With depression expected to become one of the leading causes of disability in high income countries in 2030, there is a need for evidence based options for treating depression in various settings around the world.

Depression is not only the most prevalent mental disorder and associated with a quality of life decrement, but also represents an economic burden, with substantial costs.

In treating depression, psychotherapy is just one of the evidence-based treatment options available. Although there have been considerable changes in the mental health field and we now have several treatment options for depression, it seems that many people still remain untreated (Mack et. al, 2014).

Lack of knowledge, high costs and anticipated negative social consequences are among the reasons why people do not seek help. Other reasons (more related to resources than beliefs) are the limited availability of specialists in the field, geographical inaccessibility and the limited working hours of specialists.

In recent years, Internet-Based Interventions (IBIs) have been proposed as ways of overcoming these barriers and improving people’s access to mental health services. Proponents of these new interventions suggest they have a number of advantages, e.g.

• They are more easily accepted, because they can take place in comfortable locations for the participant and they can be accessed at any time
• They are supposed to involve the participant, so they can feel active during the sessions, expanding the integration of acquired skills in daily life
• They also have reduced costs compared to face-to-face approaches and might be appealing for people who do not want to see a therapist for various reasons
• Also there are studies which show that IBIs are effective in the treatment of depression, even when they are compared directly to traditional face-to-face interventions.

All good so far, but as expected there are a few potential disadvantages here as well:

• People have low expectations regarding the effectiveness of these interventions
• They may be worried about the protection of their personal data
• They may not feel comfortable using the IBIs
• They may have low levels of Internet experience, or in some cases even high internet anxiety.

The authors of this study wanted to:

1. Evaluate the acceptance of IBIs for mental health problems in primary care patients with depressive symptoms
2. Examine the effects of a brief information video, or an Acceptance Facilitating Intervention (AFI), which provided information on patients’ acceptance of IBIs and their perceptions of the barriers to acceptance

Methods

The study was an experimental one, with a parallel group design. There were 128 primary care participants, randomly assigned to either the intervention group or to the control group. The intervention group watched AFI before completing the questionnaire.

AFI consisted of a 7 minute video that provided information about an IBI for depression with the intention of positively influencing patients’ acceptance. The content of the video was designed based on the unified theory of acceptance of technology and currently available research evidence on barriers of acceptance.

Depression symptoms were measured using the PHQ-9 questionnaire, and participants had to fulfil criteria for at least sub-threshold symptoms of depression according to DSM-IV criteria.

The level of acceptance was measured using three items developed from the literature and one item developed in previous studies by the authors:

• Concerns regarding data protection, attitudes towards seeking psychological help and knowledge about IBI were assessed with items developed within the present study
• Other dimensions such as performance expectancy, effort expectancy, social influence, and facilitating conditions were assessed using items drawn from other studies
• Attitudes toward psychological interventions in general were assessed using four items from the Attitudes Towards Seeking Professional Psychological Help Scale.

Results

The average age of the participants was 37.4 years (SD=17.3), with an equal split between males and females. The criteria for Minor Depression was met by 72.7% of the participants, while the rest meet the criteria for Major Depression.

• In the control group, patients’ acceptance scores were:
  • 40% low acceptance
  • 53.1% moderate acceptance
  • 6.3% high acceptance
• For the intervention group, patients’ acceptance scores were:
  • 37.5% low acceptance
  • 43.8% moderate acceptance
  • 18.8% high acceptance
• These results show us that acceptance was significantly higher for the intervention group.

When an IBI was offered for symptoms of depression to the participants, the following percentages of people reported an intention to use it:

• 26.6% in the control group
• 45.3% in the intervention group

The numbers of people reporting a positive intention to use antidepressant medication were:

• 21.8% in the control group
• 17.7% in the intervention group

Conclusions

Overall, the results of the study are in line with others in the field, showing that there is a low to moderate acceptance of the IBIs in depressed primary care patients.

Researchers should focus their attention on improving these numbers because IBIs are an effective way to treat depression.

This aspect might be improved using AFIs in general spaces, but there is a need for more research in the area.

Strengths and limitations

This study is said to be the first one exploring the effects of an AFI on patients’ acceptance of IBIs in the German population. Although the study has an innovative characteristic, there are some limitations to it:

• The instruments the authors used were not validated before and might interfere with the results, although the internal consistency was very good, except for two dimensions (social influence and internet anxiety).
• Also, they used only PHQ-9 for assessing depression symptoms of the participants, which is a self-reported measure and cannot differentiate really well between minor and major depression.
• Another limit might be represented by the AFI used in the study, it might have insufficient information or be irrelevant to some patients. A closer look at it and some preliminary previews and analyses could have revealed possible shortcomings.

Summary

The results of the study are promising but they cannot be generalised at this point.

People suffering from depression often remain untreated and their attitudes toward mental health are a very good predictor of treatment use. As a result, there is a pressing need for more studies that investigate the deeper components of acceptance and use of Internet based interventions.

Links

Primary paper

Ebert, D.D., Berking, M., Cuijpers, P., Lehr, D., Portner, M., Baumeister, H. 2015. Increasing the acceptance of internet-based mental health interventions in primary care patients with depressive symptoms. A randomized clinical trial. Journal of Affective Disorder, 176, 9-17. [PubMed abstract]

Other references

Mack, S., Jacobi, F., Gerschler, A., Strehle, J., Hofler, M., Busch, M.A., Maske, U.E., Hapke, U., Seiffert, I., Gaebel, W., Zielasek, J., Maier, W., Wittchen, H.U. 2014. Self-reported utilization of mental health services in the adults German population-evidence for unmet needs? Results of the DEGS1-mental Health Module (DEGS1-MH). International Journal of Methods in Psychiatric Research. [PubMed abstract]