Internet-Based Treatment for Adults with Depressive Symptoms: Randomized Controlled Trial
Open accessAbstract
BACKGROUND: Many depressed people do not receive help for their symptoms, and there are various barriers that impede help-seeking. The Internet may offer interesting alternatives for reaching and helping people with depression. Depression can be treated effectively with Internet-based cognitive behavioral therapy (CBT), but a short intervention based on problem solving therapy (PST) could constitute a worthwhile alternative to CBT. OBJECTIVE: In this study we evaluated the effectiveness of Internet-based CBT and Internet-based PST in comparison to a waiting list control group (WL), and we determined the differences between the two treatments. METHODS: We conducted a 3-arm randomized controlled trial to compare CBT, PST, and WL. The main inclusion criterion was presence of depressive symptoms (>or= 16 on the Center for Epidemiological Studies Depression scale). CBT and PST consisted of eight and five weekly lessons respectively. Participants were supported by email. Self-report measures of depression, anxiety, and quality of life were completed at pretest and after 5, 8, and 12 weeks. RESULTS: A total of 263 participants were randomized to the three conditions (CBT: n=88; PST: n=88; WL: n=87). Of the 263 participants, 184 (70%) completed questionnaires after 5 weeks, 173 (66%) after 8 weeks, and 151 (57%) after 12 weeks. Between-group effect sizes for depressive symptoms were 0.54 for CBT after 8 weeks (95% confidence interval (CI): 0.25 - 0.84) and 0.47 for PST after 5 weeks (95% CI: 0.17 - 0.77). These effects were further improved at 12 weeks (CBT: 0.69, 95% CI: 0.41 - 0.98; PST: 0.65, 95% CI: 0.36 - 0.95). For anxiety, effect sizes were also at a medium level. Effect sizes for quality of life were low. The number of participants showing clinically significant change at 12 weeks was significantly higher for CBT (n = 34, 38.6%) and PST (n = 30, 34.1%), compared to WL (n = 0). CONCLUSIONS: Both Internet-based treatments are effective in reducing depressive symptoms, although the effect of PST is realized more quickly. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 16823487; http://www.controlled-trials.com/ISRCTN16823487/16823487 (Archived by WebCite at http://www.webcitation.org/5cQsOj7xf).
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Several studies categorized participants into adherent or not, or usage categories such as low, medium, and high, while others used continuous variables or a combination of these.
“Several studies categorized participants into adherent or not [49,54,57,75], or usage categories such as low, medium, and high [60], while others used continuous variables [23,24,33-36,38-41,43-45,50-52,55,56,58,59,61,76] or a combination of these [42,46,53,64-66,77].”
From A Systematic Review of the Impact of Adherence on the Effectiveness of e-Therapies (2011) · cites this paper as [75]
No differences in improvement of depressive symptoms were found between those who completed treatment in its entirety and those who did not.
“However, Warmerdam and colleagues found no differences in improvement of depressive symptoms between those who completed treatment in its entirety and those who did not (Warmerdam et al., 2008).”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as Warmerdam et al., 2008
Studies of clinical predictors of adherence have typically reported that baseline depression symptom severity is unrelated to adherence in online interventions.
“Studies of clinical predictors of adherence have typically reported that baseline depression symptom severity is unrelated to adherence in online interventions (Andersson et al., 2005;Kenardy, McCafferty, & Rosa, 2003;Warmerdam et al., 2008).”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as Warmerdam et al., 2008
The lack of association between employment status and outcome is consistent with one study of online CBT for depression (Warmerdam et al., 2008).
“The lack of association found between employment status and outcome is consistent with one study of online CBT for depression (Warmerdam et al., 2008)”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as Warmerdam et al., 2008
The attrition rates in this study were equal or lower compared with several similar studies on guided Web-based interventions for depression with long-term follow-up assessments.
“The attrition rates in this study were equal or lower compared with several similar studies on guided Web-based interventions for depression with long-term follow-up assessments [67,73,74].”
From Long-Term Results of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [67]
The large reduction in depressive symptoms in the CAU group between baseline and posttreatment was unforeseen and sustained at the follow-up assessments.
“The large reduction in depressive symptoms in the CAU group between baseline and posttreatment was unforeseen and sustained at the follow-up assessments [34,67,68].”
From Long-Term Results of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [67]
Internet-based problem-solving therapy and psychoeducational intervention seem comparable in efficacy to CBT for depression.
“Both these treatments seem to be comparable in efficacy to CBT [13,14].”
From Internet-based psychological treatments for depression (2012) · cites this paper as [13]
The effect sizes were larger than any previous reported effect sizes across 11 RCTs comparing Internet interventions to waitlist, treatment as usual or placebo control conditions for depression.
“Effects were also larger than any previous reported effect sizes across 11 RCTs comparing Internet interventions to waitlist, treatment as usual or placebo control conditions for depression [6], [15], [17], [38], [39], [40], [41], [42], [43], [44], [45].”
From Internet-Based CBT for Depression with and without Telephone Tracking in a National Helpline: Randomised Controlled Trial (2011) · cites this paper as [17]
Some studies have collected information regarding dropout, suggesting difficulties using the computer, negative features of the program, perceiving the course as too demanding, poor clinical progress, receiving alternative treatment, feeling better, lack of time, and problems understanding the computer program.
“Some studies have collected information regarding dropout, suggesting difficulties using the computer, negative features of the program, perceiving the course as too demanding, poor clinical progress, receiving alternative treatment, feeling better, lack of time, and problems understanding the computer program [42,62].”
From Low-intensity internet-delivered treatment for generalized anxiety symptoms in routine care: protocol for a randomized controlled trial (2014) · cites this paper as [62]
Some studies report variables for dropout from online treatments such as difficulties using the computer, negative features of the program, perceived as too demanding, poor clinical progress, receiving alternative treatment, feeling better, lack of time, and problems understanding the computer program.
“Some studies have report variables such as difficulties using the computer, negative features of the program, perceived as too demanding, poor clinical progress, receiving alternative treatment, feeling better, lack of time, and problems understanding the computer program [34,41].”
Within-group improvement in depression in the intervention condition is comparable with other studies that examined the effects of Web-based PST in the general population.
“Within-group improvement in depression in the intervention condition is comparable with other studies that examined the effects of Web-based PST in the general population [38,62].”
From Short-Term Effects of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [38]
These studies showed equal improvement scores on the CES-D, but baseline scores were higher compared to this study.
“Furthermore, these studies showed equal improvement scores on the CES-D, but baseline scores were higher compared to this study.”
From Short-Term Effects of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [38]
These studies did not show such large improvements on depression in the control group.
“However, these studies did not show such large improvements on depression in the control group.”
From Short-Term Effects of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [38]
Completion of the intervention in this study was low compared with several other studies.
“Second, completion of the intervention in this study was low compared with several other studies [38,62,75,76].”
From Short-Term Effects of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [38]
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- Authors
- Warmerdam, L., van Straten, A., Twisk, J., Riper, H., & Cuijpers, P.
- Affiliations
- Vrije Universiteit Amsterdam (NL)
- Trimbos Institute (NL)
- Corresponding author
- Warmerdam, Lisanne
- Venue
- Journal of Medical Internet Research
- Publisher
- JMIR Publications Inc.
- Published
- 2008-11-20
- Volume
- 10
- Issue
- 4
- Pages
- e44
- ISSN
- 1438-8871 (ISSN-L)
- PMC
- PMC2629364
- OpenAlex
- W2092607463
- Cited by
- 255
- References
- 35
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 2 · 2023: 8 · 2022: 5 · 2021: 6 · 2020: 7 · 2019: 9 · 2018: 14 · 2017: 14 · 2016: 23 · 2015: 23 · 2014: 30 · 2013: 28 · 2012: 21
- FWCI
- 23.72
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Journal of Medical Internet Research (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
- VU Research Portal (publishedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- Vrije Universiteit Amsterdam
- 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, depressive symptoms, online therapy, cognitive behavioral therapy, problem-solving therapy, help-seeking barriers, anxiety, quality of life, email support, treatment effectiveness, adults with depression, waiting list control group, dropout, hopelessness, helplessness and hopelessness
- MeSH terms
- Adult, Advertising, Anxiety Disorders, Behavior Therapy, Cognition, Depression, Depressive Disorder, Follow-Up Studies, Humans, Newspapers as Topic, Problem Solving, Quality of Life, Self-Help Groups, Therapy, Computer-Assisted, Time Factors, Waiting Lists, Reproducibility of Results, Confidence Intervals, Patient Selection, Internet
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