Abstract
BackgroundInternet interventions can easily generate objective data about program usage. Increasingly, more studies explore the relationship between usage and outcomes, but they often report different metrics of use, and the findings are mixed. Thus, current evaluations fail to demonstrate which metrics should be considered and how these metrics are related to clinically meaningful change.ObjectiveThis study aimed to explore the relationship between several usage metrics and outcomes of an internet-based intervention for depression.MethodsThis is a secondary analysis of data from a randomized controlled trial that examined the efficacy of an internet-based cognitive behavioral therapy for depression (Space from Depression) in an adult community sample. All participants who enrolled in the intervention, regardless of meeting the inclusion criteria, were included in this study. Space from Depression is a 7-module supported intervention, delivered over a period of 8 weeks. Different usage metrics (ie, time spent, modules and activities completed, and percentage of program completion) were automatically collected by the platform, and composite variables from these (eg, activities per session) were computed. A breakdown of the usage metrics was obtained by weeks. For the analysis, the sample was divided into those who obtained a reliable change (RC)—and those who did not.ResultsData from 216 users who completed pre- and posttreatment outcomes were included in the analyses. A total of 89 participants obtained an RC, and 127 participants did not obtain an RC. Those in the RC group significantly spent more time, had more log-ins, used more tools, viewed a higher percentage of the program, and got more reviews from their supporter compared with those who did not obtain an RC. Differences between groups in usage were observed from the first week in advance across the different metrics, although they vanished over time. In the RC group, the usage was higher during the first 4 weeks, and then a significant decrease was observed. Our results showed that specific levels of platform usage, 7 hours total time spent, 15 sessions, 30 tools used, and 50% of program completion, were associated with RC.ConclusionsOverall, the results showed that those individuals who obtained an RC after the intervention had higher levels of exposure to the platform. The usage during the first half of the intervention was higher, and differences between groups were observed from the first week. This study also showed specific usage levels associated with outcomes that could be tested in controlled studies to inform the minimal usage to establish adherence. These results will help to better understand how to use internet-based interventions and what optimal level of engagement can most affect outcomes.Trial RegistrationISRCTN Registry ISRCTN03704676; http://www.isrctn.com/ISRCTN03704676International Registered Report Identifier (IRRID)RR2-10.1186/1471-244X-14-147
Highlights
BackgroundInternet- and computer-based interventions for depression have been shown to be effective in several meta-analytic reviews, reporting comparable effects to face-to-face treatments [1,2,3,4,5]
Differences between groups in usage were observed from the first week in advance across the different metrics, they vanished over time
This study showed specific usage levels associated with outcomes that could be tested in controlled studies to inform the minimal usage to establish adherence
Summary
Internet- and computer-based interventions for depression have been shown to be effective in several meta-analytic reviews, reporting comparable effects to face-to-face treatments [1,2,3,4,5] These findings have led to the use of these interventions within stepped care and collaborative care models of mental health provision, which operate on the premise that not everybody requires a high-intensity treatment in the form of face-to-face therapy provided by a trained psychologist [6]. Most of the studies about internet-based cognitive behavioral therapy (iCBT) only analyze outcomes at fixed time points, treating the intervention as a singular entity, without considering the way the program is adopted and used by the users [10] In this sense, some research has shown that the users’ uptake and long-term use of these technologies are lower than might be expected, and a median of 56% of the participants complete the whole program [11]. Current evaluations fail to demonstrate which metrics should be considered and how these metrics are related to clinically meaningful change
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