Does Internet based guided-self-help for depression cause harm?

Almost nothing is known about potential negative effects of Internet-based psychological treatments for depression. In a new study, that was just accepted for publication in Psychological Medicine we aimed at investigating deterioration and its moderators within randomised trials on Internet-based guided self-help interventions for adult depression, using an individual patient data meta-analyses (IPDMA) approach.

Studies were identified through systematic searches in bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane library). Corresponding authors were contacted and asked to provide the dataset from the identified study, and data from any further unpublished studies. Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e., 7.68 points in the CES-D; 7.63 points in the BDI). Two step IPD MA procedures, with a random effects model were used to pool data.

A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention vs. the control conditions (3.36 vs. 7.6; RR = 0.47, 95% CI: 0.29 to 0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education.  Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit-risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration.

Recommended futher reading: For better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapy

We concluded that Internet-based guided self-help interventions are associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.

Read the full paper:

Ebert, D.D., Donkin, L., Andersson, G., Andrews, G., Berger, T., Carlbring, P., Rozental, A., Choi, I., Laferton, J. A. C. D., Johansson, R., Kleiboer, A., Lange, A., Lehr, D., Reins, J. A., Newby, J., Perini, S., Riper, H., Ruwaard, J., Sheeber, L., Snoek, F. J., Titov, N., Ince, B. Ü., Van Bastelaar, K., Vernmark, K., van Straten, A., Warmerdam, L., & Cuijpers, P. (2016). Does Internet based guided-self-help for depression cause harm? An individual participant data meta-analysis on deterioration rates and its moderators in randomised controlled trials. Psychological Medicine, 46(13), 2679–2693. doi:10.1017/S0033291716001562