Improving the Course of Depressive Symptoms After Inpatient Psychotherapy Using Adjunct Web-Based Self-Help: Follow-Up Results of a Randomized Controlled Trial

Rüdiger Zwerenz, Carlotta Baumgarten, Jan Becker, Ana Tibubos, Martin Siepmann, Rudolf J Knickenberg, Manfred E Beutel, Rüdiger Zwerenz, Carlotta Baumgarten, Jan Becker, Ana Tibubos, Martin Siepmann, Rudolf J Knickenberg, Manfred E Beutel

Abstract

Background: We recently showed in a randomized controlled trial that Web-based self-help as an adjunct improved the effectiveness of multimodal inpatient psychotherapy for depression.

Objective: The aims of this study were (1) to determine whether a Web-based self-help adjunctive to multimodal inpatient psychotherapeutic treatment could also improve the course of depressive symptoms and (2) to identify predictors of residual depressive symptoms at follow-up.

Methods: Overall, 229 patients were randomized either to the Web-based self-help intervention group (Deprexis) or an active control group (Web-based information about depression and depressive symptoms) in addition to multimodal inpatient psychotherapy. Participants in both groups were able to access their respective Web-based programs for 12 weeks, which meant that they typically had access after discharge from the inpatient unit (mean hospitalization duration: 40 days, T1). Follow-up was performed 6 months after study intake (T3).

Results: At follow-up, participants of the Web-based self-help group had considerably lower symptom load regarding depressive symptoms (d=0.58) and anxiety (d=0.46) as well as a better quality of life (d=0.43) and self-esteem (d=0.31) than participants of the control group. Nearly 3 times as many participants of the intervention group compared with the control group achieved remission in accordance with less deterioration. The number needed to treat based on the Beck Depression Inventory-II (BDI-II) improved over time (T1: 7.84, T2: 7.09, and T3: 5.12). Significant outcome predictors were BDI at discharge and treatment group.

Conclusions: Web-based self-help as an add-on to multimodal inpatient psychotherapy improved the short-term course of depressive symptoms beyond termination. Residual symptoms at discharge from inpatient treatment and utilization of the Web-based self-help were the major predictors of depressive symptoms at follow-up. Challenges and barriers (eg, costs, therapists' concerns, or technical barriers) of adding Web-based interventions to inpatient treatment have to be addressed.

Trial registration: ClinicalTrials.gov NCT02196896; https://ichgcp.net/clinical-trials-registry/NCT02196896.

Keywords: aftercare; depression; inpatients; internet; mental health; psychology, clinical; psychotherapy.

Conflict of interest statement

Conflicts of Interest: None declared.

©Rüdiger Zwerenz, Carlotta Baumgarten, Jan Becker, Ana Tibubos, Martin Siepmann, Rudolf J Knickenberg, Manfred E Beutel. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 24.10.2019.

Figures

Figure 1
Figure 1
Primary outcome (BDI-II) in the course of time. BDI-II: Beck Depression Inventory II; CG: control group; IG: intervention group; T0: allocation to intervention (baseline); T3: follow-up 6 months after baseline.
Figure 2
Figure 2
Recovery, improvement, and deterioration in the course of time. BDI-II: Beck Depression Inventory II; CG: control group; IG: intervention group; T1: discharge; T2: end of intervention; T3: follow-up 6 months after baseline.

References

    1. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, Olesen J, Allgulander C, Alonso J, Faravelli C, Fratiglioni L, Jennum P, Lieb R, Maercker A, van Os J, Preisig M, Salvador-Carulla L, Simon R, Steinhausen H. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011 Sep;21(9):655–79. doi: 10.1016/j.euroneuro.2011.07.018.
    1. Wang J, Wu X, Lai W, Long E, Zhang X, Li W, Zhu Y, Chen C, Zhong X, Liu Z, Wang D, Lin H. Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis. BMJ Open. 2017 Aug 23;7(8):e017173. doi: 10.1136/bmjopen-2017-017173.
    1. Patel V, Maj M, Flisher AJ, de Silva MJ, Koschorke M, Prince M, WPA Zonal and Member Society Representatives Reducing the treatment gap for mental disorders: a WPA survey. World Psychiatry. 2010 Oct;9(3):169–76. doi: 10.1002/j.2051-5545.2010.tb00305.x.
    1. Rogers MA, Lemmen K, Kramer R, Mann J, Chopra V. Internet-delivered health interventions that work: systematic review of meta-analyses and evaluation of website availability. J Med Internet Res. 2017 Mar 24;19(3):e90. doi: 10.2196/jmir.7111.
    1. Cuijpers P, Kleiboer A, Karyotaki E, Riper H. Internet and mobile interventions for depression: opportunities and challenges. Depress Anxiety. 2017 Jul;34(7):596–602. doi: 10.1002/da.22641.
    1. Kok G, Burger H, Riper H, Cuijpers P, Dekker J, van Marwijk H, Smit F, Beck A, Bockting CL. The three-month effect of mobile internet-based cognitive therapy on the course of depressive symptoms in remitted recurrently depressed patients: results of a randomized controlled trial. Psychother Psychosom. 2015;84(2):90–9. doi: 10.1159/000369469.
    1. Holländare F, Johnsson S, Randestad M, Tillfors M, Carlbring P, Andersson G, Engström I. Randomized trial of internet-based relapse prevention for partially remitted depression. Acta Psychiatr Scand. 2011 Oct;124(4):285–94. doi: 10.1111/j.1600-0447.2011.01698.x.
    1. Twomey Conal, O'Reilly Gary. Effectiveness of a freely available computerised cognitive behavioural therapy programme (MoodGYM) for depression: Meta-analysis. Aust N Z J Psychiatry. 2017 Mar;51(3):260–269. doi: 10.1177/0004867416656258.
    1. Meyer B, Berger T, Caspar F, Beevers CG, Andersson G, Weiss M. Effectiveness of a novel integrative online treatment for depression (Deprexis): randomized controlled trial. J Med Internet Res. 2009 May 11;11(2):e15. doi: 10.2196/jmir.1151.
    1. Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, Mackinnon A, Meyer B, Botella C, Littlewood E, Andersson G, Christensen H, Klein JP, Schröder J, Bretón-López J, Scheider J, Griffiths K, Farrer L, Huibers MJ, Phillips R, Gilbody S, Moritz S, Berger T, Pop V, Spek V, Cuijpers P. Efficacy of self-guided internet-based cognitive behavioral therapy in the treatment of depressive symptoms: a meta-analysis of individual participant data. JAMA Psychiatry. 2017 Apr 1;74(4):351–9. doi: 10.1001/jamapsychiatry.2017.0044.
    1. Twomey C, O'Reilly G, Meyer B. Effectiveness of an individually-tailored computerised CBT programme (Deprexis) for depression: a meta-analysis. Psychiatry Res. 2017 Oct;256:371–7. doi: 10.1016/j.psychres.2017.06.081.
    1. Klein JP, Berger T, Schröder J, Späth C, Meyer B, Caspar F, Lutz W, Arndt A, Greiner W, Gräfe V, Hautzinger M, Fuhr K, Rose M, Nolte S, Löwe B, Anderssoni G, Vettorazzi E, Moritz S, Hohagen F. Effects of a psychological internet intervention in the treatment of mild to moderate depressive symptoms: results of the EVIDENT study, a randomized controlled trial. Psychother Psychosom. 2016;85(4):218–28. doi: 10.1159/000445355.
    1. Klein JP, Späth C, Schröder J, Meyer B, Greiner W, Hautzinger M, Lutz W, Rose M, Vettorazzi E, Andersson G, Hohagen F, Moritz S, Berger T. Time to remission from mild to moderate depressive symptoms: one year results from the EVIDENT-study, an RCT of an internet intervention for depression. Behav Res Ther. 2017 Oct;97:154–62. doi: 10.1016/j.brat.2017.07.013.
    1. Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, Barkham M, Bower P, Cooper C, Gask L, Kessler D, Lester H, Lovell K, Parry G, Richards DA, Andersen P, Brabyn S, Knowles S, Shepherd C, Tallon D, White D, REEACT Team Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. Br Med J. 2015 Nov 11;351:h5627. doi: 10.1136/bmj.h5627.
    1. Klein NS, Bockting CL, Wijnen B, Kok GD, van Valen E, Riper H, Cuijpers P, Dekker J, van der Heiden C, Burger H, Smit F. Economic evaluation of an internet-based preventive cognitive therapy with minimal therapist support for recurrent depression: randomized controlled trial. J Med Internet Res. 2018 Nov 26;20(11):e10437. doi: 10.2196/10437.
    1. Kleiboer A, Smit J, Bosmans J, Ruwaard J, Andersson G, Topooco N, Berger T, Krieger T, Botella C, Baños R, Chevreul K, Araya R, Cerga-Pashoja A, Cieślak R, Rogala A, Vis C, Draisma S, van Schaik A, Kemmeren L, Ebert D, Berking M, Funk B, Cuijpers P, Riper H. European COMPARative effectiveness research on blended depression treatment versus treatment-as-usual (E-COMPARED): study protocol for a randomized controlled, non-inferiority trial in eight European countries. Trials. 2016 Aug 3;17(1):387. doi: 10.1186/s13063-016-1511-1.
    1. Nakao S, Nakagawa A, Oguchi Y, Mitsuda D, Kato N, Nakagawa Y, Tamura N, Kudo Y, Abe T, Hiyama M, Iwashita S, Ono Y, Mimura M. Web-based cognitive behavioral therapy blended with face-to-face sessions for major depression: randomized controlled trial. J Med Internet Res. 2018 Sep 21;20(9):e10743. doi: 10.2196/10743.
    1. Schuster R, Sigl S, Berger T, Laireiter AR. Patients' experiences of web- and mobile-assisted group therapy for depression and implications of the group setting: qualitative follow-up study. JMIR Ment Health. 2018 Jul 11;5(3):e49. doi: 10.2196/mental.9613.
    1. Schuster R, Leitner I, Carlbring P, Laireiter AR. Exploring blended group interventions for depression: randomised controlled feasibility study of a blended computer- and multimedia-supported psychoeducational group intervention for adults with depressive symptoms. Internet Interv. 2017 Jun;8:63–71. doi: 10.1016/j.invent.2017.04.001.
    1. McCrone P, Knapp M, Proudfoot J, Ryden C, Cavanagh K, Shapiro DA, Ilson S, Gray JA, Goldberg D, Mann A, Marks I, Everitt B, Tylee A. Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry. 2004 Jul;185:55–62. doi: 10.1192/bjp.185.1.55.
    1. Kenter RM, van de Ven PM, Cuijpers P, Koole G, Niamat S, Gerrits RS, Willems M, van Straten A. Costs and effects of internet cognitive behavioral treatment blended with face-to-face treatment: results from a naturalistic study. Internet Interv. 2015 Mar;2(1):77–83. doi: 10.1016/j.invent.2015.01.001.
    1. NVL - Nationale VersorgungsLeitlinien — ÄZQ. 2015. [2019-08-07]. Unipolare Depression: S3-Leitlinie und Nationale Versorgungsleitlinie (Nvl) Unipolare Depression, 2. Auflage .
    1. Franz M, Seidler D, Jenett D, Schäfer R, Wutzler U, Kämmerer W, Deters MA, Schauenburg H, Becher-Dortschy N, Frommhold K, Keller W, Gosda J, Tress W, Zeller A, Beutel ME, Langenbach M, Hoffmann T, Haberger R, Hartkamp N. [Psychodynamically oriented inpatient psychotherapy of depressive disorders - first findings from a naturalistic, multicenter study] Z Psychosom Med Psychother. 2015;61(1):19–35. doi: 10.13109/zptm.2015.61.1.19.
    1. Liebherz S, Rabung S. Do patients' symptoms and interpersonal problems improve in psychotherapeutic hospital treatment in Germany? A systematic review and meta-analysis. PLoS One. 2014;9(8):e105329. doi: 10.1371/journal.pone.0105329.
    1. Zeeck A, von Wietersheim J, Weiß H, Scheidt CE, Völker A, Helesic A, Eckhardt-Henn A, Beutel M, Endorf K, Knoblauch J, Rochlitz P, Hartmann A. Symptom course in inpatient and day clinic treatment of depression: results from the INDDEP-study. J Affect Disord. 2015 Nov 15;187:35–44. doi: 10.1016/j.jad.2015.07.025.
    1. Kuehner C, Huffziger S. Factors predicting the long-term illness course in a cohort of depressed inpatients. Eur Arch Psychiatry Clin Neurosci. 2013 Aug;263(5):413–23. doi: 10.1007/s00406-012-0379-7.
    1. Judd LL, Akiskal HS, Maser JD, Zeller PJ, Endicott J, Coryell W, Paulus M, Kunovac J, Leon C, Mueller T, Rice J, Keller M. Major depressive disorder: a prospective study of residual subthreshold depressive symptoms as predictor of rapid relapse. J Affect Disord. 1998 Sep;50(2-3):97–108. doi: 10.1016/S0165-0327(98)00138-4.
    1. Zwerenz R, Becker J, Knickenberg RJ, Siepmann M, Hagen K, Beutel ME. Online self-help as an add-on to inpatient psychotherapy: efficacy of a new blended treatment approach. Psychother Psychosom. 2017;86(6):341–50. doi: 10.1159/000481177.
    1. Vittengl JR, Clark LA, Dunn TW, Jarrett RB. Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects. J Consult Clin Psychol. 2007 Jun;75(3):475–88. doi: 10.1037/0022-006X.75.3.475.
    1. Zwerenz R, Becker J, Knickenberg RJ, Hagen K, Dreier M, Wölfling K, Beutel ME. Enhancing inpatient psychotherapeutic treatment with online self-help: study protocol for a randomized controlled trial. Trials. 2015 Mar 17;16:98. doi: 10.1186/s13063-015-0620-6.
    1. SoSci Survey. 2014. [2018-08-07].
    1. Wang YP, Gorenstein C. Psychometric properties of the Beck Depression Inventory-II: a comprehensive review. Braz J Psychiatry. 2013;35(4):416–31. doi: 10.1590/1516-4446-2012-1048.
    1. Kühner C, Bürger C, Keller F, Hautzinger M. [Reliability and validity of the revised Beck Depression Inventory (BDI-II). Results from German samples] Nervenarzt. 2007 Jun;78(6):651–6. doi: 10.1007/s00115-006-2098-7.
    1. Gelaye B, Williams MA, Lemma S, Deyessa N, Bahretibeb Y, Shibre T, Wondimagegn D, Lemenhe A, Fann JR, Stoep AV, Zhou XH. Validity of the patient health questionnaire-9 for depression screening and diagnosis in east Africa. Psychiatry Res. 2013 Dec 15;210(2):653–61. doi: 10.1016/j.psychres.2013.07.015.
    1. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092–7. doi: 10.1001/archinte.166.10.1092.
    1. da Rocha NS, Power MJ, Bushnell DM, Fleck MP. The EUROHIS-QOL 8-item index: comparative psychometric properties to its parent WHOQOL-BREF. Value Health. 2012 May;15(3):449–57. doi: 10.1016/j.jval.2011.11.035.
    1. von Collani G, Herzberg PY. Eine revidierte fassung der deutschsprachigen skala zum selbstwertgefühl von rosenberg. Zeitschrift für Differentielle und Diagnostische Psychologie. 2003 Mar;24(1):3–7. doi: 10.1024//0170-1789.24.1.3.
    1. de Graaf LE, Roelofs J, Huibers MJ. Measuring dysfunctional attitudes in the general population: the dysfunctional attitude scale (Form A) revised. Cognit Ther Res. 2009 Aug;33(4):345–55. doi: 10.1007/s10608-009-9229-y.
    1. Ilmarinen J. The work ability index (WAI) Occup Med. 2006 Oct 17;57(2):160. doi: 10.1093/occmed/kqm008.
    1. Wingenfeld K, Spitzer C, Mensebach C, Grabe HJ, Hill A, Gast U, Schlosser N, Höpp H, Beblo T, Driessen M. [The German version of the childhood trauma questionnaire (CTQ): preliminary psychometric properties] Psychother Psychosom Med Psychol. 2010 Nov;60(11):442–50. doi: 10.1055/s-0030-1247564.
    1. Ehrenthal JC, Dinger U, Horsch L, Komo-Lang M, Klinkerfuss M, Grande T, Schauenburg H. [The OPD structure questionnaire (OPD-SQ): first results on reliability and validity] Psychother Psychosom Med Psychol. 2012 Jan;62(1):25–32. doi: 10.1055/s-0031-1295481.
    1. Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991 Feb;59(1):12–9. doi: 10.1016/S0005-7894(81)80119-0.
    1. Cook RJ, Sackett DL. The number needed to treat: a clinically useful measure of treatment effect. Br Med J. 1995 Feb 18;310(6977):452–4. doi: 10.1136/bmj.310.6977.452.
    1. IBM Knowledge Center. 2014. [2018-08-07]. Downloading IBM SPSS Statistics 23 .
    1. Research Randomizer. 2013. [2018-08-07].
    1. Cuijpers P, Donker T, Johansson R, Mohr DC, van Straten A, Andersson G. Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS One. 2011;6(6):e21274. doi: 10.1371/journal.pone.0021274.
    1. Cuijpers P, van Straten A, Bohlmeijer E, Hollon S, Andersson G. The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size. Psychol Med. 2010 Feb;40(2):211–23. doi: 10.1017/S0033291709006114.
    1. Zwerenz R, Becker J, Johansson R, Frederick RJ, Andersson G, Beutel ME. Transdiagnostic, psychodynamic web-based self-help intervention following inpatient psychotherapy: results of a feasibility study and randomized controlled trial. JMIR Ment Health. 2017 Oct 16;4(4):e41. doi: 10.2196/mental.7889.
    1. Stulz N, Lutz W, Kopta SM, Minami T, Saunders SM. Dose-effect relationship in routine outpatient psychotherapy: does treatment duration matter? J Couns Psychol. 2013 Oct;60(4):593–600. doi: 10.1037/a0033589.
    1. Hennemann S, Farnsteiner S, Sander L. Internet- and mobile-based aftercare and relapse prevention in mental disorders: a systematic review and recommendations for future research. Internet Interv. 2018 Dec;14:1–17. doi: 10.1016/j.invent.2018.09.001.
    1. Hennemann S, Beutel ME, Zwerenz R. ['Morbus Google' vs e-health: a qualitative study of acceptance and implementation of online-aftercare in inpatient rehabilitation] Rehabilitation (Stuttg) 2018 Feb;57(1):14–23. doi: 10.1055/s-0043-102150.
    1. Hennemann S, Witthöft M, Bethge M, Spanier K, Beutel ME, Zwerenz R. Acceptance and barriers to access of occupational e-mental health: cross-sectional findings from a health-risk population of employees. Int Arch Occup Environ Health. 2018 Apr;91(3):305–16. doi: 10.1007/s00420-017-1280-5.
    1. Hennemann S, Beutel ME, Zwerenz R. Drivers and barriers to acceptance of web-based aftercare of patients in inpatient routine care: a cross-sectional survey. J Med Internet Res. 2016 Dec 23;18(12):e337. doi: 10.2196/jmir.6003.
    1. Titzler I, Saruhanjan K, Berking M, Riper H, Ebert DD. Barriers and facilitators for the implementation of blended psychotherapy for depression: a qualitative pilot study of therapists' perspective. Internet Interv. 2018 Jun;12:150–64. doi: 10.1016/j.invent.2018.01.002.

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