Elsevier

Journal of Affective Disorders

Volume 223, 1 December 2017, Pages 28-40
Journal of Affective Disorders

Review article
Internet- and mobile-based depression interventions for people with diagnosed depression: A systematic review and meta-analysis

https://doi.org/10.1016/j.jad.2017.07.021Get rights and content

Highlights

  • IMIs are effective in reducing depression symptoms in patients with a depressive disorder diagnosis.

  • Comparisons between IMIs and face-to-face treatment need further exploration.

  • A more detailed research on guidance is needed.

Abstract

Background

To summarize and critically evaluate the effectiveness of internet- and mobile-based interventions (IMIs) for depression in adults with a diagnosed depression.

Methods

Preregistered systematic review of RCTs investigating internet- and mobile-based interventions (IMIs) targeting adults with diagnosed depression. IMIs had to be compared with waitlist, attention placebo, other IMIs or other (face-to-face) therapies. A comprehensive search of primary studies was conducted. Study selection and data extraction was done by two independent researchers. Primary outcome was symptom severity of depression. Furthermore, treatment response, depression remission, treatment adherence, anxiety and quality of life were investigated. Random-effects meta-analyses were conducted where possible, as well as pre-planned subgroup and sensitivity analyses.

Results

Database search resulted in 4858 references, of which 19 studies were eligible for inclusion and provided data on 29 IMIs. IMIs showed beneficial effects on depression severity when compared to waitlist conditions at the end of treatment (pooled standardized mean difference (SMD) g = −0.90, 95% CI −1.07 to −0.73, n = 10). The comparison between different IMIs did not result in any superiority or inferiority. All IMIs reduced depression symptoms from pre- to post-treatment (within group SMD range −2.24; −0.64, n = 29) and from pre-treatment to follow-up assessments (SMD range −3.07; −0.93, n = 27).

Conclusion

IMIs significantly reduce depression symptoms in adults with diagnosed depression at the end of treatment and at follow-up assessments when compared to waitlist conditions. These findings argue for IMIs to be recommended in depression treatment guidelines.

Introduction

Depressive disorders, are highly prevalent with 12- month prevalence rates ranging between 5.8% and 10.7% (Baumeister and Härter, 2007). Depression is associated with substantial impairment (Saarni et al., 2007; Üstün et al., 2004), high economic costs (Berto et al., 2000; Greenberg and Birnbaum, 2005) and has been identified as major reason for illness-related disability worldwide (Vos et al., 2013).

Treatment for depression, particularly psychotherapy and psychopharmacotherapy, has been shown to be effective for people with depression (Cuijpers et al., 2012, Cuijpers et al., 2010b, Khan et al., 2012). However, the majority of affected individuals remain untreated either because they do not seek help or do not have the ability to receive adequate treatment. There are many possible reasons, e.g. fear of stigmatization, low perceived need, desire to handle the problem on one's own, want of confidence in health care system (Andrade et al., 2014, Roness et al., 2005, Saxena et al., 2007).

Providing Internet- and mobile based interventions (IMI) may be a promising strategy overcoming some of the aforementioned obstacles and thereby improving mental health care. Some previous meta-analyses investigated the effectiveness of internet- or computer-based interventions for depression (Andersson and Cuijpers, 2009, Andrews et al., 2010, Cowpertwait and Clarke, 2013, Richards and Richardson, 2012, Spek et al., 2007). Pooled standardized mean differences of Cohen's d = 0.32 (Spek et al., 2007) to Hedges' g = 0.78 (Andrews et al., 2010) for the interventions compared to waitlist, treatment as usual and placebos and mainly waitlist have been reported. Thereby, larger effect sizes have been consistently reported for guided interventions compared to unguided interventions (Baumeister et al., 2014b, Cowpertwait and Clarke, 2013, Richards and Richardson, 2012).

However, notwithstanding the extensive evidence base on the effectiveness of depression IMI with several systematic reviews published during the last years, former reviews lack some important information which the present systematic review aims to overcome: First and most importantly, all except for one of the earlier reviews (Andrews et al., 2010) focused on people with depressive symptoms rather than those with a diagnosed depression. The latter is what most health care systems require to be present for depression care being provided. Accordingly, treatment guidelines such as the UK National Institute for Health and Clinical excellence (NICE) (2009) or the German S3 guideline for depression (DGPPN et al., 2015) prefer evidence from randomized clinical trials that focused on clinical depression samples. Second, previous reviews only focused on the short-term effectiveness or were inconclusive regarding long-term effects. Third, since the last comprehensive review many new trials have been published so an updated synthesis of the evidence seems warranted. Fourth, no review up to date has investigated the effects of IMIs on specific clinical relevant outcomes in depression treatment beside depression severity, such as treatment response and depression remission.

The present systematic review aims to overcome these limitation and will investigate the short- and long-term effectiveness of IMIs in adults compared to non active (no treatment, waitlist, attention placebo) or active control on depression severity, treatment response, remission, anxiety and quality of life in adults with secured clinically diagnosis of Major Depressive Disorder. In summary the following review questions are addressed:

  • 1.

    Are IMI for depression effective in adults with a diagnosed depression?

    • a)

      Are IMIs more effective than no-treatment, (attention/psychological) placebo or waitlist conditions?

    • b)

      Are IMIs as effective as non-internet- and non-mobile-based interventions?

    • c)

      Are some IMIs more or less effective than other IMIs?

  • 2.

    Are there confounding variables that impact the effectiveness of IMIs for depression in adults with a diagnosed depression?

Section snippets

Protocol and registration

Review methods, eligibility criteria and strategy for data analysis were determined in advance and reported in a study protocol available at (https://osf.io/7aw2m). The systematic review and meta-analysis was registered at PROSPERO (registration number: CRD42016039679).

Eligibility criteria

The present review included randomized controlled clinical trials published before June 2016 examining adult samples with a reliably diagnosed depressive disorder (i.e. major depression and/or persistent depressive

Study selection

The database search yielded 4858 records. 108 studies remained for full text analysis after removing duplicates and exclusion due to title and abstract. 19 studies fulfilled all eligibility criteria. The study selection process and reasons for exclusion are described in detail in Fig. 1.

Study characteristics

In sum, 1650 persons from randomized trials were included. The mean age was 41.4 years (SD = 6.6), 70% were female. Ten of the studies evaluated an IMI vs. WL comparison (Berger et al., 2011, Carlbring et al.,

Discussion

The present systematic review and meta-analysis summarizes the available evidence regarding internet- and mobile-based interventions for depression in people with a reliable diagnosis of major depressive disorder and/or dysthymia. The 19 included studies comprise a great variety of interventions, populations, control groups, health care systems and research groups which allows a comprehensive insight into the field of research.

IMIs showed a large beneficial effect on depression severity at the

Acknowledgments

No acknowledgments

References (79)

  • S. Kolovos et al.

    Economic evaluation of Internet-based problem-solving guided self-help treatment in comparison with enhanced usual care for depressed outpatients waiting for face-to-face treatment: a randomized controlled trial

    J. Affect. Disord.

    (2016)
  • D. Richards et al.

    Computer-based psychological treatments for depression: a systematic review and meta-analysis

    Clin. Psychol. Rev.

    (2012)
  • S. Saxena et al.

    Resources for mental health: scarcity, inequity, and inefficiency

    Lancet

    (2007)
  • K. Vernmark et al.

    Internet administered guided self-help versus individualized e-mail therapy: a randomized trial of two versions of CBT for major depression

    Behav. Res. Ther.

    (2010)
  • T. Vos et al.

    Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global burden of disease study 2010

    Lancet

    (2013)
  • A.D. Williams et al.

    Positive imagery cognitive bias modification (CBM) and internet-based cognitive behavioral therapy (iCBT): a randomized controlled trial

    J. Affect. Disord.

    (2015)
  • G. Andersson et al.

    Internet-based and other computerized psychological treatments for adult depression: a meta-analysis

    Cogn. Behav. Ther.

    (2009)
  • G. Andersson et al.

    Guided Internet‐based vs. face‐to‐face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta‐analysis

    World Psychiatry

    (2014)
  • L. Andrade et al.

    Barriers to mental health treatment: results from the WHO World Mental Health surveys

    Psychol. Med.

    (2014)
  • G. Andrews et al.

    Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis

    PloS One

    (2010)
  • H. Baumeister

    Implementationsforschung in der Klinischen Psychologie, Rehabilitationspsychologie und Psychotherapie

    Psychol. Rundsch.

    (2014)
  • H. Baumeister et al.

    Prevalence of mental disorders based on general population surveys

    Social. Psychiatry Psychiatr. Epidemiol.

    (2007)
  • H. Baumeister et al.

    Meta-review of depressive subtyping models

    J. Affect. Disord.

    (2012)
  • H. Baumeister et al.

    Impact of an acceptance facilitating intervention on patients' acceptance of internet-based pain interventions: a randomized controlled trial

    Clin. J. Pain.

    (2015)
  • T. Berger et al.

    Internet-based treatment of depression: a randomized controlled trial comparing guided with unguided self-help

    Cogn. Behav. Ther.

    (2011)
  • P. Berto et al.

    Depression: cost-of-illness studies in the international literature, a Review

    J. Ment. Health Policy Econ.

    (2000)
  • S.E. Blackwell et al.

    Positive imagery-based cognitive bias modification as a web-based treatment tool for depressed adults: a randomized controlled trial

    Clin. Psychol. Sci.

    (2015)
  • K. Blom et al.

    Internet treatment addressing either insomnia or depression, for patients with both diagnoses: a randomized trial

    Sleep

    (2014)
  • K. Blom et al.

    Internet treatment addressing either insomnia or depression, for patients with both diagnoses: a randomized trial

    Sleep

    (2015)
  • P. Bower et al.

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

    Br. Med. J.

    (2013)
  • Centre for Evidence-Based Medicine (CEBM), 2009. Oxford Centre for Evidence-based Medicine – Levels of Evidence...
  • H. Christensen et al.

    Adherence in internet interventions for anxiety and depression: systematic review

    J. Med. Internet Res.

    (2009)
  • L. Cowpertwait et al.

    Effectiveness of web-based psychological interventions for depression: a meta-analysis

    Int. J. Ment. Health Addict.

    (2013)
  • P. Cuijpers et al.

    Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies

    Psychol. Med.

    (2010)
  • P. Cuijpers et al.

    Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies

    Psychotherapy

    (2010)
  • P. Cuijpers et al.

    The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size

    Psychol. Med.

    (2010)
  • P. Cuijpers et al.

    Melancholic and atypical depression as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression

    Depress. Anxiety

    (2016)
  • DGPPN, BÄK, KBV, AWMF, AkdÄ, BPtK, . . . DGRW. 2015, Oct 2016. S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare...
  • S. Duval et al.

    A nonparametric “trim and fill” method of accounting for publication bias in meta-analysis

    J. Am. Stat. Assoc.

    (2000)
  • Cited by (251)

    View all citing articles on Scopus
    View full text