Online Treatment for Depression: Deprexis

Online treatment for mental disorders is not exactly a new idea. The Australian National University’s Centre for Mental Health Research released MoodGYM five years ago, with multiple studies supporting its effectiveness and validity. One of their studies even suggests that the positive effects of completing the MoodGYM program continue for up to 12 months. This is good stuff.

But under the “more is better” heading, a group of German researchers developed their own online coping with depression program called Deprexis. Like MoodGYM, participants complete each module on a website:

The Web-based intervention consists of 10 content modules representing different psychotherapeutic approaches, plus one introductory and one summary module, each of which can be completed in 10 to 60 minutes, depending on the user’s reading speed, interest, motivation, and individual path through the program.

Modules are organized as simulated dialogues in which the program explains and illustrates concepts and techniques, engages the user in exercises, and continuously asks users to respond by selecting from response options. Subsequent content is then tailored to the users’ responses, resulting in a simulated conversational flow. All modules are accompanied by illustrations (eg, drawings, photographs, flash animations).

There was no therapist support during the treatment phase of this study. Participants were on their own and took the course online over the span of 9 weeks at their own pace.

The people who took the online course improved, on average, about 6 Beck Depression Inventory points. Clinically significant? For most, yes. And better yet, the gains were maintained over a 6 month followup.

One of the interesting findings is that even for participants who only took 4 or fewer of the 10 sessions, they still received positive effects of the treatment:

A surprising observation in this study was that a large proportion of participants showed lasting positive effects even though they received only a small dosage of the treatment (ie, 4 sessions or fewer).

This finding is actually consistent with previous research showing that many psychotherapy clients experience the majority of therapeutic gains within the first few sessions. Howard et al, for example, found that 41% of therapeutic gains typically occur within the first 4 sessions.

As with virtually all online interventions, the drop-out rate was enormous — nearly half weren’t available for the first 9-week assessment. And less than half completed more than 3 sessions. Three to four sessions of treatment is basically all you get online. After that, most people have dropped out and will not complete the program.

Most people simply don’t “stick with the program” when left to their own devices. That’s why although a lot of self-help programs sound good in theory (and even in research studies like this), in the real world they fail to make the impact their authors expect.

Could it be that people have gotten all they needed from the program within those 3 or 4 sessions? Or might it be that they lose interest in the program, or lack the motivation to continue it (perhaps even as a result of the depression itself)? Research to date hasn’t answered these questions, which seem like a necessary next step to understand how to improve treatment rates.

Because what’s the point of a carefully-designed depression program if most people never experience most of it?

Strangely, the authors of the Deprexis program do not make it available online for people to try without a “prescription” from a therapist or health care provider:

Deprexis is intended as an additional treatment tool to be used by physicians and therapists in their work.

Really? Because in the introduction to the research just published, the authors decry the lack of ready, immediate access to treatment programs for depression:

Many depressed patients who could benefit from treatment also remain on waiting lists for a long time or do not engage with treatment due to geographical inaccessibility, prohibitive costs, or other reasons, such as a preference for self-help. The evidence shows that depressed patients who remain on waiting lists continue to report high levels of distress, even over many months.

What can be done to help more of these patients quickly and efficiently? […] The purpose of the project described here was to develop a novel, integrative program that could be delivered via the Internet to reduce symptoms of depression.

It seems odd that the researchers conducted a study on their own program without requiring participants be seen by a health care provider for the treatment of depression, but then require such treatment if you want to access it online.

Reference:

Björn Meyer PhD, Thomas Berger DPhil, Franz Caspar, DPhil, Christopher G Beevers, PhD, Gerhard Andersson, PhD, & Mario Weiss, MD, MBA (2009). Effectiveness of a Novel Integrative Online Treatment for Depression (Deprexis): Randomized Controlled Trial. J Med Internet Research, 11(2).