Abstract
Background and AimMild to moderate depression is common in those with cardiovascular disease and undertreated. We aimed to evaluate the effectiveness of internet-delivered Cognitive Behaviour Therapy (iCBT) on depressive symptom severity and adherence to medical advice and lifestyle interventions in adults with mild to moderate depression and high cardiovascular disease (CVD) risks.MethodsRandomised double-blind, 12 week attention-controlled trial comparing an iCBT programme (E-couch) with an internet-delivered attention control health information package (HealthWatch, n = 282). The primary outcome was depression symptom level on the nine-item Patient Health Questionnaire (PHQ-9) (trial registration: ACTRN12610000085077).Results487/562 (88%) participants completed the endpoint assessment. 383/562 (70%) were currently treated for cardiovascular disease and 314/562 (56%) had at least one other comorbid condition. In ITT analysis of 562 participants iCBT produced a greater decline in the mean PHQ-9 score compared to the attention control of 1.06 (95% CI: 0.23–1.89) points, with differences between the two arms increasing over the intervention period (time by treatment effect interaction p = .012). There were also larger improvements in adherence (2.16 points; 95% CI: 0.33–3.99), reductions in anxiety (0.96 points; 95% CI: 0.19–1.73), and a greater proportion engaging in beneficial physical activity (Odds Ratio 1.91, 95%CI: 1.01–3.61) in the iCBT participants but no effect upon disability, or walking time/day. There were no withdrawals due to study related adverse events.ConclusionsIn people with mild to moderate depression and high levels of CVD risk factors, a freely accessible iCBT programme (http://www.ecouch.anu.edu.au) produced a small, but robust, improvement in depressive symptoms, adherence and some health behaviours.Trial RegistrationAustralian and New Zealand Clinical Trials Registry ACTRN12610000085077
Highlights
In high income countries, cardiovascular disease (CVD) and depression are the two leading causes of disease burden. [1] Depression is more prevalent in people with CVD and leads to a range of poorer CVD related outcomes. [2] One important factor that may explain this worse outcome is poor adherence to CVD treatment and lifestyle recommendations
[7] These clinical guidelines recommend that ‘‘for persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, ehealth interventions, in the form of computerised cognitive behavioural therapy be used.’’ This recommendation was made on the basis of extrapolation from the internet-delivered Cognitive Behaviour Therapy (iCBT) literature in general: [7], there is no evidence to directly support this recommendation in people with depression and physical health comorbidity
Of 7086 invitations to potential participants, 1862 (26%) provided consent and proceeded to eligibility screening. Those consenting were more likely to be female, speak English at home have a higher education and a prior doctor’s diagnosis of depression: these variables were not associated with outcome amongst trial participants
Summary
Cardiovascular disease (CVD) and depression are the two leading causes of disease burden. [1] Depression is more prevalent in people with CVD and leads to a range of poorer CVD related outcomes. [2] One important factor that may explain this worse outcome is poor adherence to CVD treatment and lifestyle recommendations. [7] These clinical guidelines recommend that ‘‘for persistent subthreshold depressive symptoms or mild to moderate depression and a chronic physical health problem, ehealth interventions, in the form of computerised (or internet) cognitive behavioural therapy (iCBT) be used.’’ This recommendation was made on the basis of extrapolation from the iCBT literature in general: [7], there is no evidence to directly support this recommendation in people with depression and physical health comorbidity. We aimed to evaluate the effectiveness of internet-delivered Cognitive Behaviour Therapy (iCBT) on depressive symptom severity and adherence to medical advice and lifestyle interventions in adults with mild to moderate depression and high cardiovascular disease (CVD) risks
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