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Cited by 94Digital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesTelemedicine and Telehealth Implementation

Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care

Open access
Kooistra, Lisa C., Ruwaard, Jeroen, Wiersma, Jenneke E., van Oppen, Patricia, van der Vaart, Rosalie, van Gemert-Pijnen, Julia E.W.C., Riper, Heleen·2016·Internet Interventions
DOI 10.1016/j.invent.2016.01.003PMC PMC6096194
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Abstract

BACKGROUND: Blended care combines face-to-face treatment with web-based components in mental health care settings. Blended treatment could potentially improve active patient participation, by letting patients work though part of the protocol autonomously. Further, blended treatment might lower the costs of mental health care, by reducing treatment duration and/or therapist contact. However, knowledge on blended care for depression is still limited. OBJECTIVES: To develop a blended cognitive behavioural treatment (bCBT) for depressed patients in an outpatient specialized mental health care centre and to conduct a preliminary evaluation of this bCBT protocol. METHOD: A bCBT protocol was developed, taking recommendations into account from depressed patients (n = 3) and therapists and experts in the field of e-health (n = 18). Next, an initial evaluation of integrated high-intensive bCBT was conducted with depressed patients (n = 9) in specialized mental health care. Patients' clinical profiles were established based on pre-treatment diagnostic information and patient self-reports on clinical measures. Patient treatment adherence rates were explored, together with patient ratings of credibility and expectancy (CEQ) before treatment, and system usability (SUS) and treatment satisfaction after treatment (CSQ-8). During and after treatment, the blended treatment protocol was evaluated in supervision sessions with the participating therapists (n = 7). RESULTS: Seven out of nine patients started bCBT, of whom five completed ≥ 90% of treatment. System usability was evaluated as being above average (range 63 to 85), and patients were mostly to very satisfied with bCBT (range 16 to 32). Patients reported improvements in depression, health-related quality of life and anxiety. We observed that therapists evaluated the highly structured blended treatment as a helpful tool in providing evidence-based treatment to this complex patient group. DISCUSSION: Although no conclusions can be drawn based on the current study, our observations suggest that a blended CBT approach might shorten treatment duration and has the potential to be a valuable treatment option for patients with severe depression in specialized mental health care settings. Further exploration of the effectiveness of our bCBT protocol by means of a randomized controlled trial is warranted.

AI snapshot

Written from the paper’s full text.

TL;DR

This paper describes the development and preliminary evaluation of a blended cognitive behavioural treatment (bCBT) combining face-to-face and online sessions for major depression in specialized mental health care. Initial observations suggest bCBT may be acceptable and potentially shorten treatment duration, but the uncontrolled small sample precludes conclusions about effectiveness.

Key findings

  • Of 9 enrolled patients, 7 started bCBT and 5 completed ≥90% of the protocol; completers received bCBT in 10–13 weeks (mean = 12, SD = 1.3), compared with the 16–20 weeks recommended for standard face-to-face CBT.
  • System usability was above average for 6 of 7 respondents (SUS range 63–85; mean = 73.2, SD = 7.3), and treatment satisfaction ranged from 16 to 32 on the CSQ-8 (mean = 22.7, SD = 4.8), with six patients mostly to very satisfied.
  • Patients reported improvements in depression, health-related quality of life, and anxiety; for example, IDS-SR30 mean decreased from 40.44 (SD = 12.87) at baseline to 23.25 (SD = 14.73) post-treatment, and EQ-VAS mean increased from 44.67 (SD = 13.9) to 74.71 (SD = 10.09).
  • Therapists evaluated the highly structured blended treatment as a helpful tool for providing evidence-based treatment to this complex patient group.

Methods

  • The bCBT protocol was developed using recommendations from depressed patients (n = 3) and therapists/experts in e-health (n = 18), then evaluated in an uncontrolled initial study with depressed patients (n = 9) in an outpatient specialized mental health care centre in Amsterdam.
  • Patients were assessed at baseline and post-treatment (10 weeks) using diagnostic information, electronic patient records, and self-report measures including IDS-SR30, BAI, EQ-5D-3L, CEQ, SUS, and CSQ-8; adherence was extracted from patient files and the web-based platform.
  • Data were presented at individual patient level with simple summary statistics (M, SD), and the protocol was evaluated in supervision sessions with participating therapists (n = 7).

Limitations

  • The paper states that no conclusions can be drawn from the current sample and findings cannot be generalized beyond the included patients; it also notes that SUS gives only a general indication of usability and that future studies should examine actual use via logfiles or observation.
  • The paper states that extensive qualitative data collection and formal methods to quantify end-user needs were beyond the scope of the study.
  • Evident from the text: the evaluation was uncontrolled, pre–post, and very small (n = 9 enrolled; 7 started bCBT; 7 had follow-up data), so it cannot establish effectiveness or compare bCBT with standard care.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.invent.2016.01.003

Cites

54 of 54 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 43 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    At follow-up, a decrease in depression severity was reported by seven out of eight patients.

    “At follow-up a decrease in depression severity was reported by seven out of eight patients.”
    Quote in the paperSubstantial claim
  • Findingown data

    Treatment duration among completers ranged from 10 to 13 weeks.

    “Treatment duration among completers ranged from 10 to 13 weeks”
    Quote in the paperSubstantial claim
  • Findingown data

    Six patients reported severe to very severe depressive symptoms on the IDS-SR30.

    “Six patients reported severe to very severe depressive symptoms on the IDS-SR30”
    Quote in the paperNot a substantial claim
  • Findingown data

    Patient 7 reported an increase of two points on the IDS-SR30 compared to baseline, indicating very severe depressive symptoms.

    “Patient 7 reported an increase of two points on de IDS-SR30 compared to baseline, indicating very severe depressive symptoms.”
    Quote in the paperNot a substantial claim
  • Findingown data

    One participant (patient 8) was somewhat dissatisfied with the content of CBT treatment.

    “One participant (patient 8) was somewhat dissatisfied with the content of CBT treatment”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 27
  • May combine two claims. 25
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Reasons for the two other patients to discontinue bCBT after the start of treatment were a full remission of the depressive disorder due to the use of anti-depressant medication (patient 1) and a shift in the main focus of treatment from depression to attention deficit disorder (patient 9).

    “Reasons for the two other patients to discontinue bCBT after the start of treatment were a full remission of the depressive disorder due to the use of anti-depressant medication (patient 1) and a shift in the main focus of treatment from depression to attention deficit disorder (patient 9).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Pre-treatment CEQ total scores ranged from 31 to 42 (mean = 33.9, SD = 3.6).

    “Total scores ranged from 31 to 42 (mean = 33.9, SD = 3.6)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Six out of seven patients scored 68 or higher on the SUS, which is indicative of an above average score.

    “Six out of seven patients scored 68 or higher, which is indicative of an above average score (Sauro, 2011).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Sauro, 2011

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Patients used the open-ended question to provide information on context (n = 11).

    “We also noticed that patients used the open-ended question to provide information on context (n = 11)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Therapists noted that having access to up-to-date hardware and software at the mental health care centre is needed to ensure the online treatment environment can be accessed during face-to-face sessions.

    “Therapists also noted this during supervision sessions, adding that having access to up-to-date hard- and software at the mental health care centre is needed in order to make sure the online treatment environment can be accessed during the face-to-face session.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Four out of nine patients received the full bCBT protocol and one patient completed 90% of the protocol (all 10 face-to-face sessions and 7 out of 9 online sessions).

    “In the current study, four out of nine patients received the full bCBT protocol and one patient completed 90% the protocol (i.e. all 10 face-to-face sessions and 7 out of 9 online sessions).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Seven patients were diagnosed with a co-morbid disorder such as anxiety, post-traumatic stress disorder or an autism spectrum disorder.

    “seven were diagnosed with a co-morbid disorder such as anxiety, post-traumatic stress disorder or an autism spectrum disorder.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    We observed slight differences in the number of face-to-face sessions needed to ensure delivery of the full content of the bCBT protocol: one patient received nine face-to-face sessions, three patients received all ten sessions, and one patient received eleven sessions.

    “We observed slight differences in the number of face-to-face sessions needed to ensure delivery of the full content of the bCBT protocol, with one patient receiving nine face-to-face sessions, three patients receiving all ten sessions and one patient receiving eleven sessions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Six out of nine patients reported a neutral attitude concerning overall treatment credibility and expectancy, and three patients had a somewhat to moderately positive attitude.

    “with six out of nine patients reporting a neutral attitude concerning overall treatment credibility and expectancy and three patients having a somewhat to moderately positive attitude.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    During the two-month recruitment period, fifty-two patients with depressive symptoms were referred to the mental health care centre.

    “During the two-month recruitment period, fifty-two patients with depressive symptoms were referred to the mental health care centre.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    At follow-up, seven patients completed the system usability scale (SUS).

    “At follow-up, seven patients completed the system usability scale (SUS), evaluating system usability of the web-based treatment platform.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Characteristics of the nine participants were five females and four males.

    “Characteristics of the nine participants (five females, four males) are displayed in Table 1.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Treatment credibility scores ranged from 17 to 22 (mean = 18.6, SD = 1.8), with all patients rating bCBT as somewhat (n = 7) to moderately credible (n = 2).

    “the range of patients' treatment credibility scores was 17 to 22 (mean = 18.6, SD = 1.8,), with all patients rating bCBT as somewhat (n = 7) to moderately credible (n = 2).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Patient 3 reported having the same mild to moderate anxiety level before and after treatment.

    “Patient 3 reported having the same mild to moderate anxiety level before and after treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    At follow-up, seven patients completed the Client Satisfaction Questionnaire-8 (CSQ-8).

    “At follow-up, seven patients completed the Client Satisfaction Questionnaire-8 (CSQ-8), evaluating blended treatment satisfaction.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Out of the twenty-five patients indicated for CBT, ten were excluded because the primary diagnosis was not depression, and one patient had insufficient command of the Dutch language.

    “Out of these patients, ten were excluded because the primary diagnosis was not depression, and one patient had insufficient command of the Dutch language.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Seven out of nine patients started bCBT, of whom five completed ≥ 90% of treatment.

    “Seven out of nine patients started bCBT, of whom five completed ≥ 90% of treatment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Patient 4 chose to receive face-to-face CBT instead of bCBT because of a malfunctioning computer at home.

    “Patient 4 chose to receive face-to-face CBT instead of bCBT, because of a malfunctioning computer at home.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Patient 5 reported the same level of health-related quality of life at follow-up.

    “Patient 5 reported the same level of health-related quality of life at follow-up”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Of nine patients, four reported the current depressive episode was their first episode, two reported it was their second, and three reported two or more prior episodes.

    “Four patients reported that the current depressive episode was their first episode. For two patients the current episode was their second episode, and the remaining three patients reported having two or more prior episodes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Fourteen patients (27%) met inclusion criteria, of whom three decided not to receive treatment at the specialized mental health care centre.

    “Fourteen patients (27%) thus met inclusion criteria, of whom three decided not to receive treatment at the specialized mental health care centre.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The majority of responses (n = 25 out of 35) appeared to be of a reflective nature.

    “The majority of responses appeared to be of a reflective nature (n = 25)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Out of seven patients who started bCBT, five completed 90% or more of the blended treatment protocol, receiving the full face-to-face protocol and completing seven (n = 1) or all nine (n = 4) online sessions.

    “Out of the seven patients who started bCBT, five completed 90% or more of the blended treatment protocol, receiving the full face-to-face protocol and completing seven (n = 1) or all nine (n = 4) online sessions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Total SUS scores ranged from 63 to 85 (mean = 73.2, SD = 7.3), which can be translated into system evaluation adjectives ranging from 'OK' to 'good' (n = 2) to 'good' to 'excellent' (n = 5).

    “Total scores ranged from 63 to 85 (mean = 73.2, SD = 7.3), which can be translated into system evaluation adjectives ranging from ‘OK’ to ‘good’ (n = 2) to ‘good’ to ‘excellent’ (n = 5) (Bangor et al., 2009).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bangor et al., 2009

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Most often the indication for other treatment concerned other types of psychotherapy (n = 12) such as interpersonal therapy, psychoanalytic treatment or CBASP, or inpatient or day-treatment (n = 11).

    “Most often this concerned an indication for 1) other types of psychotherapy (n = 12) such as interpersonal therapy (IPT), psychoanalytic treatment or cognitive behavioural analysis system of psychotherapy (CBASP) or 2) inpatient or day-treatment (n = 11).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Eleven patients could be approached for study participation, of whom nine agreed to participate and filled in the baseline questionnaires.

    “Therefore, eleven patients could be approached for study participation, of whom nine agreed to participate in the study and filled in the baseline questionnaires.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Patient 6 reported a decrease in health-related quality of life after treatment, due to an increase in physical pain.

    “patient 6 reported a decrease in health-related quality of life after treatment, due to an increase in physical pain.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Patient 7 could no longer travel to the outpatient clinic for the face-to-face sessions due to financial problems.

    “Patient 7 could no longer travel to the outpatient clinic for the face-to-face sessions, due to financial problems.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Treatment expectancy ranged from 12 to 21 (mean = 15.3, SD = 3.2), ranging from slightly negative (n = 3), to neutral (n = 4), to moderately positive (n = 2).

    “Treatment expectancy ranged from 12 to 21 (mean = 15.3, SD = 3.2), ranging from slightly negative (n = 3), to neutral (n = 4), to moderately positive (n = 2).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Two patients provided their therapist with an evaluation of bCBT in general.

    “In addition to the responses on the open-ended question, two patients provided their therapist with an evaluation of bCBT in general.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Patients provided information on how they evaluated the session on six occasions.

    “Patients provided information on how they evaluated the session on six occasions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Recent studies show promising treatment effects and acceptability for patients with more severe symptoms.

    “Although most studies focussed on patients with mild to moderate symptoms (Richards and Richardson, 2012), recent studies also show promising treatment effects and acceptability for patients with more severe symptoms (Andrews and Williams, 2014, Hedman et al., 2014, Ruwaard et al., 2012, Williams and Andrews, 2013).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Andrews and Williams, 2014

      Not checked in the free run.

    • cites Hedman et al., 2014 source

      Not checked in the free run.

    • cites Ruwaard et al., 2012 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Cognitive behavioural treatment (CBT) for depression has proved to be a clinically effective psychotherapy.

    “Cognitive behavioural treatment (CBT) for depression has been studied extensively and has proved to be a clinically effective psychotherapy (Butler et al., 2006, Cuijpers et al., 2013a, Cuijpers et al., 2013b).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Butler et al., 2006 source

      Not checked in the free run.

    • cites Cuijpers et al., 2013a

      Not checked in the free run.

    • cites Cuijpers et al., 2013b

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A possible reason for relatively low uptake of online therapies is that end-users, such as patients and therapists, lack knowledge about the potential costs and benefits of online treatment.

    “A possible reason for the relatively low uptake in routine practise could be that end-users, such as patients and therapists, lack knowledge about the potential costs and benefits of online treatment (Bremmer and van Es, 2013).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bremmer and van Es, 2013

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Intensifying treatment augments the effectiveness of face-to-face psychotherapy, with a treatment intensity of two sessions per week increasing the effect size with g = 0.45 compared to one session per week.

    “A recent metaregression analysis (Cuijpers et al., 2013b) indicated that intensifying treatment augments the effectiveness of face-to-face psychotherapy, with a treatment intensity of two sessions per week increasing the effect size with g = 0.45 compared to one session per week.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Cuijpers et al., 2013b

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Integration of online treatment into routine mental health care could potentially be stimulated by offering treatment in a blended format.

    “The integration of online treatment into routine mental health care could potentially be stimulated by offering treatment in a blended format (Cuijpers and Riper, 2014).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Cuijpers and Riper, 2014

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Therapists are sceptical about whether online treatment could benefit treatment outcomes compared to face-to-face treatment.

    “Further, therapists are sceptical about whether online treatment could benefit treatment outcomes compared to face-to-face treatment (Becker and Jensen-Doss, 2013).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Becker and Jensen-Doss, 2013 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    bCBT can potentially reduce the number of face-to-face sessions and overall length of therapy.

    “Further, bCBT can potentially reduce the number of face-to-face sessions and overall length of therapy.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Due to the complex and co-morbid nature of this particular patient group, a highly structured protocol that predominantly focuses on depression will not always provide enough treatment for some patients to reach remission, and continuation of CBT or a referral to another treatment will be necessary.

    “due to the complex and co-morbid nature of this particular patient group, a highly structured protocol that predominantly focuses on depression will not always provide enough treatment for some patients to reach remission, and continuation of CBT or a referral to another treatment will be necessary.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A recent Delphi study suggested that blended treatment is positively perceived by patients and therapists.

    “Further, a recent Delphi study suggested that blended treatment is positively perceived by patients and therapists (Van der Vaart et al., 2014).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Van der Vaart et al., 2014 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    All self-report measures used in the study are considered to have good psychometric properties and were administered via the Internet.

    “All self-report measures used in our study are considered to have good psychometric properties and were administered via the Internet.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The study by Wilhelmsen and colleagues found that a sense of relatedness in terms of feeling connected to the therapist and being able to identify with the online CBT modules appears to be an important element for patients (n = 14) to persist with bCBT in primary care.

    “the study by Wilhelmsen and colleagues (Wilhelmsen et al., 2013) found that a sense of relatedness in terms of feeling connected to the therapist and being able to identify with the online CBT modules appears to be an important element for patients (n = 14) to persist with bCBT in primary care.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Wilhelmsen et al., 2013 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Extensive collection and evaluation of qualitative data was beyond the scope of the current paper.

    “extensive collection and evaluation of qualitative data was beyond the scope of the current paper.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Combining the two treatment formats rather than blending them into one treatment protocol can lead to increased treatment dosage and higher costs.

    “However, combining the two treatment formats rather than blending them into one treatment protocol can also lead to increased treatment dosage and higher costs (Kenter et al., 2015).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Kenter et al., 2015 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A recent meta-analysis found that overall, patients completed 84% of sessions in face-to-face CBT and 80% of sessions in guided online CBT.

    “a recent meta-analysis found that overall, patients completed 84% of sessions in face-to-face CBT and 80% of sessions in guided online CBT (Van Ballegooijen et al., 2014).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Van Ballegooijen et al., 2014 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    No conclusions can be drawn based on the current sample and findings cannot be generalized beyond the included group of patients.

    “no conclusions can be drawn based on the current sample and our findings cannot be generalized beyond the included group of patients.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    By treating depression first with an evidence-based treatment such as CBT, better decisions can be made concerning the next steps in treatment.

    “By treating depression first with an evidence-based treatment such as CBT, we believe better decisions can be made concerning the next steps in treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    This could benefit accessibility of care and might lower the costs of mental health care.

    “This could benefit accessibility of care and might lower the costs of mental health care.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    bCBT has the potential to be a suitable/valuable intervention for depression in specialized mental health care.

    “Our results indicate that bCBT has the potential to be a suitable intervention for depression in specialized mental health care.”
    • Also stated in: § Conclusion · hedged
      “Our observations suggest that blending face-to-face and online CBT sessions has the potential to be a valuable treatment option for patients with severe depression at specialized mental health care settings.”
    Quote in the paperSubstantial claim
49 of 49

  • The paper relies on this without support.

    A bCBT protocol for depression in specialized mental health care was not yet available.

    “Our primary objective was to develop a bCBT protocol for depression in specialized mental health care, because, to the best of our knowledge, such a protocol was not yet available.”

  • The paper relies on this without support.

    High intensity blended treatment has not yet been studied.

    “Although high intensity blended treatment has not yet been studied, preliminary evidence that a blended treatment format can offer CBT effectively was provided by the uncontrolled study of Månsson and colleagues (Månsson et al., 2013), focussing on a community-based sample of patients with moderate anxiety or depression (n = 15).”

  • The paper relies on this without support.

    Online treatment improves the accessibility and affordability of evidence-based mental health care.

    “In addition, online treatment is believed to improve the accessibility and affordability of evidence-based mental health care.”

  • The paper relies on this without support.

    Mental health services in specialized mental health care in the Dutch health care system focus on more complex, chronic and severe patients.

    “Within the Dutch health care system these potential benefits are highly relevant to specialized mental health care, because mental health services in this setting focus on more complex, chronic and severe patients.”

  • The paper relies on this without support.

    Face-to-face CBT for depression requires a minimum of 16 to 20 weeks.

    “compared to the minimum of 16 to 20 weeks needed in face-to-face CBT.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Advantages of blended care compared to classical face-to-face psychotherapy include the increase of the treatment dose, promoting patient cooperation, and improving the transfer of learned contents into everyday life.

    “Advantages of BC compared to classical f2f-psychotherapy include the increase of the treatment dose, promoting patient cooperation, and improving the transfer of learned contents into everyday life (Kooistra et al., 2016).”

    From TONI - One for all? Participatory development of a transtheoretic and transdiagnostic online intervention for blended care (2024) · cites this paper as Kooistra et al., 2016

    The Introduction (page unavailable) identifies increased treatment intensity and active patient participation as potential benefits of blended care. In Results > Initial evaluation of bCBT (page unavailable), one patient says the online component helped them put treatment into practice more easily. The paper does not establish improved transfer to everyday life as a general advantage over face-to-face psychotherapy; its claims about benefits are tentative. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • The System Usability Scale (SUS) has increasingly been applied to measure usability of internet-based cognitive behavioural therapy (iCBT) in feasibility and evaluation studies in mental healthcare.

    “In feasibility and evaluation studies on iCBT in mental healthcare, the System Usability Scale (SUS) has increasingly been applied to measure usability [7–9]”

    From Dimensionality of the system usability scale among professionals using internet-based interventions for depression: a confirmatory factor analysis (2020) · cites this paper as [7]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Five EQ-5D scores increased, not four

    Minor

    The EQ-5D rows show increases for patients 1, 2, 3, 8 and 9. One score stayed the same and one decreased, as the prose also describes.

  • BAI score of 29 has the wrong severity index

    Minor

    Patient 2's baseline BAI score of 29 is assigned index 3 in the table, but the paper defines scores from 19 to 29 as index 2.

  • Follow-up depression severity categories exceed the stated group size

    Minor

    The stated categories contain 3 + 2 + 3 = 8 patients, although the preceding sentence says seven patients had decreased depression severity. The table shows only two patients with moderate severity at follow-up.

    Reported 7 · recomputed 8

  • Patient 7 has a follow-up depression score despite reportedly missing follow-up measures

    Minor

    The text identifies patient 7 as not having completed follow-up measures, whereas Table 1 gives patient 7 an IDS-SR score of 50 at T1.

4 of 4

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Authors
Kooistra, L. C., Ruwaard, J., Wiersma, J. E., van Oppen, P., van der Vaart, R., van Gemert-Pijnen, J. E. W. C., & Riper, H.
Affiliations
  • Amsterdam Public Health (NL)
  • University of Southern Denmark (DK)
Corresponding author
Kooistra, Lisa C.
ORCID
Venue
Internet Interventions
Publisher
Elsevier BV
Published
2016-05
Volume
4
Pages
61-71
ISSN
2214-7829 (ISSN-L)
DOI
10.1016/j.invent.2016.01.003
PMC
PMC6096194
OpenAlex
W2263415765
Semantic Scholar
317257b61adea0536d90cfdedf4b0a8cd0a2387d
Cited by
92
References
54
Citations by year
2026: 1 · 2025: 6 · 2024: 8 · 2023: 13 · 2022: 10 · 2021: 7 · 2020: 16 · 2019: 9 · 2018: 11 · 2017: 10 · 2016: 1
FWCI
15.92
Type
journal article
Language
en
Open access
Licence
Locations
  • Internet Interventions (publishedVersion, cc-by-nc-nd)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion, other-oa)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
  • University of Twente Research Information (publishedVersion, other-oa)
  • Leiden Repository (Leiden University) (submittedVersion)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion, cc-by-nc-nd)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • VU Research Portal (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • University of Twente Research Information (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Funders
  • Innovatiefonds Zorgverzekeraars (837001007)
  • ZonMw (the Netherlands Organization for Health Research and Development)
Topics
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
Keywords
major depressive disorder, severe depression, web-based treatment, e-health, specialized mental health care, outpatient care, medication adherence, system usability, treatment satisfaction, therapist supervision, health-related quality of life, anxiety

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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