Evaluating the feasibility and effectiveness of an Internet-based intervention for depression in a telephone counselling setting

Abstract

Self-administered, Internet-based cognitive behaviour therapy (CBT) programs have been shown to be effective in reducing symptoms of depression. Evidence suggests that the effects of these programs may be enhanced by the provision of guidance from therapists and non-specialists (i.e. trained research staff and lay people). Telephone counselling helplines are frequently and repeatedly used by individuals with chronic mental health problems and Internet-based interventions may be an effective tool for reducing depression in this population. The delivery of web-based interventions within a telephone counselling setting also enables the combination of Internet treatments with monitoring provided by a telephone counsellor, which may improve treatment adherence and outcome, and prevent dropout. A randomised controlled trial was used to assess the effectiveness of a 6 week, Internet-based CBT program (MoodGYM and BluePages) with and without weekly telephone tracking provided by a telephone counsellor. 155 callers to Lifeline (a national telephone counselling/service) with moderate to high levels of psychological distress were recruited and randomised to receive either (a) Internet-based CBT plus weekly telephone tracking, (b) Internet-based CBT only, (c) weekly telephone tracking only, or (d) neither Internet-based CBT nor telephone tracking (control condition). Participants were assessed at pre-intervention, post-intervention, 6 month follow-up and 12 month follow-up. Depression and anxiety symptoms were the primary outcome measures. A range of secondary outcomes were examined, including dysfunctional thinking, quality of life, hazardous alcohol use, suicidal ideation, knowledge of various treatments for depression, helpseeking, stigma, depression literacy and CBT literacy. Depression symptoms were significantly reduced in participants who received the Internet only (g = 0.76) and Internet plus tracking (g = 1.04) interventions, compared with the control condition at post-intervention. Significant reductions in depression were also found at 6 month follow-up for participants in the Internet only (g = 1.19) and Internet plus tracking (g = 1.26) conditions relative to the control condition. The intervention was not found to be effective for anxiety symptoms, although between group contrasts favoured the intervention conditions over the control condition. Telephone tracking did not confer any advantage over delivery of the Internet intervention alone, in terms of both treatment adherence and outcome. Regarding secondary outcomes, participants who completed the Internet intervention either with or without telephone tracking had lower levels of hazardous alcohol use, improved quality of life, improved knowledge of psychological treatments for depression, improved knowledge of alternative treatments for depression, and improved knowledge of CBT compared to those allocated to the control condition at post-intervention. Higher educational level and higher pre-intervention motivation for treatment predicted greater adherence to the intervention. Higher baseline depression symptom severity was associated with greater reductions in depression symptoms at post-intervention, 6 month follow-up and 12 month follow-up. There is clear potential for Internet-based treatments to be disseminated through telephone counselling settings. Additional research is needed to validate this model of Internet intervention delivery and to further examine the role of therapist and non-specialist guidance in Internet-based treatments. Depression is associated with significant personal and economic burden, and the positive results of the trial suggest that the delivery of Internet-based treatments through telephone helplines may prove to be a valuable new model for the delivery of psychological services.