Self-help therapies are often effective in reducing mental health problems. We developed a new Web-based self-help intervention based on problem-solving therapy, which may be used for people with different types of comorbid problems: depression, anxiety, and work-related stress.
The aim was to study whether a Web-based self-help intervention is effective in reducing depression, anxiety, and work-related stress (burnout).
A total of 213 participants were recruited through mass media and randomized to the intervention (n = 107) or a waiting list control group (n = 106). The Web-based course took 4 weeks. Every week an automated email was sent to the participants to explain the contents and exercises for the coming week. In addition, participants were supported by trained psychology students who offered feedback by email on the completed exercises. The core element of the intervention is a procedure in which the participants learn to approach solvable problems in a structured way. At pre-test and post-test, we measured the following primary outcomes: depression (CES-D and MDI), anxiety (SCL-A and HADS), and work-related stress (MBI). Quality of life (EQ-5D) was measured as a secondary outcome. Intention-to-treat analyses were performed.
Of the 213 participants, 177 (83.1%) completed the baseline and follow-up questionnaires; missing data were statistically imputed. Of all 107 participants in the intervention group, 9% (n = 10) dropped out before the course started and 55% (n = 59) completed the whole course. Among all participants, the intervention was effective in reducing symptoms of depression (CES-D: Cohen’s
We demonstrated statistically and clinically significant effects on symptoms of depression and anxiety. These effects were even more pronounced among participants with more severe baseline problems and for participants who fully completed the course. The effects on work-related stress and quality of life were less clear. To our knowledge, this is the first trial of a Web-based, problem-solving intervention for people with different types of (comorbid) emotional problems. The results are promising, especially for symptoms of depression and anxiety. Further research is needed to enhance the effectiveness for work-related stress.
International Standard Randomized Controlled Trial Number (ISRCTN) 14881571
It has been convincingly demonstrated that self-help therapies are effective in reducing mental health problems [
The self-help therapies that are currently available have all been developed for patients with a specific disorder, such as depression, panic disorder, social phobia, general anxiety disorder, or posttraumatic stress disorder, and most are based on cognitive behavioral therapy. Problem-solving therapy, a brief form of psychotherapy where patients identify their most immediate problems and ways of regaining control over them, are not limited to one specific disorder and may be effective in several problem areas. Face-to-face problem-solving therapies have been shown to be effective in depression [
As a general framework for the intervention, we used the model developed by Bowman and colleagues, which is based on problem-solving therapy [
The aim of this study was to determine the effectiveness of this Web-based generic treatment method for participants with depression, anxiety, and work-related stress.
We recruited participants through advertisements about Internet self-help treatment for symptoms of depression, anxiety, and work-related stress placed in local and national newspapers. We aimed at including 200 participants in order to be able to demonstrate moderate effects of
Flowchart of participants
The intervention was Web-based (see Multimedia Appendix for screenshots). Participants were provided with a username and password to access the website. Every week an automated email was sent to the participants to explain the contents and exercises for the coming week. All the information as well as the exercise forms could also be downloaded from the website in case participants preferred to read the information on paper. Master’s level psychology students, trained and supervised by the authors (PC, AvS), offered feedback on the completed exercises. This feedback was not therapeutic but was directed at mastering the proposed problem-solving strategies. For a participant completing the course, the total time spent by the psychology students on feedback was approximately 45 minutes. The course takes 4 weeks.
The intervention consists of three steps:
Participants describe what really matters to them.
Participants write down their current worries and problems and categorize them into three types: (a) unimportant problems (problems unrelated to the things that matter to them), (b) problems that can be solved, and (c) problems that cannot be solved (eg, the loss of a loved one).
Participants make a plan for the future in which they describe how they will try to accomplish those things that matter most to them.
The second step is the most important of the intervention. For each of the three types of problem (ie, a, b, and c), a different strategy is proposed to cope with it. For the solvable problems (ie, b), we propose the following procedure: (1) write a clear definition of the problem, (2) generate multiple solutions to the problem, (3) select the best solution, (4) work out a systematic plan for this solution, (5) carry out the solution, and (6) evaluate as to whether the solution has resolved the problem.
All participants were randomly assigned to either the self-help course or a waiting list. Questionnaires were sent before the start of the course and 5 weeks later, after the intervention group had finished. Thereafter, the participants in the waiting list group could complete the course.
Randomization took place 1 week before the start of the intervention. We used block randomization with blocks of 10. The randomization scheme was derived by computer and carried out by an independent researcher. All participants were informed by email about the randomization outcome.
Depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale (CES-D) [
Symptoms of anxiety were measured with the seven anxiety questions of the Hospital Anxiety and Depression Scale (HADS) [
Work-related stress was measured with the Dutch version of the Maslach Burnout Inventory (MBI) [
Quality of life was assessed with the EuroQoL questionnaire (EQ-5D) [
All analyses were performed on the intention-to-treat sample. Pre-test data were available for all participants. Missing values of post-test nonresponders (17%, 36/213) were handled by using multiple imputation procedure NORM [
Effectiveness was calculated in three ways: (1) analyzing mean improvement scores, (2) calculating the proportion of participants who made significant improvements, and (3) calculating the proportion of participants who recovered. Each will be described in more detail below.
The magnitude of the effect of the intervention (Cohen’s
We calculated significant improvement as described by Jacobson and Truax [
A different definition of recovery was used for the different types of outcome. The definitions were as follows: (1) depression—no DSM-IV diagnoses of major depression according to the MDI, (2) anxiety—a HADS score lower than 8 (a score ≥ 8 is indicative of a general anxiety disorder [
Out of 213 enrolled participants, 177 filled in the post-test questionnaires (response rate 83.1%). The response was significantly higher in the control group (91%; n = 96) than in the intervention group (76%, n = 81;
All the baseline differences between responders and nonresponders on the outcome measures were in the same direction: nonresponders reported poorer health at baseline than responders. However, the differences were very small and not statistically significant (
Baseline scores of depression, anxiety, burnout, and quality of life (N = 213)
Scale | Responders |
Dropouts |
|
CES-D | 29.8 (9.3) | 30.2 (8.6) | .80 |
MDI | 24.3 (9.1) | 26.7 (10.2) | .16 |
SCL-A | 23.8 (7.1) | 24.7 (8.1) | .47 |
HADS | 10.0 (3.2) | 10.1 (3.6) | .93 |
MBI-EE | 2.8 (1.4) | 2.9 (1.3) | .76 |
MBI-PA | 3.2 (1.0) | 3.6 (1.2) | .12 |
MBI-DP | 2.4 (1.4) | 2.2 (1.4) | .60 |
EQ-5D | 0.62 (0.23) | 0.61 (0.25) | .81 |
As shown in
Baseline characteristics of the participants
Characteristic | All |
Intervention |
Control |
|
|
.85 | |||
Male | 61 (28.6) | 30(28.0) | 31 (29.2) | |
Female | 152 (71.4) | 77 (72.0) | 75 (70.8) | |
|
.02 | |||
No | 102 (47.9) | 43 (40.2) | 59 (55.7) | |
Yes | 111 (52.1) | 64 (59.8) | 47 (44.3) | |
|
.31 | |||
Netherlands | 195 (91.5) | 100 (93.5) | 95 (89.6) | |
Other | 18 (8.5) | 7 (6.5) | 11 (10.4) | |
|
.19 | |||
Lower | 96 (45.1) | 53 (49.5) | 43 (40.6) | |
Higher* | 117 (54.9) | 54 (50.5) | 63 (59.4) | |
|
.85 | |||
No | 75 (35.2) | 37 (34.6) | 38 (35.8) | |
Yes | 138 (64.8) | 70 (65.4) | 68 (64.2) | |
|
.32 | |||
No | 111 (80.4) | 54 (77.1) | 57 (83.8) | |
Yes | 27 (19.6) | 16 (22.9) | 11 (16.2) | |
|
.36 | |||
CAGE‡ < 2 | 139 (65.3) | 73 (68.2) | 66 (62.3) | |
CAGE ≥ 2 | 74 (34.7) | 34 (31.8) | 40 (37.7) | |
|
45.2 (10.6) | 45.1 (10.9) | 45.4 (10.4) | .84 |
*Higher education equals higher vocational education or university.
†Calculated only for the 64.8% (n = 138) participants with a paid job.
‡The CAGE questionnaire is a screening test for alcohol dependence.
Of all 107 participants in the intervention group, 9% (n = 10) dropped out before the course started. The first assignment (Week 1) was completed by the remaining 91% (n = 97). Then another 17% (n = 18) dropped out, and the second assignment (Week 2) was completed by 74% (n = 79). Another 8% (n = 9) dropped out, and the third assignment (Week 3) was completed by 65% (n = 70). Finally, another 10% (n = 11) dropped out, leaving 55% (n = 59) who completed the whole course. Married participants more often completed the course (66%; n = 42) than non-married participants (40%, n = 17;
In general, the intervention had a significant effect on symptoms of depression, anxiety, and quality of life but not on work-related stress (
In a subset analysis, we selected only the participants with the most severe problems at baseline and calculated their improvements for each measure (
Effects of self-examination therapy on depression, anxiety, burnout, and quality of life
Scale* | Control |
Intervention, All |
Intervention, Course Completers (N = 59), |
Effect Size† (95% CI) | ||||
Pre-Test | Post-Test | Pre-Test | Post-Test | Pre-Test | Post-Test | All | Course Completers | |
CES-D | 29.9 (9.2) | 26.2 (10.5) | 29.9 (9.1) | 20.9 (10.8) | 29.8 (8.5) | 19.3 (10.1) | 0.50 ( 0.22-0.79) | 0.67 (0.32-1.02) |
MDI | 23.6 (9.0) | 25.1 (6.8) | 25.8 (9.6) | 22.9 (6.9) | 25.1 (8.9) | 21.4 (6.2) | 0.33 ( 0.03-0.63) | 0.56 (0.22-0.90) |
SCL-A | 23.7 (7.2) | 22.7 (7.5) | 24.1 (7.4) | 19.7 (6.8) | 10.0 (2.9) | 19.1 (6.2 | 0.42 ( 0.14-0.70) | 0.51 (0.18-0.84) |
HADS | 9.9 (3.3) | 9.1 (3.3) | 10.1 (3.3) | 8.0 (3.4) | 24.2 (7.0) | 7.5 (3.2) | 0.33 ( 0.04-0.61) | 0.48 (0.15-0.82) |
MBI-EE | 2.8 (1.5) | 2.8 (1.5) | 2.9 (1.3) | 2.5 (1.5) | 2.8 (1.1) | 2.5 (1.4) | 0.28 (−0.08 to 0.64) | 0.20 (−0.26 to 0.66) |
MBI-PA | 3.4 (1.0) | 3.2 (1.0) | 3.2 (1.1) | 3.5 (1.0) | 2.2 (1.3) | 3.5 (1.0) | 0.33 (−0.03 to 0.69) | 0.36 (−0.25 to 0.98) |
MBI-DP | 2.4 (1.4) | 2.6 (1.5) | 2.4 (1.3) | 2.3 (1.4) | 3.1 (1.2) | 2.2 (1.5) | 0.20 (−0.15 to 0.56) | 0.27 (−0.22 to 0.75) |
EQ-5D | 0.61 (0.24) | 0.66 (0.20) | 0.62 (0.23) | 0.73 (0.20) | 0.63 (0.22) | 0.8 (0.2) | 0.31 ( 0.03-0.60) | 0.44 (0.11-0.77) |
*The values for the MBI subscales are only given for those with a paid job; n = 70 in the intervention condition; n = 68 in the control.
†Effect size is presented as Cohen’s
Effects of self-examination therapy on the subset of participants with severe symptoms of depression, anxiety, burnout, and quality of life at baseline
Scale | Definition of Severe Symptoms | Control |
Intervention |
Effect Size* (95% CI) | ||||
No. | Pre-Test, |
Post-Test, |
No. | Pre-Test, |
Post-Test, |
|||
CES-D | ≥ 16 | 99 | 31.1 (8.1) | 27.3 (9.8) | 97 | 31.6 (7.6) | 21.7 (10.8) | 0.54 (0.25-0.84) |
MDI | DSM-IV depression | 37 | 32.8 (5.2) | 28.3 (6.9) | 44 | 33.7 (5.5) | 25.5 (6.8) | 0.41 (−0.04 to 0.86) |
SCL-A | ≥ 18 | 89 | 25.5 (6.4) | 24.1 (7.3) | 84 | 26.7 (6.0) | 21.6 (6.4) | 0.37 (0.06-0.69) |
HADS | ≥ 8 | 78 | 11.3 (2.5) | 10.2 (3.0) | 85 | 11.3 (2.6) | 8.7 (3.3) | 0.45 (0.13-0.78) |
MBI-EE | burnout | 34 | 3.9 (1.0) | 3.8 (1.3) | 43 | 3.4 (1.0) | 2.9 (1.3) | 0.65 (0.14-1.16) |
MBI-PA | burnout | 34 | 3.1 (0.9) | 3.0 (0.9) | 43 | 2.9 (1.0) | 3.3 (1.1) | 0.33 (−0.14 to 0.81) |
MBI-DP | burnout | 34 | 3.3 (1.1) | 3.2 (1.4) | 43 | 2.9 (1.3) | 2.6 (1.5) | 0.44 (−0.06 to 0.95) |
EQ-5D | ≥ 0.55 | 74 | 0.75 (0.06) | 0.7 (0.2) | 73 | 0.76 (0.08) | 0.8 (0.2) | 0.34 (0.00-0.69) |
*Effect size is presented as Cohen’s
The proportion of participants with significant improvements (their change is so large it is unlikely to have occurred by chance, see definition under “Methods”) in both groups is compared in
Participants with significant improvement
Scale | Intervention |
Control |
OR | 95% CI |
CES-D | 52 (48.4) | 22 (20.9) | 3.5 | 1.9-6.7 |
MDI | 22 (20.7) | 7 (6.6) | 3.7 | 1.4-10.0 |
SCL-A | 23 (21.3) | 12 (11.3) | 2.1 | 1.0-4.6 |
HADS | 38 (35.9) | 16 (15.5) | 3.1 | 1.6-6.0 |
MBI-EE | 14 (13.4) | 7 (6.8) | 2.2 | 0.6-8.1 |
MBI-PA | 23 (21.4) | 7 (6.5) | 3.9 | 1.2-12.6 |
MBI-DP | 8 (7.7) | 5 (4.7) | 1.7 | 0.4-7.1 |
EQ-5D | 25 (23.7) | 17 (16.2) | 1.6 | 0.8-3.3 |
Of all 81 participants who suffered major depression according to the MDI at baseline, a total of 52 (64.4%) had recovered at post-test across both groups (
Recovery of participants with depression, anxiety, and burnout (as established at baseline)
Total No. Participants at Baseline | Definition of Recovery | Post-Test, No. (%) | OR | 95% CI | ||
Intervention | Control | |||||
Depression | 81 | No MDI diagnoses | 32/44 (72.7) | 20/37 (54.6) | 2.2 | 0.8-6.0 |
Anxiety | 134 | HADS < 8 | 26/70 (37.7) | 15/64 (23.4) | 2.0 | 0.9-4.2 |
Burnout | 77 | No MBI diagnosis | 16/43 (38.1) | 5/34 (13.5) | 4.0 | 1.2-13.5 |
We studied the effects of a short, generic, Web-based, self-help intervention for mental health problems in a randomized trial among 213 participants with symptoms of depression, anxiety, or work-related stress. We demonstrated statistically and clinically significant effects on symptoms of depression and anxiety. These effects were even more pronounced among participants with more severe baseline problems and for participants who fully completed the course. The effects on work-related stress and quality of life were less clear.
This study has several limitations. The first is related to the choice of the control group. We could have chosen a care-as-usual comparison (ie, not have given any intervention to the control group); however, this might have limited the generalizability of our results since in that case only patients willing to be randomized to a non-treatment option would have participated. It is likely that these patients differ from the ones who do want (need) treatment. We also might have chosen an attention placebo control group or comparison with another intervention. It is known that effects of attention placebo controlled trials are usually smaller than waitlist controlled trials. However, with our intervention, we especially intended to reach those people who do not get any treatment at all [
The second limitation has to do with the response rate. Although the overall response rate was satisfactory (83%), the response rate of the intervention group was significantly lower (76%) than that of the control group (91%). We could find no indications for selection bias since we could not demonstrate clear baseline differences between the responders and nonresponders (except for marital status). The bias that still might have been introduced was accounted for by imputing all missing data (multiple imputations) and performing intention-to-treat analyses. Nevertheless, imputing 24% of the data might have led to unreliable estimates.
Another limitation is the fact that participants could only be included in the study if they had computer skills and access to Internet. Thus, the participants in this study were more highly educated than the general population, and it is uncertain whether the results of this study can be generalized to people with less education.
Meta-analyses for bibliotherapy regarding different types of target problems have shown effect sizes between 0.53 and 0.96 [
The results with regard to work-related stress were less consistent. When considering only those participants who were suffering from burnout at the start of the study, the results were promising. The participants in the intervention group were four times (95% CI 1.2-13.5) more likely to recover from their burnout than participants in the control group, and they experienced a substantial improvement with regard to the EE subscale of the MBI (Cohen’s
To our knowledge, this is the first trial on a short, Web-based, problem-solving intervention for participants with different types of (comorbid) emotional problems. The results seem to be as good as other longer, disease-specific bibliotherapies. Longitudinal research is needed to study the long-term effects.
The study was performed at the Vrije Universiteit Amsterdam, the Netherlands, without additional financial support.
None declared.
Intervention screenshots
Center for Epidemiological Studies Depression Scale
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
EuroQoL questionnaire
Hospital Anxiety and Depression Scale (only Anxiety section is used)
Major Depression Inventory
Maslach Burnout Inventory
MBI Depersonalization subscale
MBI Emotional Exhaustion subscale
MBI Personal Accomplishment subscale
Symptom Checklist – Anxiety section