Abstract
BackgroundInternet-based cognitive behavior therapy (iCBT) interventions have the potential to help individuals with depression, regardless of time and location. Yet, limited information exists on the longer-term (>6 months) effects of iCBT and adherence to these interventions.ObjectiveThe primary aim of this study was to evaluate the longitudinal (12 months) effectiveness of a fully automated, self-guided iCBT intervention called Thrive, designed to enhance engagement with a rural population of adults with depression symptoms. The secondary aim was to determine whether the program adherence enhanced the effectiveness of the Thrive intervention.MethodsWe analyzed data from 181 adults who used the Thrive intervention. Using self-reports, participants were evaluated at baseline, 8 weeks, 6 months, and 12 months for the primary outcome of depression symptom severity using the Patient Health Questionnaire-9 (PHQ-9) scale and secondary outcome measures, namely, the Generalized Anxiety Disorder Scale-7 (GAD-7) scores, Work and Social Adjustment Scale (WSAS) scores, Conner-Davidson Resilience Scale-10 (CD-RISC-10) scores, and suicidal ideation (ninth item of the PHQ-9 scale) scores. The Thrive program adherence was measured using the numbers of program logins, page views, and lessons completed.ResultsThe assessment response rates for 8-week, 6-month, and 12-month outcomes were 58.6% (106/181), 50.3% (91/181), and 51.4% (93/181), respectively. By 8 weeks, significant improvements were observed for all outcome measures. These improvements were maintained at 12 months with mean reductions in severities of depression (mean –6.5; P<.001) and anxiety symptoms (mean –4.3; P<.001). Improvements were also observed in work and social functioning (mean –6.9; P<.001) and resilience (mean 4.3; P<.001). Marked decreases were observed in suicidal ideation (PHQ-9 ninth item score >1) at 6 months (16.5%) and 12 months (17.2%) compared to baseline (39.8%) (P<.001). In regard to the program adherence, cumulative counts of page views and lessons completed were significantly related to lower PHQ-9, GAD-7, and WSAS scores and higher CD-RISC-10 scores (all P values <.001 with an exception of page views with WSAS for which P value was .02).ConclusionsThe Thrive intervention was effective at reducing depression and anxiety symptom severity and improving functioning and resilience among a population of adults from mostly rural communities in the United States. These gains were maintained at 1 year. Program adherence, measured by the number of logins and lessons completed, indicates that users who engage more with the program benefit more from the intervention.Trial RegistrationClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878
Highlights
Clinician-delivered cognitive behavior therapy (CBT) is a long-standing evidence-based psychotherapy for depression and anxiety symptoms and disorders [1,2]
Using self-reports, participants were evaluated at baseline, 8 weeks, 6 months, and 12 months for the primary outcome of depression symptom severity using the Patient Health Questionnaire-9 (PHQ-9) scale and secondary outcome measures, namely, the Generalized Anxiety Disorder Scale-7 (GAD-7) scores, Work and Social Adjustment Scale (WSAS) scores, Conner-Davidson Resilience Scale-10 (CD-RISC-10) scores, and suicidal ideation scores
These improvements were maintained at 12 months with mean reductions in severities of depression and anxiety symptoms
Summary
Clinician-delivered cognitive behavior therapy (CBT) is a long-standing evidence-based psychotherapy for depression and anxiety symptoms and disorders [1,2]. Compared to clinician-delivered CBT, internet-based cognitive behavior therapy (iCBT) programs have potential for greater reach and scalability, greater standardization of content delivery, and reduced risk of stigmatization [4,5,6] Even more, they have demonstrated equivalent effectiveness for reducing depression and anxiety symptoms [7]. Acceptability, and effectiveness of self-guided (no supportive contacts by email, text, telephone, or face-to-face) iCBT interventions on depression and anxiety symptoms [4,6,8,9,10] These findings are promising for people living in rural and frontier communities, which, nationally and internationally, have greater behavioral health care access challenges [11,12,13]. Limited information exists on the longer-term (>6 months) effects of iCBT and adherence to these interventions
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