Complaint-Directed Mini-Interventions for Depressive Complaints: A Randomized Controlled Trial of Unguided Web-Based Self-Help Interventions

Heterogeneity of Treatment Effects in Internet- and Mobile-Based Interventions for Depression: A Systematic Review and Meta-Analysis

Importance

While the effects of internet- and mobile-based interventions (IMIs) for depression have been extensively studied, no systematic evidence is available regarding the heterogeneity of treatment effects (HTEs), indicating to what extent patient-by-treatment interactions exist and personalized treatment models might be necessary.

Objective

To investigate the HTEs in IMIs for depression as well as their efficacy and effectiveness.

Data Sources

A systematic search in Embase, MEDLINE, Central, and PsycINFO for randomized clinical trials and supplementary reference searches was conducted on October 13, 2019, and updated March 25, 2022. The search string included various terms related to digital psychotherapy, depression, and randomized clinical trials.

Study Selection

Titles, abstracts, and full texts were reviewed by 2 independent researchers. Studies of all populations with at least 1 intervention group receiving an IMI for depression and at least 1 control group were eligible, if they assessed depression severity as a primary outcome and followed a randomized clinical trial (RCT) design.

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. HTE was investigated using logarithmic variance ratios (lnVR) and effect sizes using Hedges g. Three-level bayesian meta-regressions were conducted.

Main Outcomes and Measures

Heterogeneity of treatment effects was the primary outcome of this study; magnitudes of treatment effect sizes were the secondary outcome. Depression severity was measured by different self-report and clinician-rated scales in the included RCTs.

Results

The systematic review of 102 trials included 19 758 participants (mean [SD] age, 39.9 [10.58] years) with moderate depression severity (mean [SD] in Patient Health Questionnaire-9 score, 12.81 [2.93]). No evidence for HTE in IMIs was found (lnVR = -0.02; 95% credible interval [CrI], -0.07 to 0.03). However, HTE was higher in more severe depression levels (β̂ = 0.04; 95% CrI, 0.01 to 0.07). The effect size of IMI was medium (g = -0.56; 95% CrI, -0.46 to -0.66). An interaction effect between guidance and baseline severity was found (β̂ = -0.24, 95% CrI, -0.03 to -0.46).

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, no evidence for increased patient-by-treatment interaction in IMIs among patients with subthreshold to mild depression was found. Guidance did not increase effect sizes in this subgroup. However, the association of baseline severity with HTE and its interaction with guidance indicates a more sensitive, guided, digital precision approach would benefit individuals with more severe symptoms. Future research in this population is needed to explore personalization strategies and fully exploit the potential of IMI.

Using Chatbot Technology to Improve Brazilian Adolescents' Body Image and Mental Health at Scale: Randomized Controlled Trial

BACKGROUND

Accessible, cost-effective, and scalable mental health interventions are limited, particularly in low- and middle-income countries, where disparities between mental health needs and services are greatest. Microinterventions (ie, brief, stand-alone, or digital approaches) aim to provide immediate reprieve and enhancements in mental health states and offer a novel and scalable framework for embedding evidence-based mental health promotion techniques into digital environments. Body image is a global public health issue that increases young peoples' risk of developing more severe mental and physical health issues. Embedding body image microinterventions into digital environments is one avenue for providing young people with immediate and short-term reprieve and protection from the negative exposure effects associated with social media.

OBJECTIVE

This 2-armed, fully remote, and preregistered randomized controlled trial assessed the impact of a body image chatbot containing microinterventions on Brazilian adolescents' state and trait body image and associated well-being outcomes.

METHODS

Geographically diverse Brazilian adolescents aged 13-18 years (901/1715, 52.54% girls) were randomized into the chatbot or an assessment-only control condition and completed web-based self-assessments at baseline, immediately after the intervention time frame, and at 1-week and 1-month follow-ups. The primary outcomes were mean change in state (at chatbot entry and at the completion of a microintervention technique) and trait body image (before and after the intervention), with the secondary outcomes being mean change in affect (state and trait) and body image self-efficacy between the assessment time points.

RESULTS

Most participants who entered the chatbot (258/327, 78.9%) completed ≥1 microintervention technique, with participants completing an average of 5 techniques over the 72-hour intervention period. Chatbot users experienced small significant improvements in primary (state: P<.001, Cohen d=0.30, 95% CI 0.25-0.34; and trait body image: P=.02, Cohen d range=0.10, 95% CI 0.01-0.18, to 0.26, 95% CI 0.13-0.32) and secondary outcomes across various time points (state: P<.001, Cohen d=0.28, 95% CI 0.22-0.33; trait positive affect: P=.02, Cohen d range=0.15, 95% CI 0.03-0.27, to 0.23, 95% CI 0.08-0.37; negative affect: P=.03, Cohen d range=-0.16, 95% CI -0.30 to -0.02, to -0.18, 95% CI -0.33 to -0.03; and self-efficacy: P=.02, Cohen d range=0.14, 95% CI 0.03-0.25, to 0.19, 95% CI 0.08-0.32) relative to the control condition. Intervention benefits were moderated by baseline levels of concerns but not by gender.

CONCLUSIONS

This is the first large-scale randomized controlled trial assessing a body image chatbot among Brazilian adolescents. Intervention attrition was high (531/858, 61.9%) and reflected the broader digital intervention literature; barriers to engagement were discussed. Meanwhile, the findings support the emerging literature that indicates microinterventions and chatbot technology are acceptable and effective web-based service provisions. This study also offers a blueprint for accessible, cost-effective, and scalable digital approaches that address disparities between health care needs and provisions in low- and middle-income countries.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04825184; http://clinicaltrials.gov/ct2/show/NCT04825184.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-021-12129-1.

The efficacy of self-guided internet and mobile-based interventions for preventing anxiety and depression - A systematic review and meta-analysis

BACKGROUND

Anxiety and depression are highly prevalent mental disorders which are associated with a considerable personal and economic burden. As treatment alone has a minimal impact on prevalence, there is now a growing focus on interventions which may help prevent anxiety and depression. Internet and mobile based interventions have been identified as a useful avenue for the delivery of preventative programmes due to their scalability and accessibility. The efficacy of interventions that do not require additional support from a trained professional (self-guided) in this capacity is yet to be explored.

METHOD

A systematic search was conducted on the Cochrane Library, PubMed, PsycARTICLES, PsycINFO, OVID, MEDline, PsycEXTRA and SCOPUS databases. Studies were selected according to defined inclusion and exclusion criteria. The primary outcome was evaluating the effect of self-guided internet and mobile based interventions on incidence of anxiety and depression. The secondary outcome was effect on symptom severity.

RESULTS

After identifying and removing duplicates, 3211 studies were screened, 32 of which were eligible for inclusion in the final analysis. Nine studies also reported incidence data (depression = 7, anxiety = 2). The overall Risk Ratios for incidence of anxiety and depression were 0.86 (95% CI [0.28, 2.66], p = .79) and 0.67 (95% CI [0.48, 0.93], p = .02) respectively. Analysis for 27 studies reporting severity of depressive symptoms revealed a significant posttreatment standardised mean difference of -0.27 (95% CI [ -0.37, -0.17], p < .001) for self-guided intervention groups relative to controls. A similar result was observed for 29 studies reporting severity of anxiety symptoms with a standardised mean difference of -0.21 (95% CI [-0.31, -0.10], p < .001).

CONCLUSIONS

Self-guided internet and mobile based interventions appear to be effective at preventing incidence of depression, though further examination of the data suggests that generalisability of this finding may be limited. While self-guided interventions also appear effective in reducing symptoms of anxiety and depression, their ability to prevent incidence of anxiety is less clear. A heavy reliance on symptom measures in the data analysed suggests future research could benefit from prioritising the use of standardised diagnostic measuring tools to assess incidence. Future systematic reviews should aim to include more data from grey literature and reduce the impact of study heterogeneity.

Challenges in Recruiting University Students for Web-Based Indicated Prevention of Depression and Anxiety: Results From a Randomized Controlled Trial (ICare Prevent)

BACKGROUND

Depression and anxiety are common mental health conditions in college and university student populations. Offering transdiagnostic, web-based prevention programs such as ICare Prevent to those with subclinical complaints has the potential to reduce some barriers to receiving help (eg, availability of services, privacy considerations, and students' desire for autonomy). However, uptake of these interventions is often low, and accounts of recruitment challenges are needed to complement available effectiveness research in student populations.

OBJECTIVE

The aims of this study were to describe recruitment challenges together with effective recruitment strategies for ICare Prevent and provide basic information on the intervention's effectiveness.

METHODS

A 3-arm randomized controlled trial was conducted in a student sample with subclinical symptoms of depression and anxiety on the effectiveness of an individually guided (human support and feedback on exercises provided after each session, tailored to each participant) and automatically guided (computer-generated messages provided after each session, geared toward motivation) version of ICare Prevent, a web-based intervention with transdiagnostic components for the indicated prevention of depression and anxiety. The intervention was compared with care as usual. Descriptive statistics were used to outline recruitment challenges and effective web-based and offline strategies as well as students' use of the intervention. A basic analysis of intervention effects was conducted using a Bayesian linear mixed model, with Bayes factors reported as the effect size.

RESULTS

Direct recruitment through students' email addresses via the central student administration was the most effective strategy. Data from 35 participants were analyzed (individually guided: n=14, 40%; automatically guided: n=8, 23%; care as usual: n=13, 37%). Use of the intervention was low, with an average of 3 out of 7 sessions (SD 2.9) completed. The analyses did not suggest any intervention effects other than anecdotal evidence (all Bayes factors₁₀≤2.7).

CONCLUSIONS

This report adds to the existing literature on recruitment challenges specific to the student population. Testing the feasibility of recruitment measures and the greater involvement of the target population in their design, as well as shifting from direct to indirect prevention, can potentially help future studies in the field. In addition, this report demonstrates an alternative basic analytical strategy for underpowered randomized controlled trials.

TRIAL REGISTRATION

International Clinical Trials Registry Platform NTR6562; https://tinyurl.com/4rbexzrk.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-018-2477-y.

Comparing a ses-sensitive and an all-ses implementation strategy to improve participation rates of patients with a lower socioeconomic background in a web-based intervention for depressive complaints: a cluster randomised trial in primary care

Background

Depression is a major public health concern, which is most pronounced in population segments with a lower social-economic status (SES). E-health interventions for depressive complaints are proven to be effective, but their reach needs to be improved, especially among people with a lower socioeconomic status (SES). Implementing e-health interventions in the primary care setting with SES-sensitive guidance from General Practice nurses (GP nurses) may be a useful strategy to increase the reach of e-health in lower SES groups. We implemented an evidence-based online intervention that targets depressive complaints in primary care.

Methods

A pragmatic cluster-randomised trial was conducted in two parallel groups where a SES sensitive (SES-sens) implementation strategy with additional face-to-face guidance by GP nurses was compared to an all-SES implementation strategy. The primary outcome was the percentage of lower SES participants in either condition. Participation was defined as completing at least 1 face-to-face session and 2 online exercises. Participation rates were evaluated using logistic mixed modelling.

Results

In both conditions, the participation rates of lower SES participants were quite high, but were notably lower in the SES-sens implementation condition (44%) than in the all-SES implementation condition (58%). This unexpected outcome remained statistically significant even after adjusting for potential confounders between the conditions (Odds Ratio 0.43, 95%-CI 0.22 to 0.81). Less guidance was provided by the GP nurses in the SES-sens group, contrary to the implementation instructions.

Conclusions

From a public health point of view, it is good news that a substantial number of primary care patients with a lower SES level used the implemented e-health intervention. It is also positive that an all-SES implementation strategy performed well, and even outperformed a SES-sensitive strategy. However, this was an unexpected finding, warranting further research into tailoring implementation strategies of e-health interventions towards specific target groups in the primary care setting.

Trial registration

Netherlands Trial Register, identifier: NL6595, registered on 12 November 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01793-w.

Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis

BACKGROUND

Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification.

OBJECTIVE

The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements.

METHODS

A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis.

RESULTS

A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=-0.27, 95% CI -0.36 to -0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=-0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=-1.93, SE=2.28; P=.40).

CONCLUSIONS

The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms.

Self-directed Technology-Based Therapeutic Methods for Adult Patients Receiving Mental Health Services: Systematic Review

BACKGROUND

Technological interventions used to treat illnesses and promote health are grouped under the umbrella term of digital therapeutics. The use of digital therapeutics is becoming increasingly common in mental health. Although many technologies are currently being implemented, research supporting their usability, efficacy, and risk requires further examination, especially for those interventions that can be used without support.

OBJECTIVE

This review aims to identify the evidence-based, self-directed, technology-based methods of care that can be used in adult patients after they are discharged from mental health services. The interventions reviewed are automated with no human input required (either at the patient's or at the technology's end), so the patients can implement them without any support.

METHODS

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PROSPERO (International Prospective Register of Systematic Reviews) guidelines in 3 databases: PubMed, Web of Science, and OVID. The inclusion criteria were self-directed, automated, and technology-based interventions related to mental health, primarily for adults, having a solid evaluation process. The interventions had to be self-directed, in that the participants could use the technology without any external guidance.

RESULTS

We identified 36 papers that met the inclusion criteria: 26 randomized controlled trials, 9 nonrandomized controlled trial quantitative studies, and 1 qualitative study. The technologies used included websites, automated text messaging, phone apps, videos, computer software, and integrated voice response. There were 22 studies focused on internet-based cognitive behavioral therapies as a therapeutic paradigm compared with the waitlist, web-based human-delivered therapy, and other interventions. Among these studies, 14 used paradigms other than the internet-based cognitive behavioral therapy. Of the 8 studies comparing guided and unguided digital care, 3 showed no differences, 3 favored guided interventions, and 2 favored unguided interventions. The research also showed that dropout rates were as high as 80%, citing potential problems with the acceptability of the suggested technologies.

CONCLUSIONS

There is limited research on the efficacy and suitability of self-directed technology-based care options for mental health. Digital technologies have the potential to bridge the gap between ambulatory care and independent living. However, these interventions may need to be developed collaboratively with the users to encourage their acceptability and to avoid high dropout rates.

The Associations of Common Psychological Problems With Mental Disorders Among College Students

Psychological problems like procrastination, perfectionism, low self-esteem, test anxiety and stress are common among college students. There are evidence-based interventions available for these problems that not only have direct effects on these problems, but also indirect effects on mental disorders such as depression and anxiety disorders. Targeting these psychological problems may offer new opportunities to prevent and treat mental disorders in a way that is less stigmatizing to students. In this study we examined the association of five psychological problems with five common mental disorders (panic, generalized anxiety, bipolar, major depressive, and substance use disorder) in a sample of 2,449 students from two Dutch universities. Psychological problems were measured with one item for each problem and mental disorders were measured with the Composite International Diagnostic Interview Screening Scales. Associations were examined with Poisson regression models as relative risks (RR) of the disorders as a function of the psychological problems. The population attributable fraction (PAF) indicates by what percentage the prevalence of the mental disorder would be reduced if the psychological problem was addressed successfully by an intervention. Especially generalized anxiety disorder was strongly associated with psychological problems (strong associations with stress and low self-esteem and moderately with test anxiety). The group with three or more psychological problems had a strongly increased risk for generalized anxiety (RR = 11.25; 95% CI: 7.51-16.85), and a moderately increase risk for major depression (RR = 3.22; 95% CI: 2.63-3.95), panic disorder (RR = 3.19; 95% CI: 1.96-5.20) and bipolar disorder (RR = 3.66; 95% CI: 2.40-5.58). The PAFs for having any of the psychological problems (one or more) were considerable, especially for generalized anxiety (60.8%), but also for panic disorder (35.1%), bipolar disorder (30.6%) and major depression (34.0%). We conclude that common psychological problems are associated with mental disorders and with each other. After adjustment, psychological problems are associated with different patterns of mental disorders. If the impact of the psychological problems could be taken away, the prevalence of several mental disorders would be reduced considerably. The psychological problems may provide a promising target to indirectly prevent and intervene in psychopathology in hard to reach college students with mental disorders.

A systematic review and meta-analysis of psychological interventions to improve mental wellbeing

Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations (n = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

The Use of the Net Promoter Score (NPS) in an Outpatient Allergy and Pulmonary Clinic: An Innovative Look into Using Tablet-Based Tool vs Traditional Survey Method

Introduction

Patient satisfaction has become an essential metric in addition to the type of care they receive. Phone calls, emails, and text to patients after their healthcare visit are the typical way of obtaining the data reflecting patient satisfaction. The purpose of this retrospective quality improvement study is to compare the traditional post-outpatient clinic survey method with an onsite concise two-question survey using a tablet method immediately after the patient visit using Net Promoter Score (NPS) questions.

Methods

Data were collected retrospectively from February to August 2018 from an outpatient subspecialty clinic in southern California using an existing database from two different sources: the traditional method (TM) and the tablet-based tool (TBT), using NPS. The TM data were obtained from a third-party company using two questions via phone, email, and text collected 2–4 weeks after the patient’s visit. The TBT has only two questions that were given to patients upon their visit check-out. These two questions assessed both provider and clinic’s performance using the NPS method.

Results

In total, there were 1708 patients seen from February to August 2018. In the TM, the total outgoing messages during this period were 580 (34.0%) with 156 responses (27%). In the TBT, 648 out of 1708 (37.9%) surveys were collected with a 100% response rate. The NPS score showed that 99.2% of the providers were promoters. The NPS score for the clinic was 96% which reflects a promoter score.

Conclusion

Our results indicate that when using the TBT immediately after their visit to the clinic, a higher response rate was noted. In addition, both methods had similar outcomes in terms of patient satisfaction NPS scores. Future prospective studies with a larger sample size are warranted to evaluate the effectiveness of the TBT tool in assessing patient satisfaction.

Implementing complaint-directed mini-interventions for depressive complaints in primary care to increase participation among patients with a lower socioeconomic status: design of a cluster randomised controlled trial

BACKGROUND

Depression is a major public health concern. E-health interventions for preventing and reducing depressive complaints have proven to be effective, and have the potential to make (mental) health care more accessible and efficient. However, the reach of these interventions needs to be improved, especially among people with a lower socioeconomic status (SES). Stimulating and supporting implementation of e-health in primary care, and offering guidance from general practice nurses (GP nurses) may be important strategies to achieve this.

METHODS/DESIGN

The online 'Complaint Directed Mini-Interventions' (CDMIs) for stress, sleep and worry complaints, which were found to be (cost-)effective in a self-guided format, will be implemented in the primary care setting using a blended care format (i.e. combining e-health with face-to-face sessions) with minimal guidance provided by the GP nurse. The main aim is to evaluate whether a SES-sensitive implementation strategy improves the participation rate (i.e. reach) of lower-SES patients in the blended online CDMIs as compared to a regular implementation strategy in a cluster randomised controlled trial. Randomisation will occur at the level of the GP nurse, and 228 patients will be included in the study. The primary outcome is the participation rate (completing at least one face-to-face session and two online exercises) of the lower-SES target group. It is hypothesised that this percentage will be higher in the SES-sensitive group as compared to the regular group. Secondary objectives are to evaluate the implementation process, to monitor and evaluate psychological complaints (depression, sleep, stress, worry and anxiety) and well-being over time. Patient assessments will take place at baseline, 3 and 12 months post baseline.

DISCUSSION

This study should contribute to our knowledge of reaching the lower-SES groups with a brief and complaint-specific blended approach for depressive complaints in primary care. It should also further our knowledge on successful strategies to implement depression prevention in primary care.

TRIAL REGISTRATION

Netherlands Trial Register, ID: NL6595. Registered on 12 November 2017.

Examining the Effectiveness of a Web-Based Intervention for Depressive Symptoms in Female Adolescents: Applying Social Cognitive Theory

BACKGROUND

Depression is a serious mental health illness among adolescents especially girls. Web-based treatment can possibly become a solution for reducing mental health problems in adolescents. This study is one of the first trials aimed to evaluate the efficiency of web-based depression improvement program among female adolescents based on the Social Cognitive Theory (SCT).

STUDY DESIGN

Randomized Controlled Trial.

METHODS

A six-month randomized controlled trial based on the SCT was implemented in female schools in Hamadan City, west of Iran in 2018 on 128 female students with mild to moderate depressive symptoms (CES-D =10-45). They were randomly assigned to either intervention or control group (n= 64 in each group). Depression improvement program was implemented through the website via short videos, animations and Power-Point slides. Depression was evaluated using Center for Epidemiologic Depression Scale. A researcher-made questionnaire based on the sheerer and Perceived-Social-Support-Scale-Revised (PSSS-R) questionnaires were used to evaluate the SCT constructs. The data were analyzed using SPSS software.

RESULTS

The intervention program resulted in the improvement of depression in 12 wk based on Intent-to-treat analyses. Nevertheless, these achievements seem to have decreased by 24 wk in intervention group. The intervention increased the mean scores of the constructs of social support and self-regulation from baseline to 12 wk in the intervention group (P<0.05). The intervention had no effect on outcome expectations and self-efficacy. There were no statistically significant associated between theory constructs changes and changes in depression (P>0.05).

CONCLUSION

The web-based intervention improved depression in female students. Future training using strategies for the sustainable improvement of depression in female students are needed.

Complaint-Directed Mini-Interventions for Depressive Symptoms: A Health Economic Evaluation of Unguided Web-Based Self-Help Interventions Based on a Randomized Controlled Trial

BACKGROUND

Depression prevention and early intervention have become a top priority in the Netherlands, but with considerable room for improvement. To address this, Web-based complaint-directed mini-interventions (CDMIs) were developed. These brief and low-threshold interventions focus on psychological stress, sleep problems, and worry, because these complaints are highly prevalent, are demonstrably associated with depression, and have substantial economic impact.

OBJECTIVE

The objective of this economic evaluation was to examine the added value of Web-based, unguided, self-help CDMIs compared with a wait-listed control group with unrestricted access to usual care from both a societal and a health care perspective.

METHODS

This health economic evaluation was embedded in a randomized controlled trial. The study entailed 2 arms, in which 3 Web-based CDMIs were compared with a no-intervention waiting-list control group (which received the intervention after 3 months). We conducted measurements at baseline, and at 3 and 6 months. The primary outcome was the rate of responders to treatment on depressive symptoms as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). We estimated change in quality of life by calculating effect sizes (Cohen d) for individual pre- and posttreatment IDS-SR scores using a conversion factor to map a change in standardized effect size onto a corresponding change in utility. We calculated incremental cost-effectiveness ratios using bootstraps (5000 times) of seemingly unrelated regression equations and constructed cost-effectiveness acceptability curves for the costs per quality-adjusted life-year (QALY) gained.

RESULTS

Of 329 study participants, we randomly assigned 165 to the CDMI group. At 3 months, the rate of responders to treatment was 13.9% (23/165) in the CDMI group and 7.3% (12/164) in the control group. At 3 months, participants in the CDMI group gained 0.15 QALYs compared with baseline, whereas participants in the control group gained 0.03 QALYs. Average total costs per patient at 3 months were €2094 for the CDMI group and €2230 for the control group (excluding baseline costs). Bootstrapped seemingly unrelated regression equations models resulted in a dominant incremental cost-effectiveness ratio (ie, lower costs and a higher rate of responders to treatment) for the CDMI group compared with the control group at 3 months, with the same result for the costs per QALY gained. Various sensitivity analyses attested to the robustness of the findings of the main analysis.

CONCLUSIONS

Brief and low-threshold Web-based, unguided, self-help CDMIs have the potential to be a cost-effective addition to usual care for adults with mild to moderate depressive symptoms. The CDMIs improved health status, while reducing participant health care costs, and hence dominated the care-as-usual control condition. As intervention costs were relatively low, and the internet is readily available in the Western world, we believe CDMIs can be easily implemented on a large scale.

TRIAL REGISTRATION

Netherlands Trial Register NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM).

Microinterventions produce immediate but not lasting benefits in mood and distress

Untreated depression remains one of the largest public health concerns. However, barriers such as unavailability of mental health providers and high cost of services limit the number of people able to benefit from traditional treatments. Though unsupported Internet interventions have proven effective at bypassing many of these barriers given their reach and scalability, attrition from interventions has been an ongoing concern. Microinterventions, or ultra-brief online tools meant to produce a rapid improvement in mood, may offer a way to provide the benefits of unsupported Internet interventions quickly, before attrition might occur. This study examined the immediate and lasting effects of three microinterventions (Breathing Exercises, Thought Records, and a Pleasant Activities Selector) on mood and distress. Participants (N=122) were randomized into three groups, each group completing two of the three microinterventions. Participants were asked to rate their mood and level of distress before and after completing the microintervention. Depression and perceived stress were assessed at baseline and at four weekly follow-ups. Although lasting effects were not found, a significant within-group reduction in distress and improvement in mood were observed immediately following the completion of the microintervention. This study demonstrates the potential benefits of microinterventions to individuals for their immediate needs vis-à-vis mood and distress.