Maintaining Outcomes of Internet-Delivered Cognitive-Behavioral Therapy for Depression: A Network Analysis of Follow-Up Effects

Tim Kaiser, Lynn Boschloo, Thomas Berger, Björn Meyer, Christina Späth-Nellissen, Johanna Schröder, Fritz Hohagen, Steffen Moritz, Jan Philipp Klein, Tim Kaiser, Lynn Boschloo, Thomas Berger, Björn Meyer, Christina Späth-Nellissen, Johanna Schröder, Fritz Hohagen, Steffen Moritz, Jan Philipp Klein

Abstract

Background: Depression is a highly prevalent mental disorder, but only a fraction of those affected receive evidence-based treatments. Recently, Internet-based interventions were introduced as an efficacious and cost-effective approach. However, even though depression is a heterogenous construct, effects of treatments have mostly been determined using aggregated symptom scores. This carries the risk of concealing important effects and working mechanisms of those treatments. Methods: In this study, we analyze outcome and long-term follow-up data from the EVIDENT study, a large (N = 1,013) randomized-controlled trial comparing an Internet intervention for depression (Deprexis) with care as usual. We use Network Intervention Analysis to examine the symptom-specific effects of the intervention. Using data from intermediary and long-term assessments that have been conducted over 36 months, we intend to reveal how the treatment effects unfold sequentially and are maintained. Results: Item-level analysis showed that scale-level effects can be explained by small item-level effects on most depressive symptoms at all points of assessment. Higher scores on these items at baseline predicted overall symptom reduction throughout the whole assessment period. Network intervention analysis offered insights into potential working mechanisms: while deprexis directly affected certain symptoms of depression (e.g., worthlessness and fatigue) and certain aspects of the quality of life (e.g., overall impairment through emotional problems), other domains were affected indirectly (e.g., depressed mood and concentration as well as activity level). The configuration of direct and indirect effects replicates previous findings from another study examining the same intervention. Conclusions: Internet interventions for depression are not only effective in the short term, but also exert long-term effects. Their effects are likely to affect only a small subset of problems. Patients reporting these problems are likely to benefit more from the intervention. Future studies on online interventions should examine symptom-specific effects as they potentially reveal the potential of treatment tailoring. Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT02178631.

Keywords: depression; health-related quality of life; internet interventions; maintenance; network analysis.

Conflict of interest statement

JK received funding for clinical trials (German Federal Ministry of Health, Servier—distributor of the internet intervention “Deprexis”), payments for presentations on internet interventions (Servier) and payments for workshops and books (Beltz, Elsevier, Hogrefe and Springer) on psychotherapy for chronic depression and on psychiatric emergencies. BM is employed as research director at GAIA AG, the company that developed, owns and operates the internet intervention “Deprexis.” The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Kaiser, Boschloo, Berger, Meyer, Späth-Nellissen, Schröder, Hohagen, Moritz and Klein.

Figures

Figure 1
Figure 1
Study flowchart of the EVIDENT trial.
Figure 2
Figure 2
Network diagram of treatment allocation, depressive symptoms and health-related quality of life at post-treatment assessment. Red edges indicate negative correlations, green edges indicate positive ones. Smaller nodes have greater pre-post mean reductions compared to the control group. Nodes directly affected by the treatment are arranged in the first line. N = 794.
Figure 3
Figure 3
Network diagram of treatment allocation, depressive symptoms and health-related quality of life at 4 and 5 months after study onset. Ns = 572 (4 months) and 530 (5 months).
Figure 4
Figure 4
Network diagram of treatment allocation, depressive symptoms and health-related quality of life at 6 months after study onset. N = 754.
Figure 5
Figure 5
Intermediary assessments for the 7 to 11-month follow-up assessments. N = 511, 508, 498, 475, and 482, respectively.
Figure 6
Figure 6
Network diagram of treatment allocation, depressive symptoms and health-related quality of life at 12 months after study onset. N = 637.

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