Clinicians should consider referring depressed patients to Internet Support Groups, according to new RCT

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It can be incredibly difficult to talk about mental health conditions like depression, both for the person going through the illness and the friends and family who are trying to offer support. We know that overcoming this fear and talking through mental health problems can be a real life-saver and this message runs through the excellent Time to Change programme that aims to stamp out mental health stigma and discrimination.

Many of the mental health charities run confidential helplines where trained staff can offer information, advice and support on everything from legal advice to crisis support.

Face-to-face support groups are also popular with people struggling with conditions like depression and there’s some evidence from a 2010 systematic review that support groups are as effective as CBT at reducing depressive symptoms.

Another popular way for people going through mental health difficulties to communicate with each other is the Internet Support Group. These groups have been around pretty much since the Internet became popular in the mid-1990s and they pride themselves on the positive impact that they have on the lives of their members.

It is perhaps surprising, given that these online groups have been around for 20 years or so, that a 2009 systematic review concluded that there is insufficient evidence to report about the effectiveness of online support groups for depression. It’s clearly an area where the practice is far ahead of the research evidence, but of course that means that trials are badly needed to ensure we are not causing more harm than good.

One of the leading researchers in this field is Professor Kathy Griffiths from the Centre for Mental Health Research at the Australian National University in Canberra. The Centre for Mental Health Research is the home of the excellent online self-help programme MoodGYM, which is designed to help people with depression and anxiety.

Professor Griffiths led the 2009 systematic review and so it’s great to see that she has now followed this up by publishing a randomised controlled trial investigating Internet Support Groups for depression.

Methods

The trial participants were recruited via a screening survey that was sent to 70,000 adults in mixed rural and urban areas of Australia. 311 people (aged 18-65) all with elevated psychological distress (measured with the Kessler Psychological Distress instrument) were included in the study. People already receiving mental health treatment and those already participating in a mutual support group were excluded, as were those with self-reported current or previous psychotic or bipolar illness.

The participants were randomised to one of four interventions:

  1. ITP: E-couch (depression stream)
    An online self-help interactive programme for depression that provides information about the diagnosis, epidemiology and treatment of depression and teaches about CBT, interpersonal therapy, applied relaxation and physical activity.
  2. ISG: WellBeing Board
    A custom built moderated bulletin-board where participants could join in with online discussions about wellbeing, feeling better and general issues. Each participant was asked to login at least twice a week and post at least 4 messages each week, but most only managed 1 post every other week. Anonymity was preserved and some topics (e.g. suicide, self harm) were not permitted.
  3. ISG+ITP: WellBeing Board plus e-couch
    This group consisted of the two above interventions in combination. A separate bulletin-board was set up for this group to avoid contamination with the ISG group.
  4. IAC: HealthWatch
    This was the control condition and it consisted of 12 online modules providing health information and asking participants a series of questions about a different topic each week (e.g. nutrition, or social and family relationships or humour).

Each intervention lasted for 12 weeks with one module delivered each week. The interventions remained available for 12 months and assessments were made at baseline, post-intervention, 6 and 12 months. For ethical reasons, control participants were given access to the ITP E-couch system after 6 months.

The primary outcome was depressive symptoms measured with the Centre for Epidemiologic Studies Depression scale.

The authors noted that the sample size was smaller than they had hoped and although it was sufficient to detect the anticipated effects of each intervention alone, it was not large enough to provide a definitive answer about the efficacy of the combined ISG and ITP group.

Results

  • At 3 months:
    • The ISG group had no change in depressive symptoms when compared to the control
  • At 6 months:
    • Both the ISG group and the ISG+ITP group showed significantly fewer depressive symptoms than the control
    • The ITP group was no better than control
  • At 12 months:
    • Both the ISG group and the ISG+ITP group showed significantly fewer depressive symptoms than the control
  • Post-intervention:
    • The ITP group was more effective than the control at reducing depressive symptoms

Conclusions

The authors concluded:

Internet Support Groups (ISGs) for depression are promising and warrant further empirical investigation.

Clinicians might consider referring interested clients to such groups and policy makers have a stronger basis for funding and promoting depression ISGs. The findings further suggest that there may be value in combining standard Internet training programs with an Internet support group since the effect of the ITP occurred immediately post-intervention and tapered off and the effect of the ISG was delayed and increased over time.

For many people, social media (Twitter, Facebook etc) has taken over from the traditional Internet Support Group as the main channel through which they can give and receive support to friends, family and others going through the same issues as them. Websites like Twitter provide access to a much larger group of people which can be positive, but it also comes with a number of challenges, not least that each message has to be less than 140 characters. It’s hard to pour your heart out in a tweet!

There remains an important place in all of this for Internet Support Groups; providing a safe, friendly and non-judgemental place for people to come together, share experiences and support each other. I look forward to seeing further studies that cement the place of these groups in the range of services that can be provided for people with mental health issues.

Links

Griffiths KM, Mackinnon AJ, Crisp DA, Christensen H, Bennett K, et al. (2012) The Effectiveness of an Online Support Group for Members of the Community with Depression: A Randomised Controlled Trial. PLoS ONE 7(12): e53244. doi:10.1371/journal.pone.0053244

Pfeiffer P, Heisler M, Piette J, Rogers M, Valenstein M (2011) Efficacy of peer support interventions for depression: a meta-analysis. General Hospital Psychiatry 33: 29–36. doi: 10.1016/j.genhosppsych.2010.10.002. [Abstract]

Griffiths KM, Calear AL, Banfield M, Tam A (2009) Systematic review on Internet Support Groups (ISGs) and depression (2): What is known about depression ISGs? J Med Internet Res 11: e41. doi: 10.2196/jmir.1303. [Abstract]

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Andre Tomlin

Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He's worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service; an innovative digital platform that helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol with his wife, dog and three little elflings.

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