Delivering interventions for depression by using the internet: randomised controlled trial
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.37945.566632.EE (Published 29 January 2004) Cite this as: BMJ 2004;328:265All rapid responses
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The objective of this e-psychology field work was strictly the evaluation of efficacy of two different interventions guided by lay interviewers on the ’ for community-dwelling people with symptoms of depression using EITHER a psychoeducation website (‘Bluepages‘) offering information about depression (symptoms, treatment (including the persisting canard that antidepressants actually work, after 2 to 4 weeks), resources, access to depression websites, test quizzes on anxiety and depression etc) each in weekly tranches, OR an interactive site (‘MoodGYM‘) offering cognitive behaviour therapy(CBT)founded on fictional character comparisons using module headings such as feelings, thoughts, unwarping of thoughts - since ‘what you think is what you feel‘, de-stressing and relationships.
These interventions, at first sight two completely approaches, were compared with a control group who were also contacted by ‘phone by lay interviewers weekly to discuss various incidental subjects, e.g. education and hobbies in week 2 and nutrition and alcohol in week 6. This is described as a sort of ‘attention placebo‘. How the lay interviewers supervised patients with advice about deterioration of the degree and range of symptoms we are not told. Were they asked to persevere? How many came to need ‘traditional treatment’ or independently took St John’s wort? We do not know if there was any real physical morbidity in the course of events.
The proposition in the work’s ‘Conclusion’ that BluePages and MoodGYM are efficacious as treatment for depression, apparently depression of any origin, is immediately undermined by the fact that both programmes in their disclaimers are published as ‘not in any way to be used as diagnosis or treatment for depression for which each is not a substitute’ on the express basis that ‘they are for information purposes only’ and anyone believing he is depressed requires to see ‘a mental health physician and the need to talk‘.
In the paragraphs for use at weekly intervals concerning both ‘About’ and ‘Help and Resources’ in BluePages we are surprised to be offered a link to MoodGYM. Here, we learn, on our leaving the BluePages website, that the BluePages team is not responsible for, and does not endorse, the content of the sites of outside agencies. MoodGYM is the only one listed. Now this is peculiar since the CVs of both female authors, who are not medically qualified, expressly claim the co-authorship of this very paper. There is a certain difficulty too in finding that the patients exploring the first website intervention are directed to include use of exploration of the second in their intervention. This makes contrast and comparison of efficacy very difficult indeed.
No claim is made as to treatment worth. The paper conclusion is that both CBT and psychoeducation via the Internet are effective in reducing symptoms of depression. Now is that a statement of their treatment value? Are they to be used separately or together? How is treatment to be related to this very costly and time consuming enterprise? Scattered throughout the paper the word treatment appears in other reports and analyses for example the ‘Limitations‘ paragraph. So are we being seduced into using information menus and modules in an account of CBT, singly or combined, as prevention in theory but in practice as treatment? It is very important because we need to know whether we can treat depressives with a website reference alone and have no need to see them until they are forced to actually seek some other help fortuitously, as they would do. How do these webs prevent what already is established to exist? What is the use of this work?
The statistics section, for someone who has waded through Campbell & Machin, are too abstruse for the poor structure of the work, and for work requiring effectively yes or no answers i.e. (read the material or not, or thought about it or not, or both). The effect sizes chosen of 0.2, 0.4 and 0.6 are highly optimistic for all the reasons given above. Are the lay interviewers a necessary part of the treatment and the conclusion? Are alpha and kappa values applied to their work? There is a strong sense that it really doesn’t matter.
Both intervention programs repay a visit, if you have the time. BluePages is dry material effectively in chapter form. MoodGYM is a considerable undertaking to review concerning itself with the possible theoretical nature of the mental dynamics of postulated ideal types, particularly students and you as patient. Each episode takes an hour or so and requires considerable powers of persistence to continue in polysyllabic medical, psychological and lifestyle literary and CBT environments. In the ‘De-stressing’ section there is a quiz on ‘Life’s whacks’ and in the unwarping module there is a Pleasant Events Schedule of 319 questions, one after the other, concerning warped thoughts and the unwarping thereof and de-stressing. To each of these questions there are two drop-down menus which need filling in. There is no doubt that approaching this task when feeling vulnerable is likely to precipitate the established condition and it is easy to understand (which the authors say they couldn’t) why the drop out rate was so high and why the mechanisms underlying the comparative success of the simple uncomplicated psychoeducation program were so successful in contrast.
But for all these and other reasons, as an example of e-mental health, this work is poor. Even as Mental Health First Aid it has major problems in establishing its foundations. Patients can and do pull themselves together until they can do it no longer. Instinctively one knows that treatment of depression is highly individual and is the personal care of people. It is not dependent on medical, psychological, cognitive behaviour therapy or lifestyle “literacies” in the subject patient. It cannot be dealt with in the abstract. It must be two way treatment and at times the illness is fundamentally shared. Its proper treatment, in short, is how you personally would like to be treated with this condition.
David Barnes
Competing interests:
None declared
Competing interests: No competing interests
Sir
It is very encouraging to see that in the paper by Christensen et al
(1), researchers are starting to probe more deeply into the potential the
Internet has to offer in medical care. Since the rise and fall of the
‘dotcom’ bubble over the past few years, much has been promised by this
new technology, but the research evidence has been slower to follow.
However, this paper further confirms my suspicion that use of the
Internet continues to be a socio-economically determined (2). Christensen
et al demonstrate that those who gained the most from their Internet
intervention were well-educated females in their late thirties. This is
particularly worrying, as groups well recognised to be particularly
greatly affected by mood disorders, namely the old and the poor, do not
seem to be represented. The explanation may lie in the fact that the old
and poor in Australia face a similar pattern of Internet access, as they
do in the United Kingdom (UK). In the UK, the old and the poor have poor
Internet access. Of those over 65 years of age, only 7% have ever accessed
the Internet (3). Of the poorest 10% of the United Kingdom’s population,
only 12% have ever accessed the Internet (4).
The Internet has the potential to offer much, but access to this
resource continues to be a problem for those who most need it. Until
access issues are addressed, it is hard to imagine that it will ever
replace more traditional face-to-face services and mental health service
providers must resist the temptation to use it as a cut-price way of
providing their psychological therapies.
References
1. Christensen H, Griffiths K, Jorm A. Delivering interventions for
depression by using the internet: randomised controlled trial. BMJ
2004;328:265-268
2. Wong G. Increasing email consultations may marginalise more
people. BMJ 2001; 323: 1189.
3. National Statistics. Households with Internet access: by household
type: Social Trends 34.
http://www.statistics.gov.uk/STATBASE/ssdataset.asp?vlnk=7203&More=Y
(accessed 1 Feb 04)
4. National Statistics. Households with home access to the Internet
by gross income decile group: Household Internet Access.
http://www.statistics.gov.uk/STATBASE/ssdataset.asp?vlnk=6937&More=Y
(accessed 1 Feb 04)
Competing interests:
None declared
Competing interests: No competing interests
Dr Al-Sheikhli raises some interesting points. I though have a
different view of rehabilitation using the internet. I am still quite
young in age, know a fair bit about the internet as it is part of my "
job" and have always been aware that the NHS is miles behind methods used
in the US.
Most psychiatric facilities do not have occupational therapy never
mind internet access. Funding is a limitation to using the internet as a
method of rehabilitation. Most psychiatric units tend to be much like a
factory production unit - you admit them, make them better ( slightly) and
then discharge them. There isn't time to fit in the use of CBT or the
internet. The cutbacks in the mental health services starve requirements
of rehabilitation to a minimum.
In the US, specialist units use computer technology for depressive
illnesses as well as other organic problems. Rehabilitation is all about
the individual. Dr Al-Sheikhli speaks like a scientist which is admirable
but sometimes techniques have to be taylored to individual patients.
Patients are not objects to be there simply to study. I would though
prefer to read about individual patients and their preference and ideas
about improving computer related rehabilitation. There are so many
programmes one can use but it needs a bit of thought - the patients
interests, lifestyle and ability.
For any GPs out there, I have found the following useful in
rehabilitation. This method of advice was created in the absence of
funding as we all rely on voluntary organisations to ensure some form of
rehabilitation.
a) First advise the patient and his or her relative to obtain a
computer. If they are disabled and have problems with money
http://www.abilitynet.org.uk/ is a really good site to refer them to. They
talk about computer availability etc.
b) Teaching people the use of computers is also assisted by a little
known charity called www.itcanhelp.org.uk . The assistance is free and it
improves the lives of many patients.
c) Programs such as Encarta, Theme Hospital, Various Encyclopedias on
CD, Cinemania, Bodyworks are all programs available very cheaply that
improves hand eye co-ordination, visual attention and depressive symptoms.
There are various Maths related programmes, cross words on CD that can
also improve their function and attention. Multimedia programmes are
important as they are "all singing and all dancing". Most of my patients
tell me that Staples is a really good place for cheap CD roms.
d) Learndirect http://www.learndirect.co.uk is one of those obvious
places that I send a fair few patients to and they do really well.
The suggestions a-d are extremely obvious yet few people or doctors
think of them. IT is not a prescription like a drug, it is something that
can be manipulated to suit the patient. Most people require practical
solutions as opposed to statistics much like the US way of "lights, camera
and action".
Kind Regards
Dr Rita Pal
www.nhs-exposed.com
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
It was interesting to read the abstract of the paper of
Christensen, Griffiths and Jorm, Delivering Intervention for depression by
using the internet:a randomised controlled trial (BMJ 2004;0:379455666-
0). My comment
1.Patients ought to satisfy certain criteria,like ICD 10,DSM-IV,..etc,for
depressive illness.
2.Whether the patients are on psychotropic drugs like antidepressants, mood stabilisers..etc , or not?
3.We ought to look into the co-morbidity issue,like depressive illness
with substance misuse, borderline personality disorder..etc.
4.We ought to examine carefully our groups. Are they similar to each other
or are different?
5.We ought to have clear improvement criteria.
6.It reminds me of few studies in the past,comparing exercise with
antidepressants which show exercise to be superior to antidepressant
medication. I wonder if the authors include exercise among their groups. It
is quite possible that exercise will be superior to other groups, including psychoeducation and cognitive behavioural therapy through the
internet.
Thanking you,
Yours sincerely,
AK.Al-Sheikhli
Competing interests:
None declared
Competing interests: No competing interests
Re: Future of research
But for the solid critical response of David Barnes I would have
serious qualms about the quality of the BMJ peer review of this study. A
basic flaw of the study's set-up lies in the fact that the intervention
groups were selected from people that had indicated they would be willing
to participate in this study and,as any therapist knows, the main
indicator of beginning improvement in depression is the (renewed) interest
in doing things, particularly new things. Thus the study selected people
that were already getting out of their (supposed)depression. This
unacceptably corrupts the results.
Competing interests:
None declared
Competing interests: No competing interests