Unguided e-therapy for adults with depressive symptoms:

IPT vs. CBT

Tara Donkera, Kathleen M. Griffithsb, Helen Christensenb, Kylie Bennettb , Anthony

Bennettb, Annemieke van Stratena , Pim Cuijpersa

a VU University, Amsterdamb Australian National University, Canberra

Introduction

Life time prevalence: 19% (Bijl et al., 1998)

Introduction

Top four leading causes of burden of disease worldwide (Lopez & Murray, 1998)

Introduction

Costs per capita for mood disorders: € 5,009 (Smit et al., 2006)

Low-intensity treatment for depression and anxiety

Obstacles

Long waitlists

Obstacles

2 hrs of travelling to the clinic

Obstacles

Take leave from work

Obstacles

Arrange a babysit

Obstacles

Costs of babysit

Obstacles

+.. Costs of travelling, babysit..

Low-intensity treatment for depression and anxiety

Psychological self-help:

•|Standardized •Independent•Homework/tasks•Via book, audio, internet..•Guidance by email, chat, telephone

Advantages

No wait lists

Advantages

Working from home

Advantages

24/7

Advantages

Cost-effective

Advantages

Anonymous

Low-intensity treatment for depression and anxiety

Intensive face-to face treatment

Obstacles

• Wait lists• Costs of therapy etc.• Time of travelling• Leave/babysit

Low-intensity treatment

Advantages

• Directly accessable• Cost-effective• Working from home• 24/7

Introduction

Introduction

Introduction

Introduction

Introduction

E-CBT = effective (e.g. Carlbring et al., 2009; Christensen et al., 2004;Kaldo et al., 2008; Ruwaard et al., 2009; Spek et al., 2008; Warmerdam et al., 2008)

Introduction

Introduction

Introduction

Depression: IPT = CBT (Cuijpers et al., 2011) Effect size: 0.04 (95% CI 0.14-0.21)

Introduction

==

??

Design

Internet-assisted

Cognitive Behavior Therapy (CBT) Cognitive Behavior Therapy (CBT)

&

Interpersonal Psychotherapy (IPT):Interpersonal Psychotherapy (IPT):

Design

Internet-assisted

Cognitive Behavior Therapy (CBT) Cognitive Behavior Therapy (CBT)

&

Interpersonal Psychotherapy (IPT):Interpersonal Psychotherapy (IPT):

Compared to

Internet-assisted

CBT MoodGYM (control group)

Design

• Non-inferiority trial

• H0: (IPT ≠ CBT) ≠ MoodGYM

• H1: (IPT= CBT) = MoodGYM

Design

MoodGYM

• Within effect size: 0.56 (95% CI: 0.33-0.79) (MacKinnon et al., 2008)

• Determined sample size: N=450 on post-test

Design

MoodGYM

• Between effect size: 0.33 (95% CI: 0.11-0.55)• Within effect size: 0.56 (95% CI: 0.33-0.79) (MacKinnon et al., 2008)

• Determined sample size: N=450 on post-test

Design

• Non-inferiority trial • 3 e-conditions (IPT, New CBT, CBT

MoodGYM)• Fully automated trial, 4 weeks • Online recruitment and screening

Design

• Inclusion: 18 years or older• Exclusion: currently under treatment by

mental health specialist • 3 measurements (baseline, after 4 weeks

and after 6-months)• Primary outcome: depressive symptoms

Interpersonal Psychotherapy

• Developed by Klerman and Weissman (1984)

• Relationship between depression and experiences

• IPT aims at improvement of interpersonal functioning and (inherent) depression

Internet-assisted IPT - overview

Internet-assisted IPT -week 1

Role disputes

• Identification of the dispute (with whom?)

• Modification of communication patterns

Internet-assisted IPT -week 2

Problems making relationships

• Realistic evaluation of can do`s/ can`t do`s

• Increase social contacts

Internet-assisted IPT -week 2 Problems making relationships

Internet-assisted IPT – week 2

Internet-assisted IPT - week 3 Role Changes

• Investigate which old role is given up

• Validate the loss

• Support letting go of old role

Internet-assisted IPT - week 3 Role Changes

• Develop new skills for the new role

• Develop new relationships and social support

Internet-assisted IPT – week 3

Internet-assisted IPT - week 4 Grief

• Activate grief proces– Psychoeducation– Learn to express emotions

• Finding new meaningful activities and social contacts replacing those which were lost

Internet-assisted IPT – week 4

Results: Participant flow N=1993

met inclusion criteria

CBT n=641

IPT n=641

MoodGYMn=642

N=1924 included

n=69 did not fill in baseline Q

Results: demographics

• Gender: 71% female • Age category: 25-29 years (15.1%) • Country: 1: Australia (38%)• 2: United Kingdom (25%)• 3: United States (19%) • Education: higher degree (26%)• Previous treatment by professional: 80% • Been depressed before: 90%

Results: depressive symptoms

Mean CES-D at baseline (n.s.):

• Moodgym: 35 (sd: 11.7) n=622

• IPT: 36 (sd: 11.9) n=623

• CBT: 36 (sd: 11.) n=615

Results: depressive symptomscompleters only

15

20

25

30

35

40

0 4weeks since randomization

CE

S-D

depre

ssio

n s

core

CBTI PTMG

Results: depressive symptomscompleters only

Pre-post test:

• No significant differences across the condition (F=2.018; P=.13)

• Effect sizes:MoodGYM: 0.81

CBT: 0.87IPT: 0.77

Results: drop out

• CES-D: p=.02* (higher CES-D)

• Sexe: p =.<0.1* (more men)

• Age: p =.<0.1* (25-29 years)

• Education: p =.04* (lower education)

• Condition: p = .02* (MoodGYM)

• Been depressed: p = .80

Conclusions

Pre-post test for completers: • H1: (CBT = IPT) = MoodGYM• Effect sizes between 0.77-0.81• E-IPT: more treatment choice• 70% “drop out” • Significant differences in drop out for

demographics, treatment allocation, baseline CES-D score

Discussion

• ‘Gold standard’ MoodGYM:

Equivalence margin: 0.33

• Follow up data not yet available

• Drop out rate: 70% →» Missing data approaches» high symptoms: seek your GP » Unguided self-help » Characteristic of population

Disadvantages

Anonymous

Disadvantages

Guided self-help

Disadvantages

High drop out rate

Discussion

Unguided self-help….

• Ethical..?

• Under which conditions?

Questions? Thank you for your attention

www.isrii.regroup.com

Email: T.Donker@psy.vu.nl