There is a high prevalence of depression in adults, which has a substantial impact at both individual and societal levels.
Psychological treatments for depression have proven effectiveness, albeit with smaller effect sizes than has previously been claimed (Gant, 2019). Yet, there is a gap between need and number accessing services for a number of reasons, including:
- Reluctance to seek help,
- Missed diagnoses in primary care,
- Lack of therapy provision, and
- Therapists not adhering adequately to evidence based protocols.
This means that often, only antidepressants are prescribed for mild to moderate depression, which is at odds with both treatment guidelines (which advocate patient choice) and with the preferences that depressed people express for being offered the option of psychological therapy.
Internet interventions hold promise for being scalable and easily accessible, as well as more cost effective (Sampson, 2016). Over recent years, internet interventions for people with depression have been shown to be effective, but we know less about who these interventions tend to work better for. As was highlighted by Lucacel (2015), acceptance of internet based interventions is low to moderate. One factor which may potentially influence both acceptance of and effectiveness of these interventions is attitudes towards treatment, which have been found to predict outcome in both psychological therapy and antidepressant medication treatment.
Therefore Schroder et al (2018) examined whether attitudes towards internet interventions affected outcome, and how these attitudes change over the duration of the intervention.
The EVIDENT trial (Klein et al, 2013) was a large, multicentre randomised control trail that compared an internet intervention, Deprexis in combination with treatment as usual, to treatment as usual only in adults with mild to moderate depression. The participants were adults, age 18-65, who scored between 5 and 14 on the PHQ-9 questionnaire.
Deprexis is a CBT-based intervention. It is divided into 10 modules, which address cognitive restructuring, behavioural activation, problem solving, interpersonal skills and acceptance and mindfulness. Subsequent content is tailored on the basis of user’s answers to exercises and their feedback. The platform includes audio material, worksheets, and automatic daily prompts. Those with moderate depression (PHQ-9 > 9) received therapist input to the Deprexis programme via email, whilst those with mild depression (PHQ-9 ≤ 9) did not. The intervention lasted for 3 months.
The main measure used in this investigation was a 16-item questionnaire called the Attitudes toward psychological online interventions questionnaire (APOI).
Over 2,000 potential participants were screened for the study, and just over 1,000 met the inclusion criteria and agreed to take part. Of these, 503 participants were randomised to the Deprexis intervention, and 501 to the control group. Uptake of the internet intervention was good, with < 5% failing to log into the platform at all, and around 80% completing at least 4 modules.
The key finding was that those participants who had more positive attitudes towards internet interventions at the outset of the study were more likely to experience a greater reduction in their depressive symptoms over time. This particularly applied to having less negative attitudes on the Technologization Threat Subscale (i.e. preferring to work with a person than a computer). Although negative attitudes on this subscale were correlated with how much time participants spent using the programme, this did not explain the detrimental effect on outcome.
Participant attitudes towards internet interventions tended to change over time in those who received Deprexis as compared to controls, although the effect size was small. There was a positive association between both the direction and magnitude of the attitude change and the change in depressive symptoms. In other words, those who benefitted more from the internet intervention had more positive attitudes towards internet interventions at follow-up.
The authors concluded that:
Participants with more positive initial attitudes experienced greater symptom reduction after using the Internet intervention, compared to those with more negative attitudes
This impact was not explained by the time participants spent using the intervention.
Post-treatment attitudes were associated with previously experienced symptom changes, such that attitudes tended to be more positive among those who experienced pronounced improvements, and vice versa, negative among those who experienced deterioration.
Strengths and limitations
- This study recruited a large sample, through multiple recruitment avenues, including clinical services.
- However, many who were screened were too severely depressed to participate so we don’t know, from this study, how this might apply to these persons.
- As this research was conducted in Germany, we also don’t know the extent to which it may (or may not) be generalisable to other countries.
- The eligibility criteria for this study specified that participants be prepared to fill in online material, and this means that those with particularly negative attitudes towards the internet may be missed.
- This study benefitted from the inclusion of a control group who did not receive the internet intervention.
- Although the quantitative scale for assessing attitudes to online interventions included 4 sub-scales, nuances in attitudes towards internet intervention, which could be elicited through qualitative methodology, may have been missed here.
- And of course, self-report questionnaires are likely to be affected by social desirability bias.
- There were 2 different forms of internet intervention delivered: one with therapist support, and one unguided. However, in the analysis, there does not appear to have been any differentiation of these different forms of delivery nor an exploration of whether this impacted on change in attitudes over time.
- Although there was some loss to follow-up, this was less than in other internet interventions. However, follow-up was at post-intervention only, so we don’t know, from these findings, whether these effects are lasting over the longer term.
Implications for practice
On the basis of these findings, we could reasonably conclude that, when offering internet interventions, it is worth exploring patient preferences and attitudes towards the treatment options on offer at the outset of therapy; those who prefer less direct therapist contact may do better in internet interventions. Questionnaires like the APOI may aid this assessment.
Furthermore, this study highlights the need to tell patients about how internet interventions might benefit them; lived user testimonies may be useful here and could be included in the initial introductory materials, but also as part of public health campaigns at national and even international level.
An important message here seems to be that seeing is believing. Those who tried the internet intervention with good effect felt more positive towards internet interventions. However, those who did not benefit felt more negative. This is where a stepped care approach, with an inbuilt progress monitoring system and an increase of intensity of therapist contact either within the internet intervention, via telephone, or face-to-face might be helpful for those who are not improving.
Internet interventions may not suit everyone, and should be offered as an option but not the only option. Also, although attitudes towards internet interventions had an effect on outcome, this was only small in size, and other variables that affect outcome need to be considered as part of an assessment for suitability.
Conflicts of interest
Schroder, J., Berger, T. Meyer. B., Lutz, W., Spath, C. Michel, P., Rose, M., Hautzinger, M., Hohagen, F., Klein, J.P. & Moritz, S (2018). Impact and change of attitudes towards internet interventions within a randomized controlled trial on individuals with depression symptoms. Depression and Anxiety, 35, 421-430. https://onlinelibrary.wiley.com/doi/full/10.1002/da.22727
Gant, E. (2019). Psychotherapy for adult depression: Is it as good as it is cracked up to be? Mental Elf.
Klein, J.P., Berger, T., Schroder, J., Spath, C., Meyer, B., Caspar, F., Lutz, W., Greiner, W., Hautzinger, M., Rose, M., Grafe, V., Hohagen, F., Andersson, G., Vettorazzi, E., & Moritz, S. (2013). The EVIDENT-trial: protocol and rationale of a mutlicentre randomized controlled trial testing the effectiveness of an online-based psychological intervention. BMC Psychiatry, 13, 239. https://doi.org/10.1186/1471-244X-13-239
Lucacel, R. (2015). Internet based interventions for depression: How can we increase acceptance? Mental Elf.
Sampson, C. (2016). Are internet interventions cost effective for mental health? Mental Elf.