Efficacy of Three Low-Intensity, Internet-Based Psychological Interventions for the Treatment of Depression in Primary Care: Randomized Controlled Trial.

Margalida Gili,Adoración Castro,Miquel Roca,Alberto Barceló-Soler,Amelia Villena,Azucena García-Palacios,Fermin Mayoral-Cleries,Javier Garcia-Campayo,Pau Riera-Serra,Mªteresa Navarro,Cristina Botella,Rosa Mª Baños,M Ángeles Pérez-Ara,María M Hurtado

doi:10.2196/15845

Abstract

BackgroundPrimary care is a major access point for the initial treatment of depression, but the management of these patients is far from optimal. The lack of time in primary care is one of the major difficulties for the delivery of evidence-based psychotherapy. During the last decade, research has focused on the development of brief psychotherapy and cost-effective internet-based interventions mostly based on cognitive behavioral therapy (CBT). Very little research has focused on alternative methods of treatment for depression using CBT. Thus, there is a need for research into other therapeutic approaches.ObjectiveThis study aimed to assess the effectiveness of 3 low-intensity, internet-based psychological interventions (healthy lifestyle psychoeducational program [HLP], focused program on positive affect promotion [PAPP], and brief intervention based on mindfulness [MP]) compared with a control condition (improved treatment as usual [iTAU]).MethodsA multicenter, 4-arm, parallel randomized controlled trial was conducted between March 2015 and March 2016, with a follow-up of 12 months. In total, 221 adults with mild or moderate major depression were recruited in primary care settings from 3 Spanish regions. Patients were randomly distributed to iTAU (n=57), HLP (n=54), PAPP (n=56), and MP (n=54). All patients received iTAU from their general practitioners. The main outcome was the Spanish version of the Patient Health Questionnaire-9 (PHQ-9) from pretreatment (time 1) to posttreatment (time 2) and up to 6 (time 3) and 12 (time 4) months’ follow-up. Secondary outcomes included the visual analog scale of the EuroQol, the Short-Form Health Survey (SF-12), the Positive and Negative Affect Schedule (PANAS), and the Pemberton Happiness Index (PHI). We conducted regression models to estimate outcome differences along study stages.ResultsA moderate decrease was detected in PHQ-9 scores from HLP (β=–3.05; P=.01) and MP (β=–3.00; P=.01) compared with iTAU at posttreatment. There were significant differences between all intervention groups and iTAU in physical SF-12 scores at 6 months after treatment. Regarding well-being, MP and PAPP reported better PHI results than iTAU at 6 months post treatment. PAPP intervention significantly decreased PANAS negative affect scores compared with iTAU 12 months after treatment.ConclusionsThe low-intensity, internet-based psychological interventions (HLP and MP) for the treatment of depression in primary care are more effective than iTAU at posttreatment. Moreover, all low-intensity psychological interventions are also effective in improving medium- and long-term quality of life. PAPP is effective for improving health-related quality of life, negative affect, and well-being in patients with depression. Nevertheless, it is important to examine possible reasons that could be implicated for PAPP not being effective in reducing depressive symptomatology; in addition, more research is still needed to assess the cost-effectiveness analysis of these interventions.Trial RegistrationISRCTN Registry ISRCTN82388279; http://www.isrctn.com/ISRCTN82388279International Registered Report Identifier (IRRID)RR2-10.1186/s12888-015-0475-0

Highlights

BackgroundDepression represents a significant personal, economic, and societal burden [1,2,3]
The low-intensity, internet-based psychological interventions (HLP and MP) for the treatment of depression in primary care are more effective than improved treatment as usual (iTAU) at posttreatment
It is important to examine possible reasons that could be implicated for positive affect promotion program Pemberton Happiness Index (PHI) (PAPP) not being effective in reducing depressive symptomatology; in addition, more research is still needed to assess the cost-effectiveness analysis of these interventions

Summary

Introduction

BackgroundDepression represents a significant personal, economic, and societal burden [1,2,3]. Multiple and complex facilitators and barriers to treatment have been described [8,9], and access to evidence-based psychotherapy is one of these difficulties Different factors such as professionals’ training, time needed, costs or work overload, professionals’ attitudes and organization, and geographical and logistic difficulties are some of the reasons that make the integration of psychotherapy in primary care difficult. (Extensive time and resources imply important difficulties for the application of this type of therapy.) For these reasons, and in an effort to reduce the high medical costs of depression treatment and overcome the difficulties of traditional treatments in primary care, brief psychotherapy for depression effective and cost-effective internet-based interventions have been extensively developed during the last decade [11,12]. Primary care is a major access point for the initial treatment of depression, but the management of these patients is far from optimal. There is a need for research into other therapeutic approaches

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