Evaluating an e-mental health program (“deprexis”) as adjunctive treatment tool in psychotherapy for depression: results of a pragmatic randomized controlled trial
Open accessAbstract
Background Depressive disorders place a significant disease burden on individuals as well as on societies. Several web-based interventions for depression have shown to be effective in reducing depressive symptoms. However, it is not known whether web-based interventions, when used as adjunctive treatment tools to regular psychotherapy, have an additional effect compared to regular psychotherapy for depression.Methods Adults (N = 98) with a unipolar affective disorder were recruited in routine outpatient psychotherapy practices in Germany from therapists over the course of their initial sessions and randomized within therapists to one of two active treatment conditions: regular psychotherapy or psychotherapy plus a web-based depression program ("deprexis"). Primary outcome was depressive symptoms measured with the Beck Depression Inventory (BDI-II) at 12 weeks. Secondary outcomes were anxiety symptoms, somatic symptoms and quality of life at 12 weeks and six months follow-up. The study also included an assessment of the working alliance after six and 12 weeks.Results The combination of psychotherapy with the web-based program was more effective than psychotherapy alone at 12 weeks, with medium between-group effect sizes on primary depressive symptoms (Cohen's d = .51) and small to medium between-group effect sizes on secondary outcomes (Cohen's d = .07-.55). Furthermore, we did not observe negative side effects in the blended format, e.g., a lower working alliance than in psychotherapy alone.Limitations The study had a smaller than planned sample size and the dropout rate at follow-up was high.Conclusions This study provides first evidence that the use of a web-based program as an adjunctive tool in regular psychotherapy could be a promising option to consider in future treatment for depression.
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In a randomized controlled trial by Berger et al., integrated blended therapy was superior over standard psychotherapy for depression (d = 0.51; n = 98).
“In this randomized controlled trial, integrated blended therapy was superior over standard psychotherapy (d = 0.51; n = 98).”
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Digital health applications in the area of mental health
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“…of simultaneous bCBT compared with face-to-face therapy in alleviating depression symptoms and mental health–related burdens on patients [18,25,29,31-33], whereas there are also studies where patient mental health outcomes in bCBT conditions were found to be similar to usual treatment…”
BackgroundMethodResultInfluentialFriedl, N., Krieger, T., Chevreul, K., Hazo, J., Holtzmann, J., Hoogendoorn, M., Kleiboer, A. M., Mathiasen, K., Urech, A., Riper, H. M., et al. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9020490 · Cited by 19 · see citing works
“For example, a randomized controlled trial by Berger and colleagues [16] showed the superiority of blended treatment, consisting of an internet‐based intervention as an adjunct to face‐to‐face psychotherapy, in comparison to regular face‐to‐face psychotherapy in a pragmatic randomized controlled study in patients with…”
Self-citationRichter, L. E., Machleit-Ebner, A., Scherbaum, N., & Bonnet, U. (2022) · Fortschritte der Neurologie · Psychiatrie · doi:10.1055/a-1826-2888 · Cited by 19 · see citing works
Tong, A. C. Y., Ho, F. S., Chu, O. H., & Mak, W. W. S. (2023) · Journal of Medical Internet Research · doi:10.2196/39029 · Cited by 19 · see citing works
Macrynikola, N., Chen, K., Lane, E., Nguyen, N. S., Pinto, J., Yen, S., & Torous, J. B. (2024) · JMIR Mental Health · doi:10.2196/65222 · Cited by 19 · see citing works
“Recent meta-analytic evidence suggests that supplementing standard interventions with an app has additive effects [7], possibly increasing therapeutic dose without taking up additional clinical resources [23].”
Walder, N., Frey, A., Berger, T., & Schmidt, S. J. (2025) · Journal of Medical Internet Research · doi:10.2196/67067 · Cited by 28 · see citing works
“In adult samples, a proposed explanation is the “good enough” effect—participants may discontinue a DMHI after achieving their personal goals [147].”
Self-citationLiu, Y. S., Hankey, J. R., Lou, N. M., Chokka, P. R., & Harley, J. M. (2021) · Journal of Technology in Human Services · doi:10.1080/15228835.2021.1902457 · Cited by 16 · see citing works
“…are widely available (Andersson, 2016; Barak & Grohol, 2011; Barak et al., 2008; Epstein et al., 2017; Hollis et al., 2018) and their clinical efficacy has been demonstrated on mobile app-based products (Bakker, Kazantzis, Rickwood, & Rickard, 2018; Berger, Krieger, Sude, Meyer, & Maercker, 2018).”
BackgroundInternet Interventions in Clinical Psychology
Andersson, G., & Carlbring, P. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-818697-8.00211-9 · Cited by 15 · see citing works
Pérez, J. C., Fernández, O., Cáceres, C., Carrasco, A. S., Moessner, M., Bauer, S., Espinosa-Duque, D., Gloger, S., & Krause, M. (2021) · JMIR Mental Health · doi:10.2196/26814 · Cited by 20 · see citing works
Schuster, R., Fischer, E., Jansen, C., Napravnik, N., Rockinger, S., Steger, N., & Laireiter, A.-R. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100551 · Cited by 15 · see citing works
“, 2018), first studies also suggest that face-to-face treatment augmented with digital interventions can lead to improved treatment outcomes (Berger et al., 2018; Zwerenz et al., 2017; Schuster et al., 2020a).”
BackgroundLopes, R. D. C. T., da Rocha, G. C., Svacina, M. A., Meyer, B., Šipka, D., & Berger, T. (2023) · JMIR Formative Research · doi:10.2196/46326 · Cited by 14 · see citing works
“Evidence for the efficacy of this program has been reported in German-speaking countries [3,10,15,18-26]) as well as in the United States [27].”
Self-citationBielinski, L. L., Bur, O. T., Wälchli, G., Suter, J. M., Walsh, N., Kley, M. A., Krieger, T., & Berger, T. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100586 · Cited by 15 · see citing works
“BT can be realized in different ways ranging from IBIs provided as stepped care (Nordgreen et al., 2016), aftercare (Hennemann et al., 2018) or add-on (Berger et al., 2018) to more intricate combinations of psychotherapy and internet-based content (Nakao et al., 2018).”
Self-citationBielinski, L. L., & Berger, T. (2020) · Counseling Psychology and Psychotherapy · doi:10.17759/cpp.2020280305 · Cited by 14 · see citing works
Self-citationRenner, J., Täuber, L., & Nieder, T. O. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11041090 · Cited by 14 · see citing works
Bielinski, L. L., Krieger, T., Moggi, F., Trimpop, L. F., Willutzki, U., Nissen, C., & Berger, T. (2020) · JMIR Research Protocols · doi:10.2196/20936 · Cited by 14 · see citing works
“For example, a study by Berger and colleagues [34] was able to show that a combination of psychotherapy and internet-based treatment was more effective than psychotherapy alone.”
Self-citationSchaeuffele, C., Heinrich, M., Behr, S., Fenski, F., Hammelrath, L., Zagorscak, P., Jansen, A., Pohl, S., Boettcher, J., & Knaevelsrud, C. (2022) · Trials · doi:10.1186/s13063-022-06757-0 · Cited by 14 · see citing works
“Those studies that compared both treatment formats directly yielded small to medium between-group effects in favor of blended therapy [6].”
ResultBraun, P., Schwientek, A.-K., Angerer, P., Guthardt, L., Icks, A., Loerbroks, A., & Apolinário-Hagen, J. (2023) · Digital Health · doi:10.1177/20552076231173568 · Cited by 13 · see citing works
Shams, F., Tai, A. M. Y., Kim, J., Boyd, M., Meyer, M., Kazemi, A., & Krausz, R. M. (2023) · Digital Health · doi:10.1177/20552076231203876 · Cited by 14 · see citing works
Kalde, J., Atik, E., Stricker, J. H., Schückes, M., Neudeck, P., Pittig, A., & Pietrowsky, R. (2023) · Psychotherapy Research · doi:10.1080/10503307.2023.2277866 · Cited by 12 · see citing works
“In most of the few available randomized clinical trials (RCTs) on bCBT, patients receiving bCBT experienced greater symptom relief than those receiving standard CBT (Berger et al., 2018; Klein et al., 2016; Schuster et al., 2020b).”
Wu, M. S., Wickham, R. E., Chen, S.-Y., Varra, A. A., Chen, C., & Lungu, A. (2024) · PLoS ONE · doi:10.1371/journal.pone.0313112 · Cited by 12 · see citing works
Internet-Interventionen: Ein Überblick
Berger, T., & Krieger, T. (2018) · PiD - Psychotherapie im Dialog · doi:10.1055/a-0592-0282 · Cited by 12 · see citing works
“[12] Berger T, Krieger T, Sude K et al.”
BackgroundSelf-citationTeo, T. P., Shi, W., Huang, F., & Hoi, C. K. W. (2020) · Patient Education and Counseling · doi:10.1016/j.pec.2020.02.035 · Cited by 11 · see citing works
Gupta, N., Leuba, S., Seifritz, E., Berger, T., & Kawohl, W. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1417784 · Cited by 10 · see citing works
Self-citationKlein, J. P., Barthel, B., Berger, T., & Moritz, S. (2020) · Internet Interventions · doi:10.1016/j.invent.2020.100341 · Cited by 10 · see citing works
Self-citationInternet-Interventionen in der Psychotherapie
Berger, T., Bur, O. T., & Krieger, T. (2019) · PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie · doi:10.1055/a-0963-9055 · Cited by 10 · see citing works
Self-citationDemyttenaere, K., Frank, E., Castle, D. J., & Cindik-Herbrüggen, E. (2019) · Advances in Therapy · doi:10.1007/s12325-019-01038-w · Cited by 9 · see citing works
Titzler, I., Egle, V., Berking, M., Gumbmann, C., & Ebert, D. D. (2019) · Verhaltenstherapie · doi:10.1159/000503408 · Cited by 9 · see citing works
Measuring mental wellbeing of children via human-robot interaction
Abbasi, N. I., Spitale, M., Jones, P. B., & Güneş, H. (2022) · Interaction Studies Social Behaviour and Communication in Biological and Artificial Systems · doi:10.1075/is.21027.abb · Cited by 8 · see citing works
Bielinski, L. L., Krieger, T., Kley, M. A., Moggi, F., & Berger, T. (2023) · Internet Interventions · doi:10.1016/j.invent.2023.100650 · Cited by 8 · see citing works
Self-citationCastro, Ó., Salamanca-Sanabria, A., Alattas, A., Teepe, G. W., Leidenberger, K., Fleisch, E., Car, L. T., Müller‐Riemenschneider, F., & Kowatsch, T. (2024) · Archives of Public Health · doi:10.1186/s13690-024-01424-z · Cited by 10 · see citing works
Köhnen, M., Kriston, L., Härter, M. C., Baumeister, H., & Liebherz, S. (2020) · Journal of Medical Internet Research · doi:10.2196/24584 · Cited by 10 · see citing works
“Interventions of 8 weeks’ duration were the most frequent (26/89; 29%) in the included studies (see Multimedia Appendix 2 [22-99] for baseline diagnoses).”
BackgroundInfluentialBlended Care: Stand der Forschung und Implementierungsmöglichkeiten
Fenski, F., Behr, S., Schaeuffele, C., Boettcher, J., & Knaevelsrud, C. (2023) · Der Nervenarzt · doi:10.1007/s00115-023-01579-0 · Cited by 7 · see citing works
Heinrich, M., Zagorscak, P., Kampisiou, C., Bohn, J., Schulze, L., Schaeuffele, C., Brose, A., & Knaevelsrud, C. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-06564-2 · Cited by 7 · see citing works
Community mental health interventions for people with major depressive disorder: A scoping review
Tan, R. X. R., & Goh, Y. S. (2022) · International Journal of Mental Health Nursing · doi:10.1111/inm.13029 · Cited by 8 · see citing works
Bielinski, L. L., Wälchli, G., Nissen, C., Berger, T., & Moggi, F. (2023) · JMIR Research Protocols · doi:10.2196/47656 · Cited by 7 · see citing works
“On the one hand, the XSL • FO RenderX addition of an internet intervention to standard care or TAU may improve overall treatment effects, as has been demonstrated previously in outpatients and in studies focusing on inpatient treatment [6,25-27].”
Self-citationLopes, R. D. C. T., Meyer, B., Berger, T., & Svacina, M. A. (2020) · Brazilian Journal of Psychiatry · doi:10.1590/1516-4446-2019-0582 · Cited by 8 · see citing works
Self-citationNeue Medien in der Psychotherapie: Blended Therapy aus der Sicht ambulanter Psychotherapeuten
Paul, J., Grünzig, S.-D., Baumeister, H., Bengel, J., & Krämer, L. V. (2019) · PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie · doi:10.1055/a-0824-7557 · Cited by 6 · see citing works
“[5] Berger T, Krieger T, Sude K et al.”
BackgroundEdelbluth, S., Klein, J. P., Schwartz, B., Hehlmann, M. I., Arndt, A., Rubel, J. A., Danilo Moggia, N., Berger, T., Meyer, B., Moritz, S., et al. (2024) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2024.2368520 · Cited by 5 · see citing works
“Randomized controlled trials have demonstrated the efficacy of the web-based self-management intervention deprexis (Beevers et al., 2017; Berger et al., 2011, 2018; Bücker et al., 2018; Fischer et al., 2015; Fuhr et al., 2018; Gräfe et al., 2020; Klein et al., 2016, 2020; Lopes et al., 2023; Meyer…”
Self-citationEffects of therapeutic alliance on patients with major depressive disorder: a literature review
Videtta, G., Busilacchi, S., Bartoccioni, G., Cirella, L., Barone, Y., & Delvecchio, G. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1465017 · Cited by 7 · see citing works
Sudarshan, S., Mehrotra, S., & Thirthalli, J. (2024) · Indian Journal of Psychological Medicine · doi:10.1177/02537176241238289 · Cited by 5 · see citing works
“24,27,63,74,76, 79, 82 A statistically significant change does not necessarily translate to clinically meaningful change.”
Steubl, L., & Baumeister, H. (2023) · Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz · doi:10.1007/s00103-022-03644-6 · Cited by 6 · see citing works
Internet-Interventionen in der Psychotherapie
Berger, T., Bur, O. T., & Krieger, T. (2020) · Fortschritte der Neurologie · Psychiatrie · doi:10.1055/a-1165-7496 · Cited by 5 · see citing works
Self-citationDech, M., Klawohn, J., & Romanczuk-Seiferth, N. (2022) · Verhaltenstherapie · doi:10.1159/000524332 · Cited by 6 · see citing works
“Erste Wirksamkeitsstudien belegen weiterhin nicht nur die Wirksamkeit der blended therapy (Cohens d = 0,51 für Depressionen [Berger et al., 2018]; d = 0,27 für verschiedene Störungsbilder [Lindhiem et al., 2015]; d = 0,44 für Depressionen [Zwerenz et al., 2017]), sondern verweisen außerdem auf ihre…”
BackgroundSextl-Plötz, T., Titzler, I., Schmidt-Hantke, J., Denninger, M., Steubl, L., Baumeister, H., Ebert, D. D., & Zarski, A. (2025) · Digital Health · doi:10.1177/20552076251377943 · Cited by 4 · see citing works
“…BT has demonstrated acceptance among patients, therapists, and stakeholders, 19,21 – 24 ef fi cacy and effectiveness in treating mental disorders, 18,25 – 27 potential time ef fi ciency advantages over traditional FTF psychotherapy, 14,15,28 and the potential of increasing effects of FTF…”
Trimpop, L. F., Bielinski, L. L., Berger, T., & Willutzki, U. (2023) · JMIR Research Protocols · doi:10.2196/41413 · Cited by 5 · see citing works
“BT, where a web-based intervention was provided as an add-on to face-to-face psychotherapy, has been shown to be more effective than psychotherapy alone [11].”
InfluentialSelf-citationNetter, A.-L., Beintner, I., & Brakemeier, E. (2022) · JMIR Formative Research · doi:10.2196/35482 · Cited by 4 · see citing works
“The superiority of blended therapy compared with standard psychotherapy has been shown in 2 studies for mild to moderate depression, also at the 6-month follow-up [36,37].”
BackgroundMiller, R. K., O'Moore, K., Kikas, K., Matheson, J.-A. T., Whitton, A. E., Baldwin, P., Li, S., Black, M., Kampel, L., Cockayne, N., et al. (2025) · JMIR Human Factors · doi:10.2196/68789 · Cited by 3 · see citing works
Digitale Interventionen in der Psychotherapie
Berger, T., Bielinski, L. L., & Klein, J. P. (2024) · PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie · doi:10.1055/a-2018-2250 · Cited by 3 · see citing works
Self-citationSchmid, D. S., Duss, S. B., Hertenstein, E., Nissen, C., Schneider, C., Urech, A., Vorster, A. P. A., & Berger, T. (2023) · Clinical and Translational Neuroscience · doi:10.3390/ctn7030027 · Cited by 3 · see citing works
Self-citationReal-world evaluation of an evidence-based telemental health program for PTSD symptoms
Owusu, J. T., Wang, L., Chen, S.-Y., Wickham, R. E., Michael, S. T., Bahrassa, N. F., Varra, A. A., Lee, J. L., Chen, C., & Lungu, A. (2025) · Scientific Reports · doi:10.1038/s41598-024-83144-6 · Cited by 5 · see citing works
“A growing body of literature has associated blended care therapy with positive clinical outcomes for common mental disorders 25,27–29 .”
Schmid, A., & Kurpicz-Briki, M. (2022) · Studies in health technology and informatics · doi:10.3233/shti220322 · Cited by 3 · see citing works
Internet-Interventionen in der Psychotherapie
Berger, T., Bur, O. T., & Krieger, T. (2019) · PSYCH up2date · doi:10.1055/a-0847-9263 · Cited by 4 · see citing works
“Erste Studien, in welchen herkömmliche Psychotherapie mit herkömmlicher Psychotherapie plus einem Selbsthilfeprogramm bei depressiven Patienten verglichen wurden, zeigten in der ambulanten und stationären Routinebehandlung eine Überlegenheit der Bedingung mit der zusätzlichen Internet-Intervention [18].”
BackgroundSelf-citationVoderholzer, U., Beintner, I., Backes, B., Esguerra, E., & Hessler, J. B. (2021) · Verhaltenstherapie · doi:10.1159/000513643 · Cited by 3 · see citing works
Einsatz und Wirksamkeit von Digitalen Gesundheitsanwendungen in der Patientenversorgung
Ballerstein, M., & Jacob, G. A. (2022) · PSYCH up2date · doi:10.1055/a-1684-6199 · Cited by 3 · see citing works
Atik, E., Stricker, J., Schückes, M., & Pittig, A. (2022) · doi:10.2196/preprints.44742 · Cited by 23 · see citing works
Digital Therapeutics for Healthy Longevity: A Roadmap
Leistner, T., & Kowatsch, T. (2023) · International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC) · doi:10.5220/0011778500003414 · Cited by 2 · see citing works
“It has been shown that this DTx results in better treatment outcomes than human-delivered psychotherapy alone (Berger et al., 2018).”
BackgroundAtik, E., Hornstein, S., Reinking, E., & Schückes, M. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100815 · Cited by 2 · see citing works
“This is frequently accomplished by assigning therapeutic homework via a digital app in between therapy sessions (Berger et al., 2018; Månsson et al., 2013).”
Schladitz, K., Buß, A., Pabst, A., Welzel, F. D., Blüher, M., Stümvoll, M., Brettschneider, C., König, H., Riedel-Heller, S. G., & Löbner, M. (2025) · BMJ Open · doi:10.1136/bmjopen-2025-107131 · Cited by 3 · see citing works
- Authors
- Berger, T., Krieger, T., Sude, K., Meyer, B., & Maercker, A.
- Affiliations
- University of Bern (CH)
- City, University of London (GB)
- Corresponding author
- Berger, Thomas
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 2018-02
- Volume
- 227
- Pages
- 455-462
- ISSN
- 0165-0327 (ISSN-L)
- OpenAlex
- W2767843933
- Cited by
- 153
- References
- 46
- Citations by year
- 2026: 15 · 2025: 18 · 2024: 14 · 2023: 19 · 2022: 23 · 2021: 17 · 2020: 19 · 2019: 15 · 2018: 12 · 2017: 1
- FWCI
- 14.68
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Affective Disorders (acceptedVersion)
- PubMed (publishedVersion)
- BORIS (University Library Bern) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Funders
- Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (PP00P1_144824/1)
- European Commission
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- depression, e-mental health, online intervention, Deprexis, adjunctive therapy, psychotherapy, blended treatment, therapeutic relationship, depressive symptoms, anxiety symptoms, somatic symptoms, quality of life, unipolar affective disorder
- MeSH terms
- Adult, Combined Modality Therapy, Major Depressive Disorder, Female, Germany, Humans, Male, Middle Aged, Psychotherapy, Software, Somatoform Disorders, Therapy, Computer-Assisted, Internet
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