[view this figure]Figure 10. Crisis link information provided.
Research and Publications
Only 12 of the 32 programs had at least one published RCT evaluating their efficacy. It was beyond the scope of the current review to summarize the results of these trials and the reader is directed to recently published systematic reviews and meta-analyses [32-34] (see Multimedia Appendix 4).
Use and wide spread dissemination of Web-based mental health care interventions is expanding and reflected by the number of currently available depression treatment programs captured in this scoping review. Web-based approaches may have several benefits beyond those of conventional psychotherapy [36-38]. Such approaches (1) are accessible at any time of day, unlike a traditional clinic setting with predetermined hours of operation, (2) are accessible from home therefore removing transportation barriers to treatment and health care provider shortages (particularly in rural communities), (3) are cost effective and reach a mass audience, (4) are self-guided by the user, and (5) allow the user to remain anonymous while in the setting of their choice (privacy). However, it is important to note that Web-based approaches may have several disadvantages including the potential perpetuation of secrecy associated with mental illness and depriving the individual of the opportunity for face-to-face interaction afforded by traditional therapeutic techniques.
We have identified 32 existing interactive Web-based programs and have found varying degrees of accessibility, quality, and evidence supporting their efficacy. Only 12 of the 32 programs had at least one peer-reviewed, published article describing the results of an efficacy study. In examining the programs, authors noted a number of similarities and differences when comparing EBP to NBP by each evaluation point (see Multimedia Appendix 3). Using the adapted evaluation criteria , each program was rated using 28 categories. Totals for a few EBP and NBP were amended if a score could not be provided for a program in the category, as indicated by a superscript “a” (a) (ie, the information was not available on the program website and/or inquiries to program developers were not returned). EBP had a smaller range in scores (68%-92%) and a higher overall average score (80%) relative to the wider range for NBP (39%-92%) and a lower overall average score (73%). While generally comparable, there were some subtle differences between EBP and NBP programs on the evaluation criteria of accessibility, program structure, use of validated assessment tools, additional features, peer support forums, safeguards, and the provision of user-statistics as further discussed below.
While Web-based programs can generally improve access to mental health care, some aspects of existing programs may present users with alternative access barriers. For example, some programs were available only in one language (eg, Interapy and Kleur je Leven in Dutch, and Internetpsykiatri in Swedish), with the majority of NBP available only in English. The addition of alternative languages could promote open accessibility to any user seeking treatment. Furthermore, some programs had accessibility restrictions based on country of residence (see Multimedia Appendix 2), which may have been due to limited therapist availability for those programs providing clinician support. Given the global nature of the Internet, consideration could be made to avoid geographic restrictions on program availability.
While a higher proportion of the NBP (9/19a; 47%) were freely available (no fees or referrals required to access) as compared to the EBP (3/10a; 30%), a higher proportion of the NBP (6/19a; 32%) than the EBP (3/10a; 30%) had a fee for accessing the program. Requirements such as therapist referral, administrator acceptance for registration, and/or user fees may act as deterrents to use as they necessitate additional motivation and resources on the part of the user. The need to obtain a referral, enter personal information to register, and/or wait for access negates the benefits of anonymity and convenience afforded by Web-based tools. Conversely, registration requirements enable the user to track their progress and build on previously completed modules. In addition, the registration of personal information would allow the program deliverers to contact the user when in need, such as when increases in depression symptoms or suicide risk (which are more prevalent among depressed individuals as compared to other mental health disorders) are reported. Also, referral-based programs often allowed for integrated therapist contact. For fee-based programs, free demonstration/trial modules could be provided to allow users to assess the program prior to making a financial commitment.
In examining the programs captured in the review, CBT was the most commonly incorporated therapeutic approach (EBP=6, NBP=9; see Table 3). Other therapeutic techniques included psychoeducation, IPT, positive psychology, and narrative therapy. Recent evidence suggests that Web-delivered, self-guided IPT is as effective as Web-delivered CBT on symptoms of depression in general community samples . Future investigations could continue to examine which techniques are most efficiently and effectively delivered through the Web and whether the mode of delivery (eg, text, audio, video) differentially affects outcome. In regards to program content and structure (evaluation point 11, ie, guided [modules must be completed in a set order] vs unguided [any module is accessible at any time]), 80% (8/10a) of EBP offered the guided approach relative to 63% (12/19a) of the NBP. Future studies should evaluate the relative effectiveness of guided versus unguided interventions.
Many of the programs captured in this review delivered treatment specifically for adolescents, adults, or both. A limited number of programs catered to special populations (eg, military personnel, older adults). Future programs could be geared toward the needs of special populations such as individuals with cognitive impairments or persons in a caregiving role. Accommodations for cognitively impaired individuals may include larger text sizing, multimodal delivery (audio and video files), in addition to programming specific to their impairments (eg, memory games, goal setting and problem solving). Caregivers of chronically ill patients also demonstrate increased psychological distress and burden [40,41]. Apart from depression, increased caregiver anxiety, guilt, rage, grief, substance abuse, and elevated risk of relapsing into a pre-existing mood disorder has been noted among caregivers [39,42,43]. Future programs could be tailored to meet the issues faced by caregivers in day-to-day life, including an emphasis on preserving and increasing available family resources in caregiving circumstances . Program developers should use feedback from members of these populations to fully understand learning preferences as well as accessibility issues specific to these individuals.
Although a target audience was identified for each of the programs (ie, adults, students, special population), course content was often generic for all users within the targeted population. Personalized treatment plans (ie, generic programs vs individual treatment plans; evaluation point 12) were offered in only a few programs: 22% of EBP (2/9a) and NBP (4/18a). Personalized treatment plans may enhance user engagement by appealing to their specific treatment needs and offering relevant treatment information. Take for example a user suffering from only a mild form of depression; they may not have found additional anxiety information useful causing them to lose interest in continuing with the program despite its potential benefit. In programs offering a personalized treatment plan, program suggestions were based on an initial assessment. All but a few EBP and NBP offered assessments; however, not all of the assessment tools used were validated (evaluation point 15). Of EBP, 75% (6/8a) relative to 67% (12/18a) of NBP employed validated assessment tools (ie, BDI, PHQ-9, or CES-D). Programs should strive to offer validated assessment tools to provide users with accurate feedback in regards to their depressive and anxiety symptoms. During this emotionally sensitive time period, individuals could be heavily influenced by program feedback and results, necessitating accurate and valid depictions of depression symptoms over time.
In addition to worksheets and assessments, some programs offered additional features that may help enhance usage and retention including emails offering encouragement, helpful quotes or testimonials, and reminders to complete modules; completion trackers for each session and/or the program overall; supplementary worksheets and mood assessments delivered during or after each session to assess and monitor progress; and automated feedback to the user. The majority of both EBP (7/10a; 70%) and NBP (10/20; 50%) offered three or more of these additional features (see Table 4). The effect of these features on user satisfaction and treatment efficacy should be further investigated.
Many of the programs included additional integrated therapist contact, peer support discussion forums, and crisis links. Programs offering therapist support (evaluation point 21) were delivered via telephone, video conference, or live chat (ie, instant messaging): 60% (6/10a) of EBP and 50% (8/19a) of NBP offered therapist support. Similarly, 60% (6/10a) of EBP and 50% (8/19a) of NBP provided a therapist name and their credentials (evaluation point 22). Providing users with this information may provide them peace of mind that they are being cared for and monitored by an accredited individual capable of intervening if required. A recent study using MoodGYM plus brief face-to-face therapist support indicated positive results in the reduction of symptoms of depression in a primary care setting . Although additional therapist support has been shown to be effective [45,46], further investigation is needed to understand therapist user interaction impact on patient outreach, treatment experience, and concept reinforcement. Conversely, efficacy has also been demonstrated in programs that did not include clinician support [47,48]. When choosing an intervention program, this option is influenced by user learning needs and should be indicated by the user. Facilitating therapist-user communication through technology could aid in maintaining user anonymity and privacy. Potential negative implications of therapist contact include reduced availability, reduced user independence, and increased pressure to complete program requirements.
Other avenues of support offered within the evaluated programs included peer discussion forums, blogs, and shared user spaces (evaluation point 23). Unlike EBP, none of which provided peer-support forums, 44% (8/18a) of NBP offered this feature. However, only 24% (4/17a) of NBP offered forums that were monitored by an overseeing authority, facilitating safe user interaction and positive constructive topics of conversation (evaluation point 24). Peer support offers a level of familiarity not offered with clinician support. The need for relatedness to others enduring similar emotional issues can be both comforting and motivating; however, the effectiveness of peer support upon symptom resolution has yet to be evaluated in this context.
In addition to peer and clinician support, some programs offered crisis links via telephone hotlines, email, or chat functions. Hotlines provided support to users under distress when therapists or other social support options were unavailable. Safeguards (evaluation point 17) were available in all the evaluated EBP; however, only 68% (13/19a) of NBP offered this feature. Due to the sensitive nature of the treatment and topics discussed, all programs should offer or provide information for available crisis links.
To evaluate program usability, we contacted each of the program’s administrators. Many were unable or did not wish to disclose user statistics in regards to registration, attrition, and program completion. Those that responded to inquiry emails or posted statistics on their program websites are listed in Table 3. Among the few programs providing data (EBP, 7/10a or 70%; NBP, 10/19a or 53%), statistics varied greatly. Examining the existing literature, completion rates in RCTs of Web-delivered treatments for depression have primarily ranged from 55%-67% [49-54] with rates as low as 20% . Future research should examine which aspects of a program could promote retention and completion such as email reminders or motivators/incentives. End-user feedback may be useful in identifying less effective areas within programs and facilitate modification.
Although not included in this review (as they did not meet the inclusion and exclusion criteria), three novel and noteworthy Web-based treatment programs for depression were identified: Depression Quest , Moodbuster , and SPARX . Depression Quest and SPARX are gaming programs that deliver innovative depression treatments to adolescents. Depression Quest invites the user to experience life from the perspective of a depressed individual. Users read scenarios, select one of the decisions provided, and navigate the path associated with their choice. Program developers aimed to (1) aid caregivers by providing insight into the depressed mindset, and (2) demonstrate to individuals affected by depression that they are not alone in their struggle. In SPARX, users navigate an avatar of their choice towards an end objective while fighting gloomy negative automatic thoughts along the way. Targeting depression, anxiety, and stress, clinical trials of the program have demonstrated positive results on symptoms of depression . The third program, Moodbuster, provides an interactive treatment program similar to those included in the review; however, it also incorporates the use of biosensors worn on the body throughout the day. Biosensors are equipped to transmit information on emotionally influenced bodily responses like electrodermal activity, respiration, and electrocardiography changes. A monitoring system for medication intake is also provided to users prescribed pharmacological treatment. Sensors are set to monitor dose and intake information. With all sensors feeding back to the program, Moodbuster interprets the information and reasons which type of therapy is most likely to be effective. Although resource intensive, a program like Moodbuster may be effective for depression resistant to alternative forms of treatment; however, research is needed to further evaluate this treatment approach.
In summary, many interactive treatment programs for depression are available on the Web; however, the efficacy and validity of most of these programs (20/32, 63%) have not been evaluated using RCTs. When comparing those programs that are evidence-based to those that have not been empirically evaluated, more of the EBP programs seemed to use a guided approach, employ validated assessment tools, offer additional features, incorporate safeguards, and provide user statistics. More of the NBP programs were available without fees or referrals (however, a higher proportion did request a user fee than the EBP) and offered peer-support forums. Based on our review, several programs emerged that are easily accessible, free to use, and have supporting evidence for their efficacy including E Couch, MoodGYM, and This Way Up (Self Help Course, Worry and Sadness; see Figure 11-13 for screenshots of these programs).
Although there is a strong and growing body of evidence in support of Web-based interventions, some perceive that the uptake and dissemination of such programs have not been commensurate with their potential to improve health-related outcomes. With respect to Web-based interventions for depression, potential barriers have been cited such as negative clinician and patient attitudes [60,61], legal and ethical regulations related to online clinician-patient interactions , a lack of practitioner willingness to refer patients to such interventions, and clinician fears of losing work . In order to increase implementation and reach across a range of settings, Burnett and Glasgow have suggested using tailored messaging and social networking functionality, in particular leveraging newer technologies that offer novel ways for users to store, view, manipulate, share, and experience their personal data (eg, Web 2.0 design principles) .