Guided Internet-Delivered Treatment for Depression: Scoping Review

Feasibility, Acceptability, and Preliminary Efficacy of a Smartphone App-Led Cognitive Behavioral Therapy for Depression Under Therapist Supervision: Open Trial

BACKGROUND

Major depressive disorder affects approximately 1 in 5 adults during their lifetime and is the leading cause of disability worldwide. Yet, a minority receive adequate treatment due to person-level (eg, geographical distance to providers) and systems-level (eg, shortage of trained providers) barriers. Digital tools could improve this treatment gap by reducing the time and frequency of therapy sessions needed for effective treatment through the provision of flexible, automated support.

OBJECTIVE

This study aimed to examine the feasibility, acceptability, and preliminary clinical effect of Mindset for Depression, a deployment-ready 8-week smartphone-based cognitive behavioral therapy (CBT) supported by brief teletherapy appointments with a therapist.

METHODS

This 8-week, single-arm open trial tested the Mindset for Depression app when combined with 8 brief (16-25 minutes) video conferencing visits with a licensed doctoral-level CBT therapist (n=28 participants). The app offers flexible, accessible psychoeducation, CBT skills practice, and support to patients as well as clinician guidance to promote sustained engagement, monitor safety, and tailor treatment to individual patient needs. To increase accessibility and thus generalizability, all study procedures were conducted remotely. Feasibility and acceptability were assessed via attrition, patient expectations and feedback, and treatment utilization. The primary clinical outcome measure was the clinician-rated Hamilton Depression Rating Scale, administered at pretreatment, midpoint, and posttreatment. Secondary measures of functional impairment and quality of life as well as maintenance of gains (3-month follow-up) were also collected.

RESULTS

Treatment credibility (week 4), expectancy (week 4), and satisfaction (week 8) were moderate to high, and attrition was low (n=2, 7%). Participants self-reported using the app or practicing (either on or off the app) the CBT skills taught in the app for a median of 50 (IQR 30-60; week 4) or 60 (IQR 30-90; week 8) minutes per week; participants accessed the app on an average 36.8 (SD 10.0) days and completed a median of 7 of 8 (IQR 6-8) steps by the week 8 assessment. The app was rated positively across domains of engagement, functionality, aesthetics, and information. Participants' depression severity scores decreased from an average Hamilton Depression Rating Scale score indicating moderate depression (mean 19.1, SD 5.0) at baseline to a week 8 mean score indicating mild depression (mean 10.8, SD 6.1; d=1.47; P<.001). Improvement was also observed for functional impairment and quality of life. Gains were maintained at 3-month follow-up.

CONCLUSIONS

The results show that Mindset for Depression is a feasible and acceptable treatment option for individuals with major depressive disorder. This smartphone-led treatment holds promise to be an efficacious, scalable, and cost-effective treatment option. The next steps include testing Mindset for Depression in a fully powered randomized controlled trial and real-world clinical settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05386329; https://clinicaltrials.gov/study/NCT05386329?term=NCT05386329.

Dropout or Drop-In Experiences in an Internet-Delivered Intervention to Prevent Depression and Enhance Subjective Well-Being During the Perinatal Period: Qualitative Study

Background

The perinatal period is a vulnerable time when women are at increased risk of depression. "Mamma Mia" is a universal preventive internet-delivered intervention offered to pregnant women, with the primary goals of preventing the onset or worsening of depression and enhancing subjective well-being during the perinatal period. However, treatment dropout from internet-delivered interventions is often reported.

Objective

The study aim was to acquire an understanding of the different experiences among participants who dropped out of the Mamma Mia intervention during pregnancy, compared to participants who dropped out during the postpartum follow-up phase.

Methods

A total of 16 women from a larger randomized controlled trial (Mamma Mia) participated in individual semistructured interviews following a strengths, weaknesses, opportunities, and threats format. Of the 16 participants included, 8 (50%) women dropped out early from the intervention during pregnancy (pregnancy group), whereas 8 (50%) women dropped out later, after giving birth (postpartum follow-up group). Data were analyzed using the framework approach.

Results

The results showed that there were differences between the groups. In general, more participants in the postpartum follow-up group reported that the program was user-friendly. They became more aware of their own thoughts and feelings and perceived that the program had provided them with more new knowledge and practical information than participants in the pregnancy group. Participants in both groups suggested several opportunities for improving the program.

Conclusions

There were differences between women who dropped out of the intervention during pregnancy and the postpartum follow-up phase. The reported differences between groups should be further examined.

Increasing the accessibility to internet-based cognitive behavioural therapy for depression: A single-blind randomized controlled trial of condensed versus full-text versions

Background

Research shows that internet-based cognitive behavioural therapy (iCBT) is an effective treatment for depression. However, little is known about how the length of the text material in iCBT affects outcomes.

Objective

The aim of this study was to test whether a condensed iCBT version for depression would be non-inferior to the existing full-text version in reducing depressive symptoms at post-treatment. We also wanted to test non-inferiority for secondary outcomes and explore reading speed and ADHD symptoms as potential moderators.

Method

A single-blind randomized controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; full-text (around 60,000 words) and condensed (around 30,000 words, with the option to listen to the text). Estimated between-group effect sizes and their confidence intervals for depression, anxiety and quality of life, were compared to a pre-determined non-inferiority margin (ES = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted.

Results

The condensed version of iCBT was non-inferior to the full-text version on post-treatment measures for depressive symptoms (95 % CI = -0.42-0.24), anxiety symptoms (95 % CI = -0.24-0.32), and quality of life (95 % CI = -0.09-0.49). Non-inferiority was inconclusive for depressive symptoms at the one-year follow-up (95 % CI = -0.60-0.47). There was no significant moderation effects of reading speed (p = 0.06) or ADHD symptoms (p = 0.11) on depressive symptoms.

Conclusion

These results indicate that a condensed version of iCBT for depression is as effective at treating depression as the full-text version. By shortening texts, iCBT may be made available to more people. Due to unequal dropout rates between the groups, these results are preliminary and need to be replicated.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.

Therapists' experiences with providing guided internet-delivered cognitive behavioral therapy for patients with mild and moderate depression: a thematic analysis

Introduction

Guided internet-delivered therapy has shown promising results for patients with mild and moderate depressive disorder, but several challenges with the format have been reported. The aim of this qualitative study was to investigate therapists' experiences providing guided internet-delivered cognitive behavioral therapy for patients with mild and moderate depression.

Material and methods

Twelve therapists were interviewed, and the interviews were analyzed using reflexive thematic analysis.

Results and conclusion

Three themes were created: (1) For the right person, at the right time. This theme is about therapists' experiences appointing patients to the program. It is challenging to predict which patients will benefit from it, and it is not the right option for all patients. (2) It is not like chatting on Facebook. The second theme was about the experiences with demands on clinics, therapists and patients that must be considered. The internet-delivered treatment should not be viewed as a simple treatment option, and the value of having contact with the patients during treatment was emphasized. (3) It is like a railroad, but without the switches. This theme was about the experiences with how the treatment content was conveyed to the patients, how the therapists expressed concerns with the usability of the program and the reported need for more possibilities in tailoring treatment for each patient.