, and personal obstacles such as stigma, lack of motivation for change, negative perception of psychological and/or drug treatments play an important role in choosing to seek diagnosis and access treatment (Kohn et al., 2004, Mohr et al., 2010).

Difficulties in accessing evidence-based treatments are universal and in Ireland, for instance, people with depression encounter additional barriers due to a shortage of trained professionals alongside the relative underdevelopment of health services, which are cause for concern (Department of Health and Children, 2006). The fact that less than one third of GPs have training in psychological therapies is also of concern, especially considering that many people will initially bring their psychological difficulties to their primary care physician (Grandes, Montoya, Arietaleanizbeaskoa, Arce, & Sánchez, 2011). More recently, it has been reported that less than 20% of patients presenting to GPs with mental health difficulties are in receipt of specialist services (Hughes et al., 2010, Tedstone-Doherty et al., 2008).

Recent attempts to overcome barriers to accessing treatment involve the evolution of a new understanding in mental healthcare that recognizes both high-intensity (e.g. face-to-face therapy) and low-intensity (e.g. bibliotherapy) interventions to meet different levels of users' needs. Services deliver interventions in a stepped-care model, matching the level of intensity to a patient's presenting needs and to maximize the use of resources. Low-intensity interventions signify treatments that limit specialist therapist time, or use this time in a cost effective manner, for example, group treatments (Bennett-Levy, Richards, & Farrand, 2010). The Irish Health Service Executive (Health Service Executive, 2012) advocate for the implementation of a stepped-care model.

In the UK, The Improving Access to Psychological Therapies (IAPT) program has successfully implemented such a stepped-care model (Clark et al., 2009). However, in many countries access is severely constrained, and even where stepped care models are implemented, there is a need to expand the evidence base regarding different forms of scalable low-intensity intervention. Given the continued growth in high prevalence disorders (depression and anxiety disorders) there is a real need to increase access.

Clinician-guided and self-administered internet-delivered CBT for specific disorders, are one of a range of interventions that have proved a suitable evidence-based option for integration as a low-intensity intervention within a stepped care model (Bennett-Levy, Richards, Farrand, et al., 2010). Internet-delivered interventions have demonstrated their effectiveness in treating depression (Richards & Richardson, 2012). The provision of human support yields enhanced results compared to unsupported interventions (Andersson and Cuijpers, 2009, Richards and Richardson, 2012).

To date, a number of small-scale studies of internet-delivered treatments have been conducted in Ireland (Richards et al., 2013, Sharry et al., 2013). However, larger community based projects are necessary to assess the effectiveness and scalability of such low-intensity interventions.

While other internet-delivered interventions exist and have shown promise the SilverCloud Space from Depression program has been developed specifically to address historical difficulties with engagement in internet-delivered interventions. The design of the platform was based using user-centered processes (Doherty, Coyle, & Matthews, 2010), and embeds a number of features designed to improve engagement, which have previously been categorized as Social, Interactive, Personal, and Supportive (Doherty et al., 2010).

The aim of this study was to demonstrate the effectiveness and potential of a novel, evidence-based internet-delivered intervention (Space from Depression) as a low-intensity community-based treatment for depression. The present paper reports on the main outcomes from the Irish national randomized control trial of the intervention (Space from Depression¹).

Aware is a charity that aims to create a society where those with depression or related mood disorders, and their families, are understood and supported, are free from stigma and have access to a broad range of support options. Their objectives are 1) to provide information and educate people about depression and mood disorders, 2) provide emotional and practical support to individuals and their families and, 3) to support research into understanding and treating depression.

They achieve their objectives through the provision of face-to-face support groups, an online support group, and a low-cost telephone line, all of which are manned by trained volunteers. Aware is a well-recognized and respected brand name in Ireland, with a high number of users nationally. Therefore they are well placed to collaborate in providing a low-intensity depression treatment for the community that will include support for participants.