Lisanne Warmerdam

Internet-Based Treatment for Adults with Depressive Symptoms: Randomized Controlled Trial

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 (≥ 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).

Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data

Objective To assess how initial severity of depression affects the benefit derived from low intensity interventions for depression. Design Meta-analysis of individual patient data from 16 datasets comparing low intensity interventions with usual care. Setting Primary care and community settings. Participants 2470 patients with depression. Interventions Low intensity interventions for depression (such as guided self help by means of written materials and limited professional support, and internet delivered interventions). Main outcome measures Depression outcomes (measured with the Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale), and the effect of initial depression severity on the effects of low intensity interventions. Results Although patients were referred for low intensity interventions, many had moderate to severe depression at baseline. We found a significant interaction between baseline severity and treatment effect (coefficient −0.1 (95% CI −0.19 to −0.002)), suggesting that patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed. However, the magnitude of the interaction (equivalent to an additional drop of around one point on the Beck Depression Inventory for a one standard deviation increase in initial severity) was small and may not be clinically significant. Conclusions The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.

Psychological treatment of depression: A meta-analytic database of randomized studies

BackgroundA large number of randomized controlled studies have clearly demonstrated that psychological interventions are effective in the treatment of depression. The number of studies in this area is increasing rapidly. In this paper, we present a database of controlled and comparative outcome studies on psychological treatments of depression, based on a series of meta-analyses published by our group. The database can be accessed freely through the Internet.DescriptionWe conducted a comprehensive literature search of the major bibliographical databases (Pubmed; Psycinfo; Embase; Cochrane Central Register of Controlled Trials) and we examined the references of 22 earlier meta-analyses of psychological treatment of depression. We included randomized studies in which the effects of a psychological therapy on adults with depression were compared to a control condition, another psychological intervention, or a combined treatment (psychological plus pharmacological). We conducted nine meta-analyses of subgroups of studies taken from this dataset. The 149 studies included in these 9 meta-analyses are included in the current database. In the 149 included studies, a total of 11,369 patients participated. In the database, we present selected characteristics of each study, including characteristics of the patients (the study population, recruitment method, definition of depression); characteristics of the experimental conditions and interventions (the experimental conditions, N per condition, format, number of sessions); and study characteristics (measurement times, measures used, attrition, type of analysis and country).ConclusionThe data on the 149 included studies are presented in order to give other researchers access to the studies we collected, and to give background information about the meta-analyses we have published using this dataset. The number of studies examining the effects of psychological treatments of depression has increased considerably in the past decades, and this will continue in the future. The database we have presented in this paper can help to integrate the results of these studies in future meta-analyses and systematic reviews on psychological treatments for depression.

Cost-Utility and Cost-Effectiveness of Internet-Based Treatment for Adults With Depressive Symptoms: Randomized Trial

Background The effectiveness of Internet-based treatments for depression has been demonstrated; their cost-effectiveness, however, has been less well researched. Objective Evaluating the relative cost-utility and cost-effectiveness of (1) Internet-based cognitive behavioral therapy, (2) Internet-based problem-solving therapy, and (3) a waiting list for adults with depressive symptoms. Methods A total of 263 participants with clinically significant depressive symptoms were randomized to Internet-based cognitive behavioral therapy (n = 88), Internet-based problem-solving therapy (n = 88), and a waiting list (n = 87). End points were evaluated at the 12-week follow-up. Results Cost-utility analysis showed that cognitive behavioral therapy and problem-solving therapy had a 52% and 61% probability respectively of being more acceptable than waiting when the willingness to pay is € 30,000 for one quality-adjusted life-year. When society is prepared to pay € 10,000 for a clinically significant change from depression, the probabilities of cognitive behavioral therapy and problem-solving therapy being more acceptable than waiting are 91% and 89%, respectively. Comparing both Internet-based treatments showed no clear preference for one or the other of the treatments. Conclusions Both Internet-based treatments have a high probability of being cost-effective with a modest value placed on clinically significant change in depressive symptoms. Trial Registration ISRCTN16823487; http://www.controlled-trials.com/ISRCTN16823487 (Archived by WebCite at http://www.webcitation.org/5u8slzhDE)

Online cognitive behavioral therapy and problem-solving therapy for depressive symptoms: Exploring mechanisms of change

The purpose of this study was to evaluate treatment specificity and potential mediators of two online therapies for depressive symptoms. We conducted a randomized controlled trial in which 263 participants were randomized to online cognitive behavioral therapy (CBT), online problem-solving therapy (PST) or a waiting list control group. Both treatments were more effective than the control group in reducing dysfunctional attitudes, worry, negative problem orientation and enhancing feelings of control. No differences between the treatments were found on each of the potential mediators. Furthermore, results suggest that dysfunctional attitudes, worrying, a negative problem orientation and perceived control all played a mediating role in CBT as well as in PST. Our findings suggest that regardless of the theoretical background to the therapy, the psychological processes necessary for symptom reduction seem to be comparable.

Are individual and group treatments equally effective in the treatment of depression in adults? A meta-analysis

Background and Objectives: It is well-established that psychological interventions are effective in the treatment of depression. However, it is not yet clear what the optima format is in which psychological treatments should be delivered. Although several studies have examined whether individual and group treatments are equally effective in the treatment of depression, no comprehensive meta-analysis has examined this. Methods: We searched major bibliographical databased and conducted a meta-analysis of 15 studies in which individual and group therapies were compared directly to each other. Results: The mean effect size indicating the difference between individual and group therapies in depressive symptomatology at post-test was 0.20 (95% CI: [0.05 0.35]; p < 0.01), in favor of individual therapies, with a lower drop-out rate in individual interventions (OR = 0.56; 95% CI: [0.37, 0.86]; p < 0.01). At follow-up no significant differences were found. Conclusions: Although individual therapy seems to be somewhat more effective than group therapy at the short term, it is not clear whether this is relevant from a clinical point of view. Because of the small number of studies and the limited quality, more research is needed to examine whether the difference between individual and group treatment is clinically relevant.

Recruiting participants for interventions to prevent the onset of depressive disorders: Possibile ways to increase participation rates

BackgroundAlthough indicated prevention of depression is available for about 80% of the Dutch population at little or no cost, only a small proportion of those with subthreshold depression make use of these services.MethodsA narrative review is conducted of the Dutch preventive services in mental health care, also addressing the problem of low participation rates. We describe possible causes of these low participation rates, which may be related to the participants themselves, the service system, and the communication to the public, and we put forward possible solutions to this problem.ResultsThere are three main groups of reasons why the participation rates are low: reasons within the participants (e.g., not considering themselves as being at risk; thinking the interventions are not effective; or being unwilling to participate because of the stigma associated with depression); reasons within the health care system; and reasons associated with the communication about the preventive services. Possible solutions to increasing the participation rate include organizing mass media campaigns, developing internet-based preventive interventions, adapting preventive interventions to the needs of specific subpopulations, positioning the services in primary care, integrating the interventions in community-wide interventions, and systematically screening high-risk groups for potential participants.DiscussionPrevention could play an important role in public mental health in reducing the enormous burden of depression. However, before this can be realized more research is needed to explore why participation rates are low and how these rates can be improved.

Predictors and moderators of response to internet-delivered Interpersonal Psychotherapy and Cognitive Behavior Therapy for depression

BACKGROUND By identifying which predictors and moderators lead to beneficial outcomes, accurate selection of the best initial treatment will have significant benefits for depressed individuals. METHOD An automated, fully self-guided randomized controlled internet-delivered noninferiority trial was conducted comparing two new interventions (Interpersonal Psychotherapy [IPT; n=620] and Cognitive Behavioral Therapy [CBT; n=610]) to an active control intervention (MoodGYM; n=613) over a period of 4 weeks to spontaneous visitors of an internet-delivered therapy website (e-couch). A range of putative predictors and moderators (socio-demographic characteristics [age, gender, marital status, education level], clinical characteristics [depression/anxiety symptoms, disability, quality of life, medication use], skills [mastery and dysfunctional attitudes] and treatment preference) were assessed using internet-delivered self-report measures at baseline and immediately following treatment and at six months follow-up. Analyses were conducted using Mixed Model Repeated Measures (MMRM). RESULTS Female gender, lower mastery and lower dysfunctional attitudes predicted better outcome at post-test and/or follow-up regardless of intervention. No overall differential effects for condition on depression as a function of outcome were found. However, based on time-specific estimates, a significant interaction effect of age was found. For younger people, internet-delivered IPT may be the preferred treatment choice, whereas older participants derive more benefits from internet-delivered CBT programs. LIMITATIONS Although the sample of participants was large, power to detect moderator effects was still lacking. CONCLUSIONS Different e-mental health programs may be more beneficial for specific age groups. The findings raise important possibilities for increasing depression treatment effectiveness and improving clinical practice guidelines for depression treatment of different age groups.

Activity recognition with smartphone support

In this paper, the authors describe a method of accurately detecting human activity using a smartphone accelerometer paired with a dedicated chest sensor. The design, implementation, testing and validation of a custom mobility classifier are also presented. Offline analysis was carried out to compare this custom classifier to de-facto machine learning algorithms, including C4.5, CART, SVM, Multi-Layer Perceptrons, and Naïve Bayes. A series of trials were carried out in Ireland, initially involving N=6 individuals to test the feasibility of the system, before a final trial with N=24 subjects took place in the Netherlands. The protocol used and analysis of 1165min of recorded activities from these trials are described in detail in this paper. Analysis of collected data indicate that accelerometers placed in these locations, are capable of recognizing activities including sitting, standing, lying, walking, running and cycling with accuracies as high as 98%.

Internet-based treatment for adults with depressive symptoms: the protocol of a randomized controlled trial

BackgroundDepression is a highly prevalent condition, affecting more than 15% of the adult population at least once in their lives. Guided self-help is effective in the treatment of depression. The purpose of this study is to investigate the effectiveness of two Internet-based guided self-help treatments with adults reporting elevated depressive symptoms. Other research questions concern the identification of potential mediators and the search for subgroups who respond differently to the interventions.MethodsThis study is a randomized controlled trial with three conditions: two treatment conditions and one waiting list control group. The two treatment conditions are Internet-based cognitive behavior therapy and Internet-based problem-solving therapy. They consist of 8 and 5 weekly lessons respectively. Both interventions are combined with support by e-mail. Participants in the waiting list control group receive the intervention three months later.The study population consists of adults from the general population. They are recruited through advertisements in local and national newspapers and through banners on the Internet. Subjects with symptoms of depression (≥ 16 on the Center for Epidemiological Studies Depression scale) are included. Other inclusion criteria are having sufficient knowledge of the Dutch language, access to the Internet and an e-mail address.Primary outcome is depressive symptoms. Secondary outcomes are anxiety, quality of life, dysfunctional cognitions, worrying, problem solving skills, mastery, absence at work and use of healthcare. We will examine the following variables as potential mediators: dysfunctional cognitions, problem solving skills, worrying, anxiety and mastery. Potential moderating variables are: socio-demographic characteristics and symptom severity. Data are collected at baseline and at 5 weeks, 8 weeks, 12 weeks and 9 months after baseline. Analyses will be conducted on the intention-to-treat sample.DiscussionThis study evaluates two Internet-based treatments for depression, namely cognitive behavioral therapy and problem-solving therapy. The effectiveness of Internet-based problem-solving therapy suggest that this may be a worthwhile alternative to other more intensive treatment options. Strengths and limitations of this study are discussed.Trial registrationCurrent Controlled Trials ISRCTN16823487