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Internet support groups (ISGs) enable individuals with specific health problems to readily communicate online. Peer support has been postulated to improve mental health, including depression, through the provision of social support. Given the growing role of ISGs for both users with depression and those with a physical disorder, there is a need to evaluate the evidence concerning the efficacy of ISGs in reducing depressive symptoms.
The objective was to systematically review the available evidence concerning the effect of ISGs on depressive symptoms.
Three databases (PubMed, PsycINFO, Cochrane) were searched using over 150 search terms extracted from relevant papers, abstracts, and a thesaurus. Papers were included if they (1) employed an online peer-to-peer support group, (2) incorporated a depression outcome, and (3) reported quantitative data. Studies included both stand-alone ISGs and those used in the context of a complex multi-component intervention. All trials were coded for quality.
Thirty-one papers (involving 28 trials) satisfied the inclusion criteria from an initial pool of 12,692 abstracts. Sixteen trials used either a single-component intervention, a design in which non-ISG components were controlled, or a cross-sectional analysis, of which 10 (62.5%) reported a positive effect of the ISG on depressive symptoms. However, only two (20%) of these studies employed a control group. Only two studies investigated the efficacy of a depression ISG and neither employed a control group. Studies with lower design quality tended to be associated with more positive outcomes (
There is a paucity of high-quality evidence concerning the efficacy or effectiveness of ISGs for depression. There is an urgent need to conduct high-quality randomized controlled trials of the efficacy of depression ISGs to inform the practice of consumers, practitioners, policy makers, and other relevant users and providers of online support groups.
Internet support groups (ISGs) provide individuals with specific health problems an opportunity to share experiences and to seek, receive, and provide information, advice, and emotional support online. It has been estimated that millions of people visit online peer-to-peer discussion groups daily [
Internet users seeking health information frequently access information about depression [
Peer support has been postulated to improve mental health, including depression, through the provision of social support, which alters cognitions, attitudes, self-attributions, and coping, which, in turn, leads to a reduction in depressive symptoms [
The current paper aims to provide a systematic and comprehensive review of the available evidence concerning the effect of ISGs on depressive symptoms regardless of the ISG health condition. A more detailed review of depression ISGs specifically is provided in a companion paper, which reports the scope and findings from all qualitative and quantitative empirical studies of depression ISGs (see [
Three databases (PubMed, PsycINFO, Cochrane) were searched using keywords and phrases for the period prior to August 2007. The search was undertaken at two time points, the first in May 2005 and the second in July 2007.
The search terms and strategies were based on those reported by Eysenbach et al [
A multi-step process was employed to select relevant studies for the current review and the review of depression ISGs reported in the companion paper to this study [
Study discussed or investigated peer-to-peer interaction.
Study discussed or investigated at least one of the following: online/electronic support groups, online/electronic social or peer support, online/computer-based communication or interaction, collaborative virtual environments or interventions.
The support “group” discussed or investigated was health/psychology related (eg, biological illness, mental illness, health risk factors, bereavement, group counseling), or the article measured a health/psychology related outcome in relation to the support group.
After removing duplicate papers (Stage 2), the remaining abstracts (n = 859) were coded as relevant, not relevant, or possibly relevant according to the following inclusion criteria:
Employed an online peer-to-peer support group
Incorporated either a depression outcome or involved a unipolar depression ISG
Reported either quantitative or qualitative empirical data (Stage 3)
Studies were included whether they incorporated a stand-alone ISG or involved a complex multi-component intervention. Reviews of ISGs satisfying the first two criteria were identified and analyzed separately. Abstracts were coded by one author (AC or KG) and checked by a second author (KG or AC). Any disagreement was resolved by discussion. After excluding the irrelevant abstracts, 158 papers were obtained, read (if in English), and coded against the inclusion criteria by one author (KG). The coding was checked by a second author (AC). Those papers that did not report a depression outcome or did not concern an ISG exclusively devoted to depression were excluded (Stage 4), as were any duplicate papers generated as a result of conducting a two-phase searches process (n = 2). In addition, two papers were judged to be non-English versions of an English-language publication and were excluded [
The above process yielded a total of 38 relevant papers and five systematic reviews. Two additional relevant papers were identified from the five reviews, and a further two papers cited in at least one of the 38 relevant papers were included among the pool of relevant papers (Stage 5). This resulted in a total of 42 relevant papers of which 31 papers comprising 28 separate trials incorporated a depression outcome (Stage 6) and 11 (studies of depression ISGs) did not. The current paper focuses on the 28 trials reporting a depression outcome.
Study identification flow diagram: PubMed (PM), PsycINFO (PI), Cochrane (C)
The 31 papers reporting a depression outcome were independently coded by two raters (KG, AC), and discrepancies were subsequently resolved by discussion between the two raters.
Quantitative studies that included depression outcomes were coded for ISG, participant and study characteristics, and depression outcomes. The ISG characteristics extracted included the psychological or physical condition experienced by members of the group, the format of the ISG (newsgroup, bulletin board, chatroom), whether moderated (yes, no, don’t know), and, if so, by whom (consumer, health professional, both, don’t know), ISG type (public, research, other restricted access), and ISG origin (United States, Europe, other). Participant characteristics recorded included age (median older than 25 years or 25 years and younger), gender, education, ethnicity, and rurality. Study design characteristics and quality were also coded, including sample size, attrition, design type (randomized controlled trial [RCT], controlled trial, historical control, pre-post, cross-sectional, case series), appropriateness of randomization process and reporting, whether the study employed an intent-to-treat (ITT) analysis (yes, no), and how missing data were treated (last observation carried forward, multiple imputation, other). Each study was also rated as to whether it involved a multi-component design of which the ISG was just one component, or whether the study evaluated a stand-alone ISG or at minimum used a control group that controlled for the non-ISG components of the intervention. Intervention characteristics recorded included duration of intervention and length of longest follow-up. The depression outcome measures used in each study were recorded, and each sample was rated according to whether it yielded a statistically significant positive outcome. Finally, raters coded the type of publication (thesis, journal, book), country of primary author (United States, Europe, other), and whether consumers were actively involved in the design or conduct of the research.
A formal quantitative meta-analysis was not conducted due to the low quality of the studies meeting the inclusion criteria and the heterogeneous nature of the conditions studied. However, the possible role of different characteristics and quality were explored by comparing the characteristics of samples reported to have yielded positive, statistically significant results with those that did not, using a series of Fisher exact tests for categorical attributes and Mann-Whitney tests for other data. For the purposes of this analysis, data were analyzed at the comparison rather than the study level. In addition, for descriptive purposes, where possible, Cohen’s d standardized effect sizes were calculated and reported. For uncontrolled studies, the pre-post standardized effect size was calculated from the mean pre-test and post-test scores and standard deviations. For controlled studies, the study effect size was the difference between the pre-post effect size for the control group and the pre-post effect size for the intervention group. In a study involving the comparison between depression scores for high-use compared to low-use Internet users, effect size was based on the standardized difference for the two groups. Effect sizes were not calculated in several instances. Where only the
Of the 28 studies with depression outcomes, five reported results separately for two different populations (patient versus carer [
Of the 28 studies with depression outcomes, 16 involved the evaluation of stand-alone ISGs or used a design that controlled for the use of intervention components other than the peer-to-peer component or involved cross-sectional studies of online groups (single component). The remaining studies incorporated a multi-component intervention that comprised the discussion group plus at least one additional component such as health education, skills training, or decision aids.
Study characteristics and findings for single-component or cross-sectional studiesa
Study | Participants | Design/Control | Intervention/Nature of ISG | Outcome Measures/ Follow-Up | ITT | Completer No. and % Dropout (d/o) | Results/Effect Sizeb | Significant? |
|
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Winzelberg 2003 [ |
N = 72 women with BC, diagnosed in past 32 mths |
RCT/WLC |
12-wk Web-based structured newsgroup ISG (Bosom Buddies) |
CES-D |
Yes |
N = 58 (19.4% d/o) |
Greater reduction in depressive symptoms in ISG group than control |
Yes |
Lieberman |
N = 32 women with BC Recruitment: Online advertisement on BC websites and via media, physicians, hospitals, and community centers | Pre-post | 16 week × 1.5 hr chatroom sessions with experienced leader therapist plus 24 hr/day bulletin board access | CES-D |
No | I = 26 (18.8% d/o) |
Significant reduction in depressive symptoms after use of ISG |
Yes |
Lieberman |
N = 114 women with BC who joined 1 of 5 frequently used public bulletin boards < 8 wks previously |
Pre-post | 6- to 8-mth membership on public BC moderated bulletin board ISG providing emotional support | CES-D |
No | 6 mths |
Significant reduction in depressive symptoms after use of ISG |
Yes |
Lieberman |
N = 74 women with BC who joined 1 of 4 frequently used bulletin boards < 8 wks previously |
Pre-post | 6- to 8-mth membership on public BC bulletin board providing emotional support No information about moderator status | CES-D “Baseline” |
No | 6 mths |
Significant reduction in depressive symptoms after use of ISG | Yes |
Rodgers 2005 [ |
N = 100 randomly selected women with BC who posted to a BC bulletin board during particular 1-wk period |
Pre-post |
Variable duration membership (mean 247 days; range 44-1001 days) of public BC bulletin board |
Thematic analysis of mood |
I = 100 (only followed up while members) |
Significant association between frequency of posting and improved mood |
Possibly |
|
|
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Andersson |
N = 60 participants with depression (CIDI diagnosis major depression and MADRS-S score 15-30 [mild to moderate depression]) |
Pre-post armc |
10-wk moderated bulletin board ISG |
BDI |
Yes |
Post-treatment |
NS reduction in depressive symptoms with use of ISG |
No |
Houston |
N = 103 users of public depression ISGs |
Pre-post | Participation in public listservs/bulletin boards at least 12 mths | CES-D |
No | 6 mths |
Resolution of depression greater in more frequent ISG users after adjustment for baseline depression severity/ demographic variables ( |
Yes |
Golkaramnay 2007 [ |
N = 228 adults discharged from psychiatric hospital with non-psychotic mental disorder |
CT/TAU | 12- to 15-wk exposure to psychotherapist-guided chatroom ISG comprising 8-10 people for 90 mins/wk | LIFE semi- structured interview |
No | I = 97 (14.9% d/o)d
|
NS difference in the percentage of ISG and control participants with a diagnosis of disorder at 12 mths follow-up | No |
|
||||||||
McKay |
N = 160 primary care DB patients aged 40 to 75 yrs with no Internet access at home or work |
RCT /info controlf
|
I_1: 10-mth professionally moderated bulletin board/chatroom and informationg |
CES-D |
No |
3 mths: |
No effect of ISG on reduction in depressive symptoms at either follow-up period |
No |
|
||||||||
Quick |
N = 3 people undergoing dialysis for renal disease |
MT |
5-wk participation in a pre-existing public email discussion list ISG for renal patients |
BDI |
Yes | N = 3 (0% d/o) | No improvement in depressive symptoms over time | No |
|
||||||||
Gross 2006 [ |
N = 77 adolescents aged 11 to 15 yrs |
RCTh
|
12 mins of instant online messaging to an unknown peer after experimental induction of low mood in control and intervention group | Dysphoria measure devised for study |
No | Adolescentsi: |
Adolescentsj: |
A:Yes |
Shaw 2002 [ |
N = 46k introductory psychology university students |
MT | 4-8 wks of online chat sessions with the same anonymous partner |
CES-D |
No | I = 40 (13%k d/o) | Significant reduction in depressive symptoms following use of ISG |
Yes |
Morgan 2003 [ |
N = 287 (or 256) first-year residential university students |
XS | Chatroom unspecified /instant messaging | Modified CES-D (11-item, Iowa version) | N/A | N/A | Significant correlation between chatroom hrs and depressive symptoms |
Yes |
Sun 2005 [ |
N = 2373 7th grade students (age 11 to 16 yrs) |
XS | Chatroom unspecified | Not specified | N/A | N/A | Daily chatroom users more depressed than those with Internet access who did not use chatrooms |
Yes |
Campbell 2006 [ |
N = 188 self-selected global sample of online users of whom 137 were frequent chat users and 51 were not |
XS |
High chatroom (unspecified) use |
ZDS |
N/A |
N/A |
NS difference in depressive symptoms for high chatroom compared to low chatroom use |
No |
Kang 2007 [ |
N = 158 chatroom users from US university community (57% female) |
XS | Chatroom unspecified | CES-D |
N/A | N/A | Higher chatroom use predicted lower depression |
Yes |
a APA = American Psychological Association; BC = breast cancer; BDI = Beck Depression Inventory; C = control sample size; CES-D = Center for Epidemiologic Studies Depression Scale; CIDI = Composite International Diagnostic Interview; CT = controlled trial; DASS = Depression Anxiety Stress Scales; DB = diabetes; ES = effect size; I = intervention sample size; ITT = intent to treat; LIFE = Longitudinal Interval Follow-up Evaluation; LOCF = last observation carried forward; MADRS-S = Montgomery-Asberg Depression Rating Scale; MT = multiple time points; N/A = not applicable; OR = odds ratio; NS = no significant difference; RCT = randomized controlled trial; TAU = treatment as usual; TK = Techniker Krankenkassde; WLC = wait list control; XS = cross-sectional; ZDS = Zung Depression Scale.
b Pre-post standardized effect size (for pre-post design) or difference between intervention and control pre-post effect sizes (for controlled designs).
c This study was an RCT involving an intervention group comprising CBT self-help and an ISG and a control group involving an ISG alone. This design does not permit an evaluation of the effect of ISG alone. Therefore, only the data for the control group (pre-post) are presented here.
d Did not complete both baseline and follow-up assessments; other dropout information not available.
eAlso, I_2 = 40, I_3 = 40.
f Online articles on diabetes (information only).
gAlso two other conditions: I_2: access to professional coach and blood glucose tracking; I_3: a combination of I_1 & I_2.
hParticipants randomized to one of three groups: (1) control, (2) intervention, (3) intervention group partners.
i These figures are for participants across all groups including dyad partners who had not undergone negative mood induction. Sample size and dropout figures were not available for the groups separately.
j Outcome measures recorded and analyzed for mood induction intervention and control samples only.
k Unclear if n = 46 before or after consent.
Study characteristics for multi-component interventionsa
Study | Participants | Design/Type of Control | Intervention/Nature of ISG | Outcome Measures/ Follow-Up | ITT | Completer No. and % Dropout (d/o) | Results/Effect Sizeb | Significant? | |
|
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Owen 2003 [ |
N = 59 women with BC |
RCT/WLC |
12-wk SURVIVE online program comprising health professional, moderated bulletin board group, cancer information, resources, self-management advice, art/poetry forum, structured coping skills exercises (including stress management, assertiveness, and structured problem solving training) |
HADS |
No | I = 25 (13.8% d/o) |
NS difference in baseline adjusted mean at 12 wks for intervention and control groups | No | |
Van Den Brink 2007 [ |
N = 184 people post-surgery for head or neck cancer |
CT/TAU | 6-wk electronic health information support system comprising peer-to-peer forum and email communication; information and monitoring via electronic questionnaire | “Feelings of depression” |
No | N = 163 (11.4% d/o) |
NS baseline adjusted difference in change at 6 or 3 mths for intervention compared to control groups | No | |
|
|||||||||
Brennan |
N = 102 caregivers of people with Alzheimer’s disease |
RCT/TAU |
12-mth access to bulletin board moderated by nurse who posted messages to “foster systematic group cohesion” and information and decision support (expert Q&A) | CES-D |
No | I = 47 (7.8%c d/o) |
Depression was treated as a intervening variable rather than an outcome |
N/R | |
Liebermann 2005d
|
N = 66 or 65 patients with PD assigned to: |
Pre-post | 20 wks × 1.5 hrs weekly health-professional moderated chatroom and bulletin board available at all times and Q&A weekly health education session with an expert | CES-D |
No | Dropout rates could not be calculated separately for Hom and Het |
Significant reduction in depressive symptoms following intervention involving Hom but not Het ISGd |
Hom: |
|
|
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Battles [ |
N = 32 children (age 8-19 yrs) with serious chronic illness (HIV, cancer, granuloma, neurofibromatosis) participating as residential out patients in pediatric clinical trials at the NIH |
(1) Restricted randomly alternating (A, B) treatment design |
4 × 30 min sessions on the STARBRIGHT World (SBW) program comprising network connection to other children in a hospital (video) Connect/Find a Friend and information about medical conditions and entertainment and distraction |
Depression Analogue Scale |
d/k |
d/k |
NS improvement in depression ratings or symptoms |
No |
|
Hill |
N = 120 female, rural residents (35 to 65 yrs) with chronic illness (diabetes/rheumatoid condition/ heart condition/multiple sclerosis/cancer) |
RCTd Randomization: Method not specified | 22-wk professionally moderated online support group and online health information modules |
CES-D |
No | I = 43 (29.5% d/o) |
NS differences in reduction in depressive symptoms in intervention compared to the control group |
No | |
|
|||||||||
Bragadottir |
N = 21 parents of children who had completed cancer treatment within past 5 yrs |
Pre-post | 4-mth access to health professional–moderated mailing list |
SCL-90 depression subscale |
No | 3 mths and 4 mths |
Mothers: NS reduction in depressive symptoms |
Mothers: No |
|
|
|||||||||
Dew 2004 [ |
N = 124 heart recipients and family caregivers |
Controlled/ “Historic” TAU comparison group enrolled in other longitudinal studies and matched for demographic distribution and assembled before or after intervention | 4-mth HeartNet programs comprising discussion groups (online moderated bulletin boards, separate caregiver and recipient boards) and interactive online stress and medical regimen management skills training grounded in CBT principles and Ask an Expert (online questions to transplant team expert plus Q&A Library plus archived responses to Ask and Expert plus Health living tips plus Resources plus References Library) | SCL-90 |
No |
Recipients: |
Recipients: Receiving intervention showed a greater reduction in depressive symptoms than the control group Caregivers: NS difference in reduction in depressive symptoms in intervention compared to the control group | Recipients:Yes |
|
|
|||||||||
McKay |
N = 78 sedentary people with type 2 diabetes aged 40 years or older |
RCT /online information, blood glucose tracking Control Randomization: |
8-wk D-Net Active Lives program comprising tailored online physical activity program with tracking of daily physical activity, information about a physical activity plus online personal coach counseling plus health professional moderated online peer support (Active Lives Support Group) | CES-D |
No | N = 68 (13% d/o) |
NS difference in reduction in depressive symptoms in intervention compared to control group |
No |
|
|
|||||||||
Gustafson |
N = 219; I = 118; C = 97 with HIV |
RCT/TAU |
6 mths (Cohort 1) and 3 mths (Cohorts 2 and 3) CHESS program comprising online facilitated bulletin board discussion group plus Q&A plus Instant Library (information articles) plus Ask an Expert (communication with medical experts) plus Getting help/support plus Referral Directory plus Personal stories plus assessment (of lifestyle risks) plus Decision Aid plus Action Plan for implementing decisions |
MOSdepression subscale |
No | Dropout rates could not be calculated separately for 3-mth and 6-mth intervention groups |
NS differences in reduction in depressive symptoms in intervention compared to control group for any follow-up/cohort combination | 3-mth Int |
|
|
|||||||||
Taylor |
N = 480 college women (18 to 30 yrs) at high risk of developing an eating disorder |
RCT/WLC |
8-wk professionally modified bulletin board and cognitive behavioral intervention |
CES-D |
No |
I = 191 (21.7% d/o)e
|
NS difference in reduction in depressive symptoms in intervention compared to control group |
No |
|
|
|||||||||
Tuil |
N = 244 participants undergoing IVF or ICSI treatment in authors’ hospital |
RCT “Randomization”: |
Access to professionally moderated bulletin board and chatroom (for communication with peers and professionals) plus information and access to own records during period of IVF/ICSI treatment cycle | Beck Depression Index for Primary Care |
No | Males: |
Males: |
Males: No |
a BC = breast cancer; C = control sample size; CBCL = Child Behavior Checklist; CBT = cognitive behavioral therapy; CES-D = Center for Epidemiologic Studies Depression Scale; CT = controlled trial; d/k – don’t know; ES = effect size; HADS = Hospital Anxiety & Depression Scale; I = intervention sample size; ITT = intent to treat; MOS = Medical Outcomes Study; NIH = National Institutes of Health; N/R = not reported; PD = Parkinson’s disease; RCT = randomized controlled trial; SCL-90 = Symptom Checklist 90; TAU = treatment as usual; WLC = wait list control.
b Pre-post standardized effect size (for pre-post design) or difference between intervention and control pre-post effect sizes (for controlled designs).
c Includes three (5.9%) dropouts “not able to have computer installed.”
d Due to apparent inconsistencies within and between the two papers on this study, effect sizes have not been computed, individual sample sizes are not reported, and individual dropout rates not computed.
e Computed for completers of CES-D only; data for overall completers not available.
Study and sample characteristicsa
Study (Samplec) Variable | Total |
Single Component |
Multi-Component |
|
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Journal article | 24 (87.5) | 14 (87.5) | 10 (83.3) |
Thesis | 4 (14.3) | 2 (12.5) | 2 (16.7) |
|
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United States | 23 (81.2) | 13 (81.3) | 10 (83.3) |
Europe | 4 (14.3) | 2 (12.6) | 2 (16.7) |
Australia | 1 (3.6) | 1 (6.3) | - |
|
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Randomized controlled trial | 10 (35.7) | 3 (18.8) | 7 (58.3) |
Controlled trial | 2 (7.1) | 1 (6.3) | 1 (8.3) |
Historic control | 1 (3.6) | - | 1 (8.3) |
Pre-post | 9 (32.1) | 7 (43.8) | 2 (16.7) |
Pre-post + single case randomization | 1 (3.6) | - | 1 (8.3) |
Cross-sectional | 4 (14.3) | 4 (25.0) | - |
Case series | 1 (3.6) | 1 (6.3) | - |
|
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Bulletin Board | 9 (32.1) | 4 (25.0) | 5 (41.7) |
Chatroom | 5 (17.9) | 5 (31.3) | - |
Mailing list/newsgroup | 2 (7.1) | 1 (6.3) | 1 (8.3) |
Instant Messaging | 2 (7.1) | 1 (6.3) | 1 (8.3) |
Combination | 6 (25.0) | 3 (18.9) | 3 (25.0) |
Mailing list or bulletin board | 2 (7.2) | 2 (12.5) | - |
Unclear | 2 (7.2) | - | 2 (16.6) |
|
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Public, accessible | 9 (32.1) | 9 (56.3) | 0 (0) |
Closed, research ISG | 17 (60.7) | 7 (43.8) | 10 (83.3) |
Restricted access hospital | 2 (7.1) | - | 2 (16.7) |
|
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Moderated | 14 (50) | 6 (37.5) | 8 (66.7) |
Some moderated | 1 (3.6) | 1 (56.3) | - |
Not specified | 13 (46.4) | 9 (6.3) | 4 (33.3) |
|
(n = 15) | (n = 7) | (n = 8) |
Health professional | 11 (73.3) | 5 (71.4) | 6 (75) |
Don’t know | 4 (26.7) | 3 (28.6) | 2 (25) |
|
16 wks |
15.5 wks |
17 wks |
|
22 wks |
26 wks |
18.5 wks |
|
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Cancer | 7 (20.6) | 5 (29.4) | 2 (11.8) |
No disorder | 7 (20.6) | 7 (41.2) | - |
Diabetes | 2 (5.9) | 1 (5.9) | 1 (5.9) |
Carers | 4 (11.8) | - | 4 (23.5) |
Chronic illness | 2 (5.9) | - | 2 (11.8) |
Neurological | 2 (5.9) | - | 2 (11.8) |
Depression | 2 (5.9) | 2 (11.8) | - |
Other mental disorder | 2 (5.9) | 1 (5.9) | 1 (5.9) |
Cardiovascular | 1 (2.9) | 1 (5.9) | 1 (5.9) |
Renal | 1 (2.9) | 1 (5.9) | - |
HIV/AIDS | 2 (5.9) | - | 2 (11.8) |
IVF | 2 (5.9) | - | 2 (11.8) |
|
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11 to 17 yrs | 3 (8.8) | 2 (11.8) | 1 (5.9) |
18 to 25 yrs | 4 (11.8) | 3 (17.6) | 1 (5.9) |
26 to 40 yrs | 5 (14.7) | 2 (11.8) | 3 (17.6) |
41 to 65 yrs | 11 (32.4) | 4 (23.5) | 7 (41.2) |
Not certain | 11 (32.4) | 6 (35.3) | 5 (29.4) |
|
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> 70% women | 16 (47.1) | 9 (56.3) | 7 (46.7) |
> 70% men | 4 (11.8) | - | 4 (25.0) |
Neither gender > 70% | 11 (32.4) | 7 (43.8) | 4 (50) |
Don’t know | 3 (8.8) | 1 (6.3) | 2 (11.8) |
|
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> 50% rural | 1 (2.9) | 0 (0) | 1 (5.9) |
a Values are no. (%) unless otherwise specified.
b Multiple samples receiving different intervention durations treated separately (one study: [
c Multiple samples treated separately (six studies: [
The majority of studies were reported in published journal articles, and, in most cases, the senior author was located in the United States.
The studies primarily employed bulletin boards, chatrooms, or mailing lists, either alone or in combination (see
More samples were focused on ISGs for breast cancer than any other condition. In addition, a significant percentage of the samples related to depression and ISG use in those without a physical or psychological condition. As noted above, only two samples were exposed to depression ISGs. The median age of participants in the samples typically fell between 26 and 65 years. Some of the samples comprised college-aged or younger adolescents. None was concerned specifically with older people, although the median age of one sample was 64 years [
Half of the studies (n = 14) used the Center for Epidemiologic Studies Depression Scale (CES-D) as an outcome measure, with the next most common measures (with two trials each) being the Symptom Checklist 90 (SCL-90) and the Beck Depression Inventory (BDI). Each of the remaining measures was administered in one trial only.
One third of the studies involved an RCT, and almost half of the 28 studies employed a control group. The majority of the remaining studies used a pre-post design. Of the 23 studies that used at least a pre-post design, only three (13%) used an ITT design, with a further study neither specifying if an intent-to-treat design was employed nor indicating the level of dropout if any [
Intervention and control sample sizes ranged from 10 to 244 (median 46) and 30 to 236 (median 51), respectively, for samples derived from studies of at least pre-post test quality. Cross-sectional study sample sizes ranged from 158 to 2373 (median 230). Dropout among samples in studies of at least pre-post test quality ranged from 7.9% to 41.7% and 0% to 37% for intervention and control conditions, respectively. Of the 22 studies of at least pre-post design with some dropout, 46% (n = 10) compared the characteristics of completers and non-completers. All but one of these (n = 9, 90%) reported no difference in baseline characteristics for these groups.
The outcomes for single and multiple studies are discussed separately.
Of the 17 intervention samples (16 studies) involving a peer-to-peer component alone or a cross-sectional design, 10 (59%) yielded a positive effect of the ISG on depressive symptoms. However, only two of these involved a controlled trial.
The largest number of single-component samples involved women with breast cancer (n = 5) [
Three samples (three studies) involved ISGs comprising members with a mental disorder, two of them depression [
There were two other single-component samples (2 studies) involving medical conditions, one of them involving a trial of an ISG for diabetes [
Finally, seven samples (six studies) involved people with no psychological or physical disorder [
Of the 17 samples (12 studies) that involved intervention components in addition to the ISG, only two (12%) reported a positive effect [
Multi-component studies were significantly less likely to yield significant, positive outcomes than stand-alone interventions and cross-sectional studies (Fisher exact test,
With respect to study quality, there was a trend toward an association between lower design quality and positive outcomes, with 19% (n = 3) of samples involving controlled comparisons (RCT, controlled trial, historic control) and 53% (n = 9) of uncontrolled effects yielding significant positive findings. However, this association fell short of statistical significance (Fisher exact test,
The most salient finding of this review was the paucity of high-quality studies of the impact of depression or other ISGs on depression outcomes. Only a minority of the identified studies employed a control group, and two-thirds of RCTs either failed to use an adequate method of randomization or failed to specify the method of randomization. In addition, only 13% of studies of at least pre-post quality used an ITT analysis, and no study used multiple imputation for treating missingness. This low level of quality is a cause for concern, particularly given the trend toward an association between significant positive findings and low design quality.
Despite the apparent popularity of the Internet as a source of support for people with depression, there were only two studies of the effectiveness or efficacy of depression ISGs in improving mood. One comprised the control arm in a study of the effectiveness of a psychological therapy, and the other involved an uncontrolled multi-time-point study of an existing public depression ISG. Although the findings from the latter study were promising, neither study was of sufficient quality to evaluate whether depression ISGs improve or do not improve depression outcomes. Clearly, there is a need to undertake an RCT of the effect of a depression ISG on depression status.
Although there were more studies of the effect on depression for ISGs for conditions other than depression, many of these studies were of low quality and almost 50% employed multi-component interventions of which the ISG was only one component. Indeed, only two studies employed both a controlled design and a single-component intervention [
The finding that breast cancer ISGs were significantly more likely to be associated with positive results than ISGs of other types requires further investigation given that women with breast cancer are known to be at increased risk of depression [
The finding that chatroom use tends to be associated with lower levels of depression among participants without depression or other medical conditions raises the possibility that chatroom usage may protect against depression in universal samples of members of the community. However, much of the evidence is based on cross-sectional surveys. Thus, the direction of causation cannot be determined, and chatroom usage may be associated with other behaviors and these rather than the chatroom use may mediate the depression levels.
Theoretically, online support groups could be particularly relevant and appropriate for users who are isolated or not able to access conventional or face-to-face services, either due to lack of mobility or geographic location. It is therefore of some concern that none of the studies investigated ISGs among older people and that only one study specifically focused on the effectiveness of an ISG for rural participants.
A limitation of this study is that it does not include trials published after July 2007. To investigate this, a further search was conducted by the first author incorporating the time period from August 2007 to May 2009 and using the same search terms employed in the reported searches but limiting results to those incorporating the terms “depression” or “depressive” or “mood.”
After excluding a published study reporting data from a dissertation already incorporated into the review [
Of the four multi-component trials [
There is a need for high-quality research to investigate the effect of ISGs on depression outcomes. We acknowledge that there are significant challenges associated with designing and undertaking efficacy studies of ISGs. We acknowledge too that the appropriateness and feasibility of conducting such research on online self-help groups have been questioned [
KG is supported by NHMRC Fellowship 425413, AC is supported by NHMRC Capacity Grant No 418020, and MB is supported by an Australian Rotary Health Ian Scott PhD Scholarship. KG conceived the project, designed the study, rated the abstracts, undertook the statistical analyses, and drafted the paper. AC designed the search terms; identified, screened, and rated the abstracts; and edited the paper. MB screened abstracts and edited the paper. Ada Tam provided editorial assistance.
None declared.
Internet support group
intent to treat
randomized controlled trial