1. Unguided e-therapy for adults with depressive symptoms: IPT vs. CBT Tara Donker a, Kathleen M. Griffiths b, Helen Christensen b, Kylie Bennett b, Anthony Bennett b, Annemieke van Straten a, Pim Cuijpers a a VU University, Amsterdam b Australian National University, Canberra

2. Introduction Life time prevalence: 19% (Bijl et al., 1998)

3. Introduction Top four leading causes of burden of disease worldwide (Lopez & Murray, 1998)

4. Introduction Costs per capita for mood disorders: € 5,009 (Smit et al., 2006)

5. Low-intensity treatment for depression and anxiety Marijke »36 years » Single » Two children »Town »Part-time working »Mild depression

6. Obstacles Long waitlists

7. Obstacles 2 hrs of travelling to the clinic

8. Obstacles Take leave from work

9. Obstacles Arrange a babysit

10. Obstacles Costs of babysit

11. Obstacles +.. Costs of travelling, babysit..

12. Low-intensity treatment for depression and anxiety Psychological self-help: |Standardized Independent Homework/tasks Via book, audio, internet.. Guidance by email, chat, telephone

13. Advantages No wait lists

14. Advantages Working from home

15. Advantages 24/7

16. Advantages Cost-effective

17. Advantages Anonymous

18. Low-intensity treatment for depression and anxiety Intensive face-to face treatment Obstacles Wait lists Costs of therapy etc. Time of travelling Leave/babysit Low-intensity treatment Advantages Directly accessable Cost-effective Working from home 24/7

19. Introduction

23. E-CBT = effective (e.g. Carlbring et al., 2009; Christensen et al., 2004;Kaldo et al., 2008; Ruwaard et al., 2009; Spek et al., 2008; Warmerdam et al., 2008)

24. Introduction

26. Depression: IPT = CBT (Cuijpers et al., 2011) Effect size: 0.04 (95% CI 0.14-0.21)

27. Introduction = ?

28. Design Internet-assisted Cognitive Behavior Therapy (CBT) & Interpersonal Psychotherapy (IPT):

29. Design Internet-assisted Cognitive Behavior Therapy (CBT) & Interpersonal Psychotherapy (IPT): Compared to Internet-assisted CBT MoodGYM (control group)

30. Design Non-inferiority trial H0: (IPT ≠ CBT) ≠ MoodGYM H1: (IPT= CBT) = MoodGYM

31. Design MoodGYM Within effect size: 0.56 (95% CI: 0.33-0.79) (MacKinnon et al., 2008) Determined sample size: N=450 on post-test

32. Design MoodGYM Between effect size: 0.33 (95% CI: 0.11-0.55) Within effect size: 0.56 (95% CI: 0.33-0.79) (MacKinnon et al., 2008) Determined sample size: N=450 on post-test

33. Design Non-inferiority trial 3 e-conditions (IPT, New CBT, CBT MoodGYM) Fully automated trial, 4 weeks Online recruitment and screening

34. Design Inclusion: 18 years or older Exclusion: currently under treatment by mental health specialist 3 measurements (baseline, after 4 weeks and after 6-months) Primary outcome: depressive symptoms

35. Interpersonal Psychotherapy Developed by Klerman and Weissman (1984) Relationship between depression and experiences IPT aims at improvement of interpersonal functioning and (inherent) depression

36. Internet-assisted IPT - overview

37. Internet-assisted IPT -week 1 Role disputes Identification of the dispute (with whom?) Modification of communication patterns

38. Internet-assisted IPT -week 2 Problems making relationships Realistic evaluation of can do`s/ can`t do`s Increase social contacts

39. Internet-assisted IPT -week 2 Problems making relationships

40. Internet-assisted IPT – week 2

41. Internet-assisted IPT - week 3 Role Changes Investigate which old role is given up Validate the loss Support letting go of old role

42. Internet-assisted IPT - week 3 Role Changes Develop new skills for the new role Develop new relationships and social support

43. Internet-assisted IPT – week 3

44. Internet-assisted IPT - week 4 Grief Activate grief proces –Psychoeducation –Learn to express emotions Finding new meaningful activities and social contacts replacing those which were lost

45. Internet-assisted IPT – week 4

46. Results: Participant flow N=1993 met inclusion criteria CBT n=641 IPT n=641 MoodGYM n=642 N=1924 included n=69 did not fill in baseline Q

47. Results: demographics Gender: 71% female Age category: 25-29 years (15.1%) Country: 1: Australia (38%) 2: United Kingdom (25%) 3: United States (19%) Education: higher degree (26%) Previous treatment by professional: 80% Been depressed before: 90%

48. Results: depressive symptoms Mean CES-D at baseline (n.s.): Moodgym: 35 (sd: 11.7) n=622 IPT: 36 (sd: 11.9) n=623 CBT: 36 (sd: 11.) n=615

49. Results: depressive symptoms completers only

50. Pre-post test: No significant differences across the condition (F=2.018; P=.13) Effect sizes: MoodGYM: 0.81 CBT: 0.87 IPT: 0.77

51. Results: drop out CES-D: p=.02* (higher CES-D) Sexe: p =.<0.1* (more men) Age: p =.<0.1* (25-29 years) Education: p =.04* (lower education) Condition: p =.02* (MoodGYM) Been depressed: p =.80

52. Conclusions Pre-post test for completers: H1: (CBT = IPT) = MoodGYM Effect sizes between 0.77-0.81 E-IPT: more treatment choice 70% “drop out” Significant differences in drop out for demographics, treatment allocation, baseline CES-D score

53. Discussion ‘Gold standard’ MoodGYM: Equivalence margin: 0.33 Follow up data not yet available Drop out rate: 70% → »Missing data approaches »high symptoms: seek your GP »Unguided self-help »Characteristic of population

54. Disadvantages Anonymous

55. Disadvantages Guided self-help

56. Disadvantages High drop out rate

57. Discussion Unguided self-help…. Ethical..? Under which conditions?

58. Questions? Thank you for your attention www.isrii.regroup.com Email: T.Donker@psy.vu.nl