An Online Intervention Targeting Depression and Low Reward Sensitivity

Evaluation of an Online Intervention Targeting Depression and Low Reward Sensitivity - A Randomized Controlled Trial

This study aims to evaluate and compare the effectiveness of different online interventions targeting reward sensitivity and depressive symptoms. We hypothesize that behavioral activation, a mindfulness and gratitude intervention, as well as a combination of both, will significantly reduce depressive symptoms and increase reward sensitivity, compared to the waitlist group. In addition, we assume that behavioral activation will have an increased effect on reward sensitivity compared to the mindfulness and gratitude intervention.

The investigators will further investigate factors influencing treatment success in another paper based on data of this study (see secondary and other pre-specified outcome measures).

Study Overview

• Status: Completed
• Conditions: Depression Moderate; Depression Mild
• Intervention / Treatment: Behavioral: Behavioral Activation; Behavioral: Mindulness and Gratitude; Behavioral: Combination of Behavioral Activation and Mindfulness and Gratitude

Detailed Description

Depression is characterized by low reward sensitivity, which is a potential maintaining factor of depressive symptoms. This is why treatment for depression should include evidence-based interventions that target reward insensitivity. Up until now, there is a lack of research that studies reward sensitivity as main outcome measure or focus of interventions, especially in the online format. However, it is crucial to identify psychological interventions that are most effective in treating low reward sensitivity. Previous studies showed that behavioral activation can be a powerful intervention to increase the availability of rewards in everyday life. In addition, mindfulness-based interventions offer effective interventions with regards to low reward sensitivity since mindfulness refocusses attention on the present moment.

This study aims to evaluate the effectiveness of different online interventions compared to a waitlist control condition in a randomized controlled trial. The sample will include participants with mild to moderate depressive symptoms, who have been preselected for their low trait reward responsiveness. Inclusion and exclusion criteria will be confirmed via a preliminary online survey and a telephone screening, which will be administered by a trained psychologist. Suicidal participants or participants who suffer from severe depression will be excluded. Those will be informed about possibilities to get intensive professional help. Further exclusion criteria will be an ongoing psychotherapy, an antidepressant medication which has been taken for a shorter time period than four weeks, persons with a lifetime diagnosis of bipolar disorder (I and II), psychotic disorders or a substance use disorder.

Participants will be randomly assigned into four groups. The randomization will be stratified according to their depression score (mild or moderate). The investigators aim to include 50 participants per group (N = 200 in total). The first group ("Behavioral Activation") will be instructed to include daily positive activities and fill out a mood protocol, which covers the time period shortly before, during and after the activity. The second group ("Mindfulness and Gratitude") will fill out a mindfulness diary and reflect upon daily pleasant situation via revisiting the impressions of their five senses during this situation. In addition, participants will specify how long they have dealt with the situation and will name something they are grateful for. The third group will do a combination of the two interventions. The fourth group will be the waitlist control condition and receive the intervention material of the third group after two weeks.

Participants will receive a pre-intervention online survey with questionnaires as a baseline measurement. This survey includes a psychoeducation video and an instruction video explaining the intervention rationale and the daily excercises. Participants will receive working sheets to protocol their daily exercises over a course of two weeks. In addition, participants are encouraged to report their results and possible problems with the implementation of the excercises in a short online survey. In addition, every day a different case study will be presented which deals with obstacles and shows strategies to solve problems. Furthermore, participants are able to contact the principal contact person of the study (Laura Potsch) via telephone to help with problems. After two weeks of daily interventions, participants will receive a post-questionnaire to measure treatment effects and will receive a follow up questionnaire after 4 months.

• Study Type: Interventional
• Enrollment (Actual): 224
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Winfried Rief, Prof. Dr.; Email: rief@staff.uni-marburg.de
• Study Contact Backup: Name: Laura Potsch, M.Sc.; Phone Number: +496421- 2824046; Email: laura.potsch@uni-marburg.de

Study Locations

• Germany
  • Marburg, Germany, 35037
    • Philipps University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 18 or above
• Fluent in German
• Informed consent
• Depressive symptoms (PHQ-9 > 5)

Exclusion Criteria:

• suicidality, severe depression
• current or lifetime: substance use disorder, psychotic disorders, bipolar I or II
• current psychotherapy
• if antidepressant medication: has not been stable over the last 4 weeks

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: None (Open Label)

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Behavioral Activation; 14 days of daily excercises	Behavioral: Behavioral Activation; instruction to create a list of individual positive activities.; instruction to include daily positive activities and fill out a mood protocol, which covers the time period shortly before, during and after the activity.
Experimental: Mindfulness and Gratitude; 14 days of daily excercises	Behavioral: Mindulness and Gratitude; instruction to fill out a mindfulness diary: reflection of daily pleasant situation, instructing the participants to revisit the impressions of their 5 senses during this situation, in addition they should specify how long they have actually dealt with these pleasant impressions of the situation they reflected upon; instruction to do a gratitude exercise and name one or more things they are generally grateful for each day.
Experimental: Combination: Behavioral Activation and Mindfulness and Gratitude; 14 days of daily excercises	Behavioral: Combination of Behavioral Activation and Mindfulness and Gratitude; This group will do a combination of the two intervention types.
No Intervention: Waitlist control group; Will receive the intervention (combination) after two weeks of intervention time of the other groups.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in depressive symptoms (Patient Health Questionnaire-9, PHQ-9)	Items range from 0 to 3 (0 = not at all; 1 = several days; 2 = more than a week; 3 = nearly every day).; PHQ-9 total score ranges from 0 to 27 (classification of scores: 5-9 mild depression; 10-14 as moderate depression; 15-19: moderately severe depression; 20 - 27 severe depression).; Consequently, a higher score means worse depressive symptoms.	baseline, post intervention (after 2 weeks), 4 months follow up
Change in reward sensitivity (Positive Valence System Scale-21, PVSS-21)	Items range from 1 to 9 (1 = extremely untrue of me, 2 = very untrue of me, 3 = moderately untrue of me, 4 = slightly untrue of me, 5 = neutral, 6 = slightly true of me, 7 = moderately true of me, 8 = very true of me, 9 = extremely true of me).; PVSS-21 total score ranges from 21 to 189.; Consequently, a higher score means a higher reward responding.	baseline, post intervention (after 2 weeks), 4 months follow up

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Somatization psychopathology (Patient Health Questionnaire-15, PHQ-15)	Items in the PHQ-15 range from 0 to 2 (0 = not bothered at all, 1 = bothered a little, 2 = bothered a lot), two items (which are included in the PHQ-9 (question 2c and d) originally range from 0 to 3 (0 = not at all; 1 = several days; 2 = more than a week; 3 = nearly every day), here 2 and 3 are counted as 2.; PHQ-15 total score ranges from 0 to 30 (classification of scores: ≥5 mild level of somatization, ≥10 moderate level of somatization, ≥15 severe level of somatization).; Consequently, a higher score means a worse somatization.	Baseline, post intervention (after 2 weeks), 4 months follow up
Generalized anxiety disorder psychopathology (Generalizied Anxiety Disorder Scale-7, GAD-7)	Items range from 0 to 3 (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day).; GAD-7 total score ranges from 0 to 21 (classification of scores: 0 - 4: no to low risk, 5 - 9: mild, 10 - 14: moderate, >= 15 severe).; Consequently, a higher score means a worse generalized anxiety disorder psychopathology.	Baseline, post intervention (after 2 weeks), 4 months follow up
Eating disorder psychopathology (Eating Disorder Examination-Questionnaire-8, EDE-Q-8)	Items range from 0 to 6 (0 = characteristic was not present to 6 = characteristic was present every day or in extreme form).; Subscale scores (restraint, eating concern, weight concern, shape concern), as well as a total score can be calculated, the total score ranges from 0 to 48.; Consequently, a higher score means a worse eating disorder psychopathology.	Baseline, post intervention (after 2 weeks), 4 months follow up
Social anxiety disorder psychopathology (Mini-Social Phobia Inventory, Mini-SPIN)	Items range from 0 to 4 (0 = not at all, 1 = a little bit, 2 = somewhat, 3 = very much, 4 = extremely).; Mini-Spin total score ranges from 0 to 12.; Consequently, a higher score means a worse social anxiety disorder psychopathology.	Baseline, post intervention (after 2 weeks), 4 months follow up
Treatment expectation (Generic Rating for Treatment Pre-Experiences, Treatment Expectations, and Treatment Effects, G-EEE)	- Items range from 0 to 10 (depending on the item from "no improvement" to "greatest improvement imaginable", from "no worsening" to "greatest worsening imaginable", from "no complaints" to "greatest complaints imaginable") and one item, where previous treatment experience is assessed via a choice of "I have never experienced this treatment." (continue with question 8), "I have experienced this treatment during the last 12 months (nearly) daily.", "I have experienced this treatment during the last 12 months on more than 10 days.", "I have experienced this treatment during the last 12 months on about 5 to 10 days.", I have experienced this treatment during the last 12 months on about 1 to 4 days." And "I have not experienced this treatment during the last 12 months, but I have experienced it before."	Baseline, post intervention (after 2 weeks)
Treatment credibility and expectancy (Credibility/Expectancy Questionnaire, CEQ)	Items range from 1 to 9 (Item 1 of Set 1: 1= not at all logical, 5 = somewhat logical, 9 = very logical, Item 2 of Set 1: 1= not at all useful, 5 = somewhat useful, 9 = very useful, Item 3 of Set 1: 1 = not at all confident, 5 = somewhat confident, 9 = very confident, Item 1 of Set 2: 1 = not at all, 5 = somewhat, 9 = very much), Item 4 of Set 1 and Item 2 of Set 2 give a choice of 0% to 100% in steps of 10 %.; CEQ composite score can be derived for each factor (expectancy and credibility)	Baseline
Trait reward responsiveness (Reward Responsiveness Scale, RRS)	Items range from 1 to 4 (1= strong disagreement, 2 = mild disagreement, 3 = mild agreement, 4 = strong agreement); RRS total score ranges from 8 to 32.; Consequently, a higher score means a higher reward responsiveness.	Baseline, post intervention (after 2 weeks), 4 months follow up
Stress level (Perceived-Stress-Scale 10, PSS-10)	Items range from 1 to 5 (1= never, 2 = almost never, 3 = sometimes, 4 = fairly often, 5 = very often) Items 4, 5, 7 and 8 are reverse scored for the total score.; PH=perceived helplessness subscale; PSE=perceived self-efficacy subscale; PH subscale is computed by summing up Items 1, 2, 3, 6, 9 and 10; the PSE subscale is computed by summing up items 4, 5, 7 and 8; PSS-10 total score is the sum of all PH and reversed PSE items; Consequently, a higher score means a greater level of stress.	Baseline, post intervention (after 2 weeks), 4 months follow up
Anhedonia (Snaith-Hamilton-Pleasure-Scale, SHAPS-D)	Items range from "Definitely Agree", "Agree", "Disagree", and "Strongly Disagree". Either of the "Disagree responses" receive a score of 1 and either of the "Agree responses" receive a score of 0.; SHAPS-D total score ranges from 0 to 14.; Consequently, a higher score means a greater state anhedonia.	Baseline, post intervention (after 2 weeks), 4 months follow up
Depressive expectations (Depressive Expectations Scale, DES)	Items range from 1 to 5 (1 = I disagree , 2 = I partially disagree, 3 = neutral, 4 = I partially agree, 5 = I agree).; DES total score ranges from 25 to 125; Consequently, a higher score means more dysfunctional depressive expectations.	Baseline, post intervention (after 2 weeks), 4 months follow up
Personality traits (Big Five Inventory 10, BFI-10)	Items range from 1 (disagree strongly) to 5 (agree strongly).; Scales: openness to experience, conscientiousness, extraversion, agreeableness and neuroticism	Baseline, post intervention (after 2 weeks), up to four months follow up

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Adherence	Number of completed online surveys regarding the intervention exercises (T1 to T14: daily online surveys over the course of two weeks); Self report of implementation of daily excercises in post intervention survey and follow up survey.	post intervention (after 2 weeks), 4 months follow up
Influence of type of positive activity/type of pleasant situation	- Type of activities and reflected pleasant situations that have been selected in the daily online surveys (e.g. social, sports ...)	during daily excercises (14 days)
Problems and obstacles during the intervention	- Frequency of telephone contacts made with the principal contact person (Laura Potsch) and specified problems with the implementation of the daily excercises in the daily online survey	post intervention (after 2 weeks), 4 months follow up
Sociodemographic variables	- Gender, age, education, employment, medication, self report lifetime diagnosis of psychiatric conditions, previous experience with psychotherapy etc.	baseline
Perceived system usability (System usability Scale, SUS), general feedback about the online intervention	Items of the SUS range from 1 to 5 (1= strongly disagree to 5 = strongly agree).; After a computation, the SUS score can range from 0 to 100. A SUS score above a 68 is considered above average.; general feedback about the online intervention: free text entries about the online intervention: criticism, change requests, praise, one closed question: "Would you recommend the online intervention to someone else?" Yes/No	post intervention (after 2 weeks)

Collaborators and Investigators

• Sponsor: Philipps University Marburg Medical Center
• Investigators: Principal Investigator: Winfried Rief, Prof. Dr., Dept. of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Germany

Publications and helpful links

General Publications

• Alloy LB, Olino T, Freed RD, Nusslock R. Role of Reward Sensitivity and Processing in Major Depressive and Bipolar Spectrum Disorders. Behav Ther. 2016 Sep;47(5):600-621. doi: 10.1016/j.beth.2016.02.014. Epub 2016 Mar 7.
• Craske MG, Meuret AE, Ritz T, Treanor M, Dour HJ. Treatment for Anhedonia: A Neuroscience Driven Approach. Depress Anxiety. 2016 Oct;33(10):927-938. doi: 10.1002/da.22490.
• Craske MG, Meuret AE, Ritz T, Treanor M, Dour H, Rosenfield D. Positive affect treatment for depression and anxiety: A randomized clinical trial for a core feature of anhedonia. J Consult Clin Psychol. 2019 May;87(5):457-471. doi: 10.1037/ccp0000396.
• Eshel N, Roiser JP. Reward and punishment processing in depression. Biol Psychiatry. 2010 Jul 15;68(2):118-24. doi: 10.1016/j.biopsych.2010.01.027. Epub 2010 Mar 29.
• Geschwind N, Peeters F, Drukker M, van Os J, Wichers M. Mindfulness training increases momentary positive emotions and reward experience in adults vulnerable to depression: a randomized controlled trial. J Consult Clin Psychol. 2011 Oct;79(5):618-28. doi: 10.1037/a0024595.
• Kryza-Lacombe M, Pearson N, Lyubomirsky S, Stein MB, Wiggins JL, Taylor CT. Changes in neural reward processing following Amplification of Positivity treatment for depression and anxiety: Preliminary findings from a randomized waitlist controlled trial. Behav Res Ther. 2021 Jul;142:103860. doi: 10.1016/j.brat.2021.103860. Epub 2021 Apr 15.
• Linke J, Wessa M. Mental Imagery Training Increases Wanting of Rewards and Reward Sensitivity and Reduces Depressive Symptoms. Behav Ther. 2017 Sep;48(5):695-706. doi: 10.1016/j.beth.2017.04.002. Epub 2017 Apr 18.
• Renner F, Ji JL, Pictet A, Holmes EA, Blackwell SE. Effects of Engaging in Repeated Mental Imagery of Future Positive Events on Behavioural Activation in Individuals with Major Depressive Disorder. Cognit Ther Res. 2017;41(3):369-380. doi: 10.1007/s10608-016-9776-y. Epub 2016 Apr 9.

Study record dates

Study Major Dates

• Study Start (Actual): May 30, 2022
• Primary Completion (Actual): May 15, 2023
• Study Completion (Actual): September 15, 2023

Study Registration Dates

• First Submitted: May 23, 2022
• First Submitted That Met QC Criteria: May 30, 2022
• First Posted (Actual): June 2, 2022

Study Record Updates

• Last Update Posted (Actual): October 3, 2023
• Last Update Submitted That Met QC Criteria: October 2, 2023
• Last Verified: October 1, 2023

More Information

Terms related to this study

• Keywords: randomized controlled trial; depression; mindfulness; behavioral activation; online intervention; reward processing; reward sensitivity; gratitude
• Additional Relevant MeSH Terms: Behavioral Symptoms; Mental Disorders; Mood Disorders; Immune System Diseases; Depression; Depressive Disorder; Hypersensitivity
• Other Study ID Numbers: ReSet your Mind

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No