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Am Fam Physician. 2004;70(7):1368-1370

Internet-based interventions have been effective in patients with symptoms of panic and anxiety, but the only reported randomized controlled trial of Web-based treatment for depression found modest effect that was limited to patients with mild symptoms. Christensen and colleagues used Web-based programs to compare the effect of sites providing psychoeducation with those offering cognitive-behavior therapy in Australian patients with significant depressive symptoms.

They used a randomly mailed community survey to identify volunteers who were not receiving psychologic care but had significant depressive symptoms (Kessler psychologic distress score of 22 or more) and had access to the Internet. More than 500 participants were assigned randomly to the psychoeducation, cognitive-behavior therapy, or control groups of the study. The psychoeducation site (BluePages, focused on information about depression, including evidence-based discussions of treatment. The cognitive-behavior site (MoodGYM, provided therapy for prevention of depression. The 165 and 182 patients assigned to these respective Web sites were sent detailed guides for using their site and weekly assignments. Lay interviewers contacted the participants weekly. With all participants, the lay interviewers discussed lifestyle and environmental factors influencing depressive symptoms, such as physical activity, hobbies, family issues, financial concerns, medications, alcohol use, and symptoms experienced, especially pain.

In patients assigned to the treatment groups, the interviewers also assisted in use of the Web sites. The main outcomes assessed by the study were a self-reported 20-item depression scale and a questionnaire about dysfunctional thinking. The outcomes in the two intervention groups were compared with those of 178 control patients who received only weekly contact with a lay interviewer.

The three groups were comparable in all important variables, including depression and psychologic distress scores at the beginning of the study. Web logs indicated that participants in the BluePages group visited the site an average of 4.49 times, and that MoodGYM participants completed an average of one half of the 29 exercises. After six weeks, both groups assigned to Web interventions showed significant reductions in depressive symptoms compared with the control group and with baselines. Compared with the control group, dysfunctional thinking significantly improved in participants assigned to MoodGYM but not in those assigned to BluePages. Conversely, knowledge of interventions for depression significantly improved only in participants assigned to BluePages. Participants reported high rates of satisfaction with the interventions, which included ease of use of the Web sites and overall satisfaction with the interview process.

The authors conclude that Internet-based interventions can be effective in select community-based patients with significant depression.

editor’s note: In practice, modified cognitive-behavior therapy can be a highly effective treatment or adjunctive therapy for depression. Although it is professionally rewarding to coach patients through development of more realistic thinking and effective approaches to life, this therapy is demanding on the time and energy of the physician. This study indicates that well-selected Web sites could be used to develop a more independent role for patients and holds out the prospect of achieving good results with fewer demands on physicians. Patients must be cautioned, however, that not all Web sites are helpful or provide valid clinical advice.—a.d.w.

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