Brief report
Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome

https://doi.org/10.1016/j.jad.2008.12.009Get rights and content

Abstract

Background

In a recent randomized trial, we were unable to confirm the previously reported high effectiveness of CCBT. Therefore, the aim of the current study was to have a closer look at usage and acceptability (i.e. expectancy, credibility, and satisfaction) of the intervention.

Methods

Depressed participants (N = 200) were given login codes for unsupported online CCBT. A track-and-trace system tracked which components were used. We used a 9-month follow-up period.

Results

Uptake was sufficient, but dropout was high. Many usage indices were positively associated with short-term depressive improvement, whereas only homework was related to long-term improvement. Acceptability was good and expectancy could predict long-term, but not short-term outcome.

Limitations

Associations between use of CCBT and improvement are merely correlational. Our sample was too depressed in relation to the scope of the intervention. We relied on online self-report measures. Analyses were exploratory in nature.

Conclusions

Although CCBT might be a feasible and acceptable treatment for depression, means to improve treatment adherence are needed for moderately to severely depressed individuals.

Introduction

Although cognitive behavioral therapy (CBT) is an effective treatment for depression (Butler et al., 2006), many depressed patients in primary care remain untreated (Hirschfeld et al., 1997). An effective, acceptable, and feasible solution might be computerized CBT (CCBT) (Kaltenthaler et al., 2006, Kaltenthaler et al., 2008a). Especially, unsupported websites of CCBT can have high potential in improving access to care, and they can be effective (Spek et al., 2007b). We recently evaluated the effectiveness of unsupported online CCBT (i.e. Colour Your Life/CYL) for depression in primary care compared with usual GP care (TAU) and a combination of both treatments and found no differences in outcome between the three interventions (De Graaf et al., 2008). The intensity of unsupported online CCBT might have been too low in our study population of moderately to severely depressed patients.

Since we were unable to confirm the previously reported high effectiveness of CCBT, we aimed to investigate usage and acceptability (i.e. expectancy, credibility, and pre- and post-treatment satisfaction) of the intervention and how these factors were related to treatment outcome. This has rarely and insufficiently been investigated, but informs us about the feasibility of the intervention and helps to optimize CCBT effectiveness. Some studies showed that completion of more site material was associated with better outcomes for depression (e.g. Christensen et al., 2006a, Osgood-Hynes et al., 1998). Acceptability can be important in predicting response to CCBT (Kaltenthaler et al., 2008b, Osgood-Hynes et al., 1998). We hypothesized that frequent use of unsupported online CCBT and positive expectations would be associated with better outcomes regarding depressive symptoms.

Section snippets

Design

The design of the study is a randomized trial with three conditions: (a) unsupported online CCBT, (b) TAU by a GP, and (c) CCBT and TAU combined. Details of the study method have been described elsewhere (De Graaf et al., 2008).

Participants

Participants were recruited in the general population by means of a large-scale Internet-based screening in the South of the Netherlands. Potentially eligible participants (age 18–65 years) were invited to visit the research centre for an intake to assess final

Study participants

Two-hundred depressed patients were randomly allocated to CYL (N = 100) or CYL&TAU (N = 100). At nine months of follow-up, data were available for 178 participants (attrition rate 11%). Demographic characteristics and the flow of the participants have been described elsewhere (De Graaf et al., 2008). To summarize, male gender was distributed as follows: CYL (48%) and CYL&TAU (37%). Mean age was 44.3 (SD 11.8) years for CYL and 45.2 (SD 10.9) years for CYL&TAU. Baseline BDI-II scores are high: 28.2

Discussion

Comparable to previous studies (e.g. Proudfoot et al., 2003, Spek et al., 2007b), the uptake of CYL was rather good. However, drop-out was high, which is common in unsupported online CCBT (Spek et al., 2007a). The use of sophisticated technologies in CYL might not have been enough to stimulate engagement. Moreover, many short visits were made to the program. The intervention was perhaps too demanding to complete a session in one visit. Improving adherence to CCBT is needed, which can be

Role of funding resource

The trial is financed by ZonMw (Netherlands Organisation for Health Research and Development; project number 945-04-417), research institute EPP and research institute CAPHRI. Municipalities Eijsden, Meerssen, Sittard-Geleen, Valkenburg and Maastricht sponsored the study. The study sponsors had no role in the design of the study; in the collection, analysis, and interpretation of the data; in the writing of the report; and in the decision to submit the article for publication.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

We thank Annie Hendriks and Greet Kellens for their assistance during the study and Rosanne Janssen for the development of the infrastructure for online data-collection. Municipalities Eijsden, Meerssen, Sittard-Geleen, Valkenburg and Maastricht sponsored the study.

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