Unguided etherapy for adults with depressive symptoms IPT

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, Amsterdam b 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 Marijke » 36 years » Single » Two children » Town » Part-time working » Mild depression

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 Low-intensity treatment Obstacles Advantages • • Wait lists Costs of therapy etc. Time of travelling Leave/babysit 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) & Interpersonal Psychotherapy (IPT):

Design Internet-assisted Cognitive Behavior Therapy (CBT) & Interpersonal Psychotherapy (IPT): Compared to Internet-assisted CBT Mood. GYM (control group)

Design • Non-inferiority trial • H 0: (IPT ≠ CBT) ≠ Mood. GYM • H 1: (IPT= CBT) = Mood. GYM

Design Mood. GYM • Within effect size: 0. 56 (95% CI: 0. 33 -0. 79) (Mac. Kinnon et al. , 2008) • Determined sample size: N=450 on post-test

Design Mood. GYM • Between effect size: 0. 33 (95% CI: 0. 11 -0. 55) • Within effect size: 0. 56 (95% CI: 0. 33 -0. 79) (Mac. Kinnon et al. , 2008) • Determined sample size: N=450 on post-test

Design • Non-inferiority trial • 3 e-conditions (IPT, New CBT, CBT Mood. GYM) • 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 n=69 did not fill in baseline Q N=1924 included IPT n=641 Mood. GYM n=642 CBT n=641

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 symptoms completers only

Results: depressive symptoms completers only Pre-post test: • No significant differences across the condition (F=2. 018; P=. 13) • Effect sizes: Mood. GYM: 0. 81 CBT: 0. 87 IPT: 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* (Mood. GYM) Been depressed: p =. 80

Conclusions Pre-post test for completers: • H 1: (CBT = IPT) = Mood. GYM • 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’ Mood. GYM: 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