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Working through a self-help program online can prevent or delay major depression disorder in people who are vulnerable, a study finds. Similar programs have been used to treat depression, but this may be the first one tested to prevent it, the researchers say.
Online programs for mental health problems can be as effective as face-to-face treatment and offer some advantages: Low cost, available at any time and customizable. But they’re not panaceas.
In this experiment, half of the participants were asked to do six half-hour-long exercises that were based on cognitive behavioral therapy and problem-solving therapy, which are techniques commonly used for in-person therapy.
In the cognitive behavioral therapy, participants were asked to identify positive activities they used to engage in and then are asked to actively plan those activities again. At the next session, participants reflect on their experiences.
For the problem-solving therapy, people were asked to create a list of the things that matter most to them in their lives and brainstorm on how to incorporate those things into daily life. They next were asked to categorize problems and worries into “manageable” and “unmanageable”; the main focus in problem-solving therapy is to tackle those problems that are considered manageable.
Both cognitive-behavioral therapy and problem-solving therapy are intended to change negative thinking in order to alter mood and behavior.
After completing each exercise, participants in the intervention group received written individualized feedback from an online trainer. The trainers did not offer any therapeutic advice, only motivation and encouragement to continue the exercises. Participants also could repeat the online sessions as often as they liked.
The control group received information about depression but was under no obligation to read it.
The study, which was conducted by researchers from Leuphana University in Lueneburg, Germany, recruited 406 people with subthreshold depression, which is defined as having some symptoms of depression but not enough to be diagnosed with major depressive disorder. It was published Tuesday in JAMA, the journal of the American Medical Association.
Of the 406 participants that began the study, 335 completed the telephone follow-up at the end of 12 months. Twenty-seven percent in the intervention group experienced depression compared with 41 percent in the control group.
It is unclear if the people who went on to develop major depressive disorder had experienced it before. Lead author Claudia Buntrock, a PhD candidate in clinical psychology at Leuphana, says that because the study only tracked participants’ mental health over the course of 12 months, the long-term effectiveness of the intervention is unknown.
It’s also not clear if this kind of program could be scaled up. It took the trainers about 30 minutes to provide feedback for each session, and they also stayed in touch with participants via instant messaging, Buntrock says.
Other experiments with online therapy have found that people didn’t continue it if it wasn’t guided by an actual human. One reason could be that when people are depressed, they can have a hard time getting motivated to do things.
“More studies are needed to evaluate the preventive effects of unguided web-based interventions on the onset of major depressive disorder,” Buntrock wrote in an email. Still, Buntrock seems pleased with the results, especially since the German insurance company BARMER GEK that sponsored the trial is now providing it to its customers.
“I was surprised by the big response to our study,” Buntrock wrote. “And of course, I’m surprised about what happens now; that a health insurance company offers the intervention to its members. It’s a success story you might dream of when you start, but it actually seeing to happen is a great feeling.”
The story looks at a study published recently in JAMA that found patients who were at risk of developing major depressive disorder (MDD) were less likely to experience MDD if they engaged in online self-help interventions, within a 12-month timeframe.
The story does a good job of describing the interventions and the bulk of the study design. However, the story doesn’t note that study participants could be on antidepressant medications, nor address whether the use of antidepressants may have skewed the results. The story also would have benefitted from an independent source, and a contextual comparison of this treatment to existing alternatives.
Depression can have a devastating effect on individuals suffering from the disease, affecting not only their quality of life but the quality of life for their loved ones. And those effects have societal impacts as well. For example, the CDC notes that “the economic burden of depression, including workplace costs, direct costs and suicide-related costs, was estimated to be $210.5 billion in 2010.” Research that is aimed at preventing the onset of MDD is important, affects many people, and is well worth covering.
Cost is not addressed in a meaningful way. The story simply refers to online programs for mental health problems as “low cost.” Given that the online programs used in the study involved generating feedback from online trainers for each session and for each patient, the cost may not be negligible. And it’s not clear whether insurers in the U.S. would be willing to pay for preventive mental health treatment. The research was done in Germany, which has a different health care system than the U.S., but the issue of cost should have been addressed more fully.
The story made clear that patients who participated in one of two online self-help interventions had a 27 percent rate of experiencing major depression disorder (MDD) in the 12 months following the study, compared to a 41 percent rate for those who did not participate in the online interventions. That’s enough to earn a satisfactory rating.
It would have been even better if the story had addressed whether there was any difference in performance for patients who received the “cognitive behavioral therapy” intervention versus the “problem-solving therapy” intervention. And if the study didn’t differentiate between results for the two interventions, the story could have said that. This is significant because it’s not clear to readers whether one approach might have been significantly more effective at preventing the onsite of MDD, or if they had comparable results.
The story does not address potential harms, but there are few potential harms associated with the relevant interventions–other than temporary discomfort, stress or anxiety that can come along with addressing difficult feelings. We’ll rate this not applicable.
The story does a lot of things right here: It tells us the number of study participants (406), describes the experimental and control groups, and lays out the broad study design.
But the discussion of limitations fell short, especially since the study itself outlined many to keep in mind. One limitation that felt especially important to include, and which the JAMA paper noted, was that study participants were allowed to take antidepressants. How did the study control for that?
No disease mongering here.
The story does tell readers who funded the work, which is great. However, the only source quoted in the article is the lead author of the relevant study. An independent expert opinion would have been extremely valuable.
The study compared online self-help interventions to an online education course about depression, and the story reflects that. The story doesn’t discuss the use of in-person therapy for preventing the onset of MDD, nor does it discuss the use of pharmaceutical interventions.
The story not only makes clear that this preventive approach to online interventions is fairly novel, but that there are significant questions about whether it could be scaled up.
The story establishes this early on, noting that “Similar programs have been used to treat depression, but this may be the first one tested to prevent it.”
The story appears to go beyond any news release on the work.