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Cited by 92Digital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesTelemedicine and Telehealth Implementation

Internet-Based Therapy for Mild to Moderate Depression in Swedish Primary Care: Short Term Results from the PRIM-NET Randomized Controlled Trial

Open access
Kivi, Marie, Eriksson, Maria C. M., Hange, Dominique, Petersson, Eva-Lisa, Vernmark, Kristofer, Johansson, Boo, Björkelund, Cecilia·2014·Cognitive Behaviour Therapy
DOI 10.1080/16506073.2014.921834PMC PMC4260664
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Abstract

Depression presents a serious condition for the individual and a major challenge to health care and society. Internet-based cognitive behavior therapy (ICBT) is a treatment option supported in several trials, but there is as yet a lack of effective studies of ICBT in “real world” primary care settings. We examined whether ICBT differed from treatment-as-usual (TAU) in reducing depressive symptoms after 3 months. TAU comprised of visits to general practitioner, registered nurse, antidepressant drugs, waiting list for, or psychotherapy, or combinations of these alternatives. Patients, aged ≥ 18 years, who tentatively met criteria for mild to moderate depression at 16 primary care centers in the south-western region of Sweden were recruited and then assessed in a diagnostic interview. A total of 90 patients were randomized to either TAU or ICBT. The ICBT treatment included interactive elements online, a workbook, a CD with mindfulness and acceptance exercises, and minimal therapist contact. The treatment period lasted for 12 weeks after which both groups were assessed. The main outcome measure was Beck Depression Inventory-II (BDI-II). Additional measures were Montgomery Åsberg Depression Rating Scale – self rating version (MADRS-S) and Beck Anxiety Inventory (BAI). The analyses revealed no significant difference between the two groups at post treatment, neither on BDI-II, MADRS-S, nor BAI. Twenty patients (56%) in the ICBT treatment completed all seven modules. Our findings suggest that ICBT may be successfully delivered in primary care and that the effectiveness, after 3 months, is at par with TAU. © 2014, © 2014 The Author(s). Published by Taylor & Francis.

Integrity signals

Registry

Crossref · 10.1080/16506073.2014.921834

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

4 of 18 cited sources checked · 1 supported · 0 flagged · accuracy not yet measured

  • Interpretationown data

    The mean number of completed modules in ICBT (5.1) implies a high adherence rate compared with live CBT in primary care and ICBT in previous efficacy studies.

    “The mean number of completed modules in the ICBT treatment was 5.1 which implies that compared with live CBT in primary care and ICBT in previous efficacy studies (Cuijpers, Huibers, Ebert, Koole, & Andersson, 2013; Newby et al., 2013), we found a high adherence rate.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Cuijpers, Huibers, Ebert, Koole, & Andersson, 2013 source
    • cites Newby et al., 2013 source

      The Adherence Results report 89% completion of Newby et al.’s six-lesson efficacy trial, while Primary Outcome Measures, Effect Sizes, and Adherence reports an average of 4.21 lessons and 41.2% completion in primary care. These provide benchmarks for the citing authors’ own mean of 5.1 modules, but the paper does not establish that 5.1 represents higher adherence than previous efficacy studies; its discussion describes poorer primary-care adherence to psychological treatments generally, not a direct comparison with live CBT. (LLM, conf=0.79)

      Experimental — accuracy not yet measured
  • Premisecitation

    Previous studies comparing treatments while allowing stable medication find that medication status seems unrelated to change in depth of depression.

    “Previous studies comparing treatments while allowing for stable medication find that medication status seem to be unrelated to change in depth of depression (Proudfoot et al., 2004; Vernmark et al., 2010).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Proudfoot et al., 2004 source

      The Beck Depression Inventory score section reports that the computerised therapy’s effect was the same for patients taking and not taking medication, supporting the claim that medication status did not alter the treatment comparison. But it also reports that patients receiving medication were less depressed on average. The Treatment section says drug treatments were not constrained, so the paper does not establish the claim’s stable-medication condition. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites Vernmark et al., 2010 source
  • Findingown data

    On the primary outcome measure BDI-II, the mean between-group effect size at post-treatment was d = 0.

    “On the primary outcome measure (BDI-II), the mean between group effect size at post was d = 0 with within-group effect size for the ICBT group d = 1.09 (pre vs. post) and for the TAU group d = 1.27 (pre vs. post).”
    Quote in the paperSubstantial claim
  • Findingown data

    Within-group effect size for the TAU group on BDI-II from pre- to post-treatment was d = 1.27.

    “On the primary outcome measure (BDI-II), the mean between group effect size at post was d = 0 with within-group effect size for the ICBT group d = 1.09 (pre vs. post) and for the TAU group d = 1.27 (pre vs. post).”
    Quote in the paperNot a substantial claim
  • Findingown data

    There was no difference between treatment groups in the proportion of recovered patients (BDI-II score ≤ 13) at post-treatment.

    “There was no difference between treatment groups concerning the proportion of recovered patients, with a score of ≤ 13, on the BDI-II at post-treatment.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 15
  • May combine two claims. 18

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

    Premisecitation

    Difficulties in recruiting patients are a well-known problem in clinical trials, and long recruitment periods seem common.

    “Finally, difficulties in recruiting patients is a well-known problem in clinical trials (Clarke et al., 2005; De Graaf et al., 2009; Mead et al., 2005) and long recruitment periods seem to be a common problem.”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites Clarke et al., 2005 source
    • cites De Graaf et al., 2009 source

      The Methodological considerations section (page unavailable) reports that only 0.14% of the original recruitment population entered the trial and describes its low response rate, supporting recruitment difficulty in this study. It does not say that recruitment difficulties are a well-known problem across clinical trials or that long recruitment periods are common. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites Mead et al., 2005 source

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

    Findingown data

    Login time ranged from 0 to 868 minutes with a mean of 249 minutes (median 188 minutes).

    “The login time ranged from 0 to 868 minutes with a mean time of 249 minutes (median 188 minutes).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    52 (66%) participants were women.

    “The mean age of participants was 36.6 years (SD = 11.3) and 52 (66%) were women.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    A total of 22 patients, 11 in each group, were on pharmacological therapy at inclusion.

    “A total of 22 patients, 11 in each group, were on pharmacological therapy when they were included in the study.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The mean age of participants was 36.6 years (SD = 11.3).

    “The mean age of participants was 36.6 years (SD = 11.3) and 52 (66%) were women.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    For ICBT patients, the correlation of reduction in depressive symptoms (BDI-II) with number of accessed modules was r = −.328, p = .072 (ns).

    “For the ICBT patients, the correlation of the reduction of depressive symptoms, measured by reduction of BDI-II, to the number of accessed modules was r = − .328, p = .072 (ns).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At inclusion, 5 (6%) patients had minimal, 15 (19%) mild, 27 (34%) moderate, and 32 (41%) severe depression according to BDI-II cut-off scores.

    “At inclusion, 5 (6%) patients suffered from minimal, 15 (19%) from mild, 27 (34%) from moderate, and 32 (41%) from severe depression according to BDI-II cut-off scores.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A post hoc analysis revealed that effectiveness was similar across age groups, although the sample was younger and more Internet literate than the average primary care patient.

    “Although our sample was younger and more Internet literate than the average primary care patient, a post hoc analysis revealed that the effectiveness was in fact similar across age groups.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The mean age among all patients diagnosed with depression at participating primary care centers during PRIM-NET was roughly 53 years, while the mean age of included patients was 36.6 years.

    “The mean age among all patients diagnosed with depression at participating primary care centers during PRIM-NET was roughly 53 years while the mean age of our included patients was 36.6 years.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    During the PRIM-NET study period, 3603 patients were diagnosed with depression but only 90 (2.5%) were included.

    “During the PRIM-NET study period, 3603 patients were diagnosed with depression but only 90, i.e., 2.5% of the diagnosed, were included.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    Of the remaining 90 patients, 11 later withdrew from participation.

    “Of the remaining 90 patients, 11 later withdrew from their participation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Baseline scores showed no significant difference between treatment groups, and randomization produced a similar distribution across conditions.

    “A comparison of baseline scores revealed no significant difference between treatment groups and the randomization as expected produced a similar distribution across conditions (see Table 1).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Sixty-five of 79 patients (82%) completed post-treatment forms: 30 (83%) in ICBT and 35 (81%) in TAU.

    “Sixty-five of the 79 patients (82%) completed the post-treatment forms: 30 (83%) in the ICBT and 35 (81%), in the TAU condition (see Figure 1).”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Two patients were incorrectly included due to human error and were removed from analyses (1 in ICBT and 1 in TAU).

    “The post study assessment of interview protocols identified two patients who had, due to human error, been incorrectly included. They were consequently removed from the analyses (1 in ICBT and 1 in TAU).”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Sweden is one of the countries with the highest Internet usage: 84.7% of the population.

    “Sweden is one of the countries in the world with the highest Internet usage: 84.7% of the population.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Statistics Sweden, 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationown data

    Recruitment of mild to moderately depressed individuals from the general population or primary health care is a challenge and often attracts interest by more severely depressed patients.

    “Recruitment of mild to moderately depressed individuals from the general population or in primary health care is a challenge and often attracts interest by more severely depressed patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    The recruitment of patients makes this study one of very few RCTs on ICBT in primary care and with results relevant to other primary care patients with mild to moderate depression.

    “Furthermore, the recruitment of patients makes our study one of very few RCTs on ICBT accomplished in primary care and with results relevant to other primary care patients with mild to moderate depression.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given

    Implementation of ICBT in primary care offers a convenient and effective psychological therapy for patients with mild to moderate depression.

    “In conclusion, the implementation of ICBT in primary care offers a convenient and effective psychological therapy in patients affected by mild to moderate depression.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    As the population grows older, Internet literacy and usage follow individuals into old age, so use of computers/Internet in everyday life will increase for a growing proportion of the population.

    “As the population grows older, internet literacy and usage follows individuals into old age and the trend is therefore increased use of computers/Internet in everyday life for a growing proportion of the population.”
    Quote in the paperNot a substantial claim

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

    Interpretationcitation

    One reason why interventions aimed at mild to moderate depression attract fewer patients than expected based on prevalence rates could be that those with mild to moderate depression are less likely to actively seek treatment.

    “One reason why interventions aimed at mild to moderate depression attract fewer patients than expected based on prevalence rates could be that those with mild to moderate depression are less likely to actively seek treatment (Kessler et al., 2003).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kessler et al., 2003 source

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

    Interpretationreasoning

    The younger sample might reflect a more positive attitude to ICBT among younger primary care patients.

    “Our younger sample might reflect a more positive attitude to ICBT among younger primary care patients, but there is also a possibility that the primary care center staff selected patients who were believed to be Internet literate and for whom they also, for various reasons, thought the ICBT would be an accurate treatment rather than invite all with suspected depression.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The generalizability of the results to primary care patients might be limited, but time suggests the opposite.

    “The generalizability of our results to primary care patients might be limited, but time suggests the opposite.”
    Quote in the paperSubstantial claim

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

    Interpretationown data

    There is a possibility that primary care center staff selected patients believed to be Internet literate and thought ICBT would be an accurate treatment rather than invite all with suspected depression.

    “Our younger sample might reflect a more positive attitude to ICBT among younger primary care patients, but there is also a possibility that the primary care center staff selected patients who were believed to be Internet literate and for whom they also, for various reasons, thought the ICBT would be an accurate treatment rather than invite all with suspected depression.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    PRIM-NET excluded patients with any suicidal ideation, a criterion probably not applied in regular care.

    “Third, PRIM-NET excluded patients with any suicidal ideation, a criterion probably not applied in regular care.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    The young are more Internet literate: 94% of 16-24-year-olds use it daily, compared to 50% of 65-74-year-olds.

    “The young are more Internet literate with 94% of 16–24-year-olds using it daily, compared to only 50% of 65–74-year-old (Statistics Sweden, 2013).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Statistics Sweden, 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Study design and conductown data

    The study did not achieve its recruitment goal of 142 patients, leaving it underpowered.

    “First, despite an extended study period, we did not achieve our goal of recruiting 142 patients which left the study underpowered.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The inclusion criteria allowed stable medication, and patients might have received other treatments for depression during the study period.

    “Second, because the aim of the study was to assess the effectiveness in a real life primary care setting, our inclusion criteria allowed stable medication, which is common in similar studies (e.g., Carlbring et al., 2013; Vernmark et al., 2010) and our patients might have received other treatments for depression during the study period.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Carlbring et al., 2013 source
    • cites Vernmark et al., 2010 source

  • May combine two claims.

    Interpretationown data

    From a patient perspective, ICBT might be seen as a new appealing treatment, even though the first PRIM-NET report based on short-term follow-up provides no clear support for superior effectiveness than TAU.

    “From a patient perspective, ICBT might be seen as a new appealing treatment even if our first PRIM-NET Study report, based on short-term follow-up data provides no clear support for a superior effectiveness than TAU.”
    Quote in the paperSubstantial claim
28 of 28

  • The paper relies on this without support.

    The GPs and nurses invited all patients they met and suspected of mild to moderate depression as instructed.

    “The GPs and nurses were instructed to invite all patients they met and suspected for mild to moderate depression.”

  • The paper relies on this without support.

    Missingness at random is unlikely in clinical trials, so complete-case analysis is appropriate.

    “The assumption of “missingness” at random in clinical trials is typically unlikely and inferences about treatment effects are in principle valid only for those who actually accept or adhere to treatment.”
2 of 2

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?

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.

  • Randomized patient count conflicts with the count after exclusions

    Minor

    The abstract says 90 patients were randomized. The results say two patients were removed after randomization and that 90 remained, which implies 92 were randomized.

  • Suicidal-ideation exclusion is overstated

    Minor

    The discussion says any suicidal ideation was excluded, but the stated criteria exclude a prior attempt or a specified medium-to-high current suicide risk. They do not exclude every level of suicidal ideation.

2 of 2

Cites

Flagged first, then by citations

1 of the 41 references couldn’t be matched to a known paper.

Research works printed but not linked: 4

  1. Beck, A. T., Steer, R. A. & Brown, G. K. (2006). BDI-II, Beck Depression Inventory – Second edition. Manual. Svensk version (Swedish version). Stockholm: Psykologiförlaget AB.
  2. 2014, Internet Interventions
  3. SBU (2004). Behandling av depressionssjukdomar, En systematisk litteraturöversikt. SBU-rapport nr 166/1 [Treatment of depressive disorders, a systematic literature review. SBU report No. 166/1].Stockholm: Stockholm SBU.
  4. 10.1016/s0924-9338(97)83296-8 · DOI · Paper page

Cited by

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Related

Authors
Kivi, M., Eriksson, M. C. M., Hange, D., Petersson, E.-L., Vernmark, K., Johansson, B., & Björkelund, C.
Affiliations
University of Gothenburg (SE)
Corresponding author
Kivi, Marie
ORCID
Venue
Cognitive Behaviour Therapy
Publisher
Informa UK Limited
Published
2014-06-09
Volume
43
Issue
4
Pages
289-298
ISSN
  • 1650-6073 (ISSN-L)
  • 1651-2316
DOI
10.1080/16506073.2014.921834
PMC
PMC4260664
OpenAlex
W2068639747
Cited by
92
References
41
Citations by year
2025: 4 · 2024: 7 · 2023: 10 · 2022: 3 · 2021: 9 · 2020: 6 · 2019: 9 · 2018: 16 · 2017: 10 · 2016: 8 · 2015: 9 · 2014: 1
FWCI
14.47
Type
journal article
Language
en
Open access
Locations
  • Cognitive Behaviour Therapy (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
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
internet-based cognitive behavioral therapy, mild to moderate depression, primary care, usual care, depressive symptoms, mindfulness, acceptance and commitment therapy, treatment completion, antidepressants, anxiety
MeSH terms
Adolescent, Adult, Depression, Female, Humans, Male, Patient Compliance, Primary Health Care, Sweden, Therapy, Computer-Assisted, Cognitive Behavioral Therapy, Treatment Outcome, Internet, Young Adult

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