NIHR DC Discover

Man looking at computer screen with head in hand

NIHR Signal Guided online interventions can help people recover from depression

Published on 6 November 2018

doi: 10.3310/signal-000672

Internet-based interventions combined with remote professional support can improve outcomes for people with depression. Those receiving the intervention show better initial response to treatment and higher recovery rates compared with control groups who are either waiting for treatment or receiving less support.

This meta-analysis shows people using guided internet therapy are over twice as likely to respond to treatment and achieve remission. This finding reinforces current NICE guidance which recommends this type of approach for mild to moderate depression.

This type of treatment has the potential to reach more people than face to face therapy and provides more support than wholly self-directed interventions. It may help bridge the gap between the demand for therapy and the limited resources available. However, certain groups such as ethnic minorities responded less well, which may mean further work is needed to tailor interventions.

Share your views on the research.

Why was this study needed?

Depression affects around 1 in 10 people during their lifetime. Symptoms range from feelings of unhappiness and hopelessness to physical aches and pains. More severe cases can make people feel suicidal.

Treatments include medication such as antidepressants. Cognitive behaviour therapy (CBT) is also recommended. This aims to help people become aware of, and hopefully change, the patterns of thought that trap them within a cycle of negative thinking. Access to therapist led treatments is hindered by a lack of resources, and many people experience a delay in access. As such, exploring the effectiveness of less resource intensive options is important.

While research suggests that guided internet-based interventions are effective, it is not clear how clinically significant the benefits are. This study sought to address this by looking at response (the proportion of those improving, initially) and remission (the proportion of those recovering long-term), as these have been suggested as optimal outcomes in research on depression.

What did this study do?

This meta-analysis looked at 24 randomised controlled trials of 4,889 adults with mild to moderate depression and explored the effectiveness of internet based interventions in conjunction with remote support provided by a professional or trained staff working alongside a professional. Most interventions were CBT based. Support tended to be feedback provided weekly by phone or email. The control groups received interventions ranging from waiting for treatment to care as usual.

Individual participant data were extracted from each trial to measure response, defined using the Reliable Change Index, or remission.

Studies were mostly conducted in Sweden, Denmark and the Netherlands. These countries have similar health systems to the UK.

What did it find?

  • A positive response was more likely in the intervention group, with 56% responding to treatment compared with 35% in the control group (odds ratio [OR] 2.49, 95% confidence interval [CI] 2.17 to 2.85).
  • A greater than 50% reduction in symptoms occurred in 40% of the intervention group compared with 19% of the control group (OR 2.83, 95% CI 2.45 to 3.28).
  • Remission was more than twice as likely with the intervention, observed in 39% of the intervention group compared with 22% in the control group (OR 2.41, 95% CI 2.07 to 2.79).
  • People described as born in the study country were more likely to respond than those identified as from ethnic minorities (OR 1.66, 95% CI 1.07 to 2.59).

What does current guidance say on this issue?

Recently updated NICE guidance on depression in adults recommends a stepped care approach which means that the most effective but least intrusive intervention is tried first. If a different approach or additional treatment is needed, the person should be offered the option from the next step up.

For people with mild or moderate depression, self-help based CBT should be offered. Other options are computer or internet delivered CBT as well as group physical activity programmes.

NICE suggests that computer based CBT should encourage individuals to practice between sessions and include thought challenges and behaviour monitoring components. Support from a trained practitioner needs to be available in order to review progress over a 9-12 week period.

What are the implications?

Online interventions for depression combined with support are an effective way of ensuring people can access therapy as quickly as possible. Other studies confirm that the support component is critical to success. The fact that remote support can be also be delivered by trained non-professionals means that it may offer savings overall. This assumption will need further testing.

Not being bound by time or location may also make people more likely to adhere to treatment. However, it is important to ensure that they are confident using technology. An initial face to face session may be useful to demonstrate the programme.

The differences observed in responses between the sub groups also suggest that this option might not be suitable for everyone. This may be offset by developing existing packages so that they enable greater customisation.

Bibliography

Gilbody S, Littlewood E, Hewitt C, et al. Computerised cognitive behavioural therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015;351:h56271.

NHS website. Clinical depression. London: Department of Health; updated 2016.

NICE. Depression in adults: recognition and management. CG90. London: National Institute for Health and Care Excellence; 2009.

Why was this study needed?

Depression affects around 1 in 10 people during their lifetime. Symptoms range from feelings of unhappiness and hopelessness to physical aches and pains. More severe cases can make people feel suicidal.

Treatments include medication such as antidepressants. Cognitive behaviour therapy (CBT) is also recommended. This aims to help people become aware of, and hopefully change, the patterns of thought that trap them within a cycle of negative thinking. Access to therapist led treatments is hindered by a lack of resources, and many people experience a delay in access. As such, exploring the effectiveness of less resource intensive options is important.

While research suggests that guided internet-based interventions are effective, it is not clear how clinically significant the benefits are. This study sought to address this by looking at response (the proportion of those improving, initially) and remission (the proportion of those recovering long-term), as these have been suggested as optimal outcomes in research on depression.

What did this study do?

This meta-analysis looked at 24 randomised controlled trials of 4,889 adults with mild to moderate depression and explored the effectiveness of internet based interventions in conjunction with remote support provided by a professional or trained staff working alongside a professional. Most interventions were CBT based. Support tended to be feedback provided weekly by phone or email. The control groups received interventions ranging from waiting for treatment to care as usual.

Individual participant data were extracted from each trial to measure response, defined using the Reliable Change Index, or remission.

Studies were mostly conducted in Sweden, Denmark and the Netherlands. These countries have similar health systems to the UK.

What did it find?

  • A positive response was more likely in the intervention group, with 56% responding to treatment compared with 35% in the control group (odds ratio [OR] 2.49, 95% confidence interval [CI] 2.17 to 2.85).
  • A greater than 50% reduction in symptoms occurred in 40% of the intervention group compared with 19% of the control group (OR 2.83, 95% CI 2.45 to 3.28).
  • Remission was more than twice as likely with the intervention, observed in 39% of the intervention group compared with 22% in the control group (OR 2.41, 95% CI 2.07 to 2.79).
  • People described as born in the study country were more likely to respond than those identified as from ethnic minorities (OR 1.66, 95% CI 1.07 to 2.59).

What does current guidance say on this issue?

Recently updated NICE guidance on depression in adults recommends a stepped care approach which means that the most effective but least intrusive intervention is tried first. If a different approach or additional treatment is needed, the person should be offered the option from the next step up.

For people with mild or moderate depression, self-help based CBT should be offered. Other options are computer or internet delivered CBT as well as group physical activity programmes.

NICE suggests that computer based CBT should encourage individuals to practice between sessions and include thought challenges and behaviour monitoring components. Support from a trained practitioner needs to be available in order to review progress over a 9-12 week period.

What are the implications?

Online interventions for depression combined with support are an effective way of ensuring people can access therapy as quickly as possible. Other studies confirm that the support component is critical to success. The fact that remote support can be also be delivered by trained non-professionals means that it may offer savings overall. This assumption will need further testing.

Not being bound by time or location may also make people more likely to adhere to treatment. However, it is important to ensure that they are confident using technology. An initial face to face session may be useful to demonstrate the programme.

The differences observed in responses between the sub groups also suggest that this option might not be suitable for everyone. This may be offset by developing existing packages so that they enable greater customisation.

Bibliography

Gilbody S, Littlewood E, Hewitt C, et al. Computerised cognitive behavioural therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015;351:h56271.

NHS website. Clinical depression. London: Department of Health; updated 2016.

NICE. Depression in adults: recognition and management. CG90. London: National Institute for Health and Care Excellence; 2009.

Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis

Published on 26 June 2018

Karyotaki, E.,Ebert, D. D.,Donkin, L.,Riper, H.,Twisk, J.,Burger, S.,Rozental, A.,Lange, A.,Williams, A. D.,Zarski, A. C.,Geraedts, A.,van Straten, A.,Kleiboer, A.,Meyer, B.,Unlu Ince, B. B.,Buntrock, C.,Lehr, D.,Snoek, F. J.,Andrews, G.,Andersson, G.,Choi, I.,Ruwaard, J.,Klein, J. P.,Newby, J. M.,Schroder, J.,Laferton, J. A. C.,Van Bastelaar, K.,Imamura, K.,Vernmark, K.,Boss, L.,Sheeber, L. B.,Kivi, M.,Berking, M.,Titov, N.,Carlbring, P.,Johansson, R.,Kenter, R.,Perini, S.,Moritz, S.,Nobis, S.,Berger, T.,Kaldo, V.,Forsell, Y.,Lindefors, N.,Kraepelien, M.,Bjorkelund, C.,Kawakami, N.,Cuijpers, P.

Clin Psychol Rev Volume 63 , 2018

Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients' groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR=2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR=2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR=1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR=1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving internet-based treatment (OR=1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.

Expert commentary

The limited capacity of mental health services results in many people with anxiety and depression being unable to access effective psychological treatment. Brief, guided internet-based self-help interventions provide a way of making psychological interventions more available.

This meta-analysis, using more stringent outcome criteria of reliable change and recovery, demonstrates that considerable improvements can be obtained with limited professional input.

These findings support the use of guided internet-based self-help as a low intensity first step-intervention for the treatment of anxiety and depression.

Paul Stallard, Professor of Child and Family Mental Health, University of Bath

The commentator declares no conflicting interests.