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Major depression accounts for the greatest burden of all diseases globally. The peak onset of depression occurs between adolescence and young adulthood, and for many individuals, depression displays a relapse-remitting and increasingly severe course. Given this, the development of cost-effective, acceptable, and population-focused interventions for depression is critical. A number of online interventions (both prevention and acute phase) have been tested in young people with promising results. As these interventions differ in content, clinician input, and modality, it is important to identify key features (or unhelpful functions) associated with treatment outcomes.
A systematic review of the research literature was undertaken. The review was designed to focus on two aspects of online intervention: (1) standard approaches evaluating online intervention content in randomized controlled designs (Section 1), and (2) second-generation online interventions and services using social networking (eg, social networking sites and online support groups) in any type of research design (Section 2).
Two specific literature searches were undertaken. There was no date range specified. The Section 1 search, which focused on randomized controlled trials, included only young people (12-25 years) and yielded 101 study abstracts, of which 15 met the review inclusion criteria. The Section 2 search, which included all study design types and was not restricted in terms of age, yielded 358 abstracts, of which 22 studies met the inclusion criteria. Information about the studies and their findings were extracted and tabulated for review.
The 15 studies identified in Section 1 described 10 trials testing eight different online interventions, all of which were based on a cognitive behavioral framework. All but one of the eight identified studies reported positive results; however, only five of the 15 studies used blinded interviewer administered outcomes with most trials using self-report data. Studies varied significantly in presentation of intervention content, treatment dose, and dropout. Only two studies included moderator or clinician input. Results for Section 2 were less consistent. None of the Section 2 studies reported controlled or randomized designs. With the exception of four studies, all included participants were younger than 25 years of age. Eight of the 16 social networking studies reported positive results for depression-related outcomes. The remaining studies were either mixed or negative. Findings for online support groups tended to be more positive; however, noteworthy risks were identified.
Online interventions with a broad cognitive behavioral focus appear to be promising in reducing depression symptomology in young people. Further research is required into the effectiveness of online interventions delivering cognitive behavioral subcomponents, such as problem-solving therapy. Evidence for the use of social networking is less compelling, although limited by a lack of well-designed studies and social networking interventions. A range of future social networking therapeutic opportunities are highlighted.
Major depressive disorder is reported as the leading cause of disability worldwide [
Cognitive behavioral therapy (CBT) is recommended as a first line treatment for depression [
Given young people’s enthusiasm for Web-based communication, the development of innovative, online psychosocial interventions may help improve treatment acceptability and engagement for young people experiencing depressive symptoms [
In recent years, a range of online interventions have been successfully tested for the management of a number of mental disorders, with research supporting the efficacy of these interventions in alleviating anxiety and depressive symptoms [
To date, there has been a relative lack of online intervention studies focusing on young people with depression [
Service delivery gaps in the provision of youth specific psychotherapeutic services [
Electronic searches were conducted in June 2013 of the PsycINFO, Cochrane Library, Embase, and MEDLINE databases accessed via the University of Melbourne library. Search strategies were devised using relevant subject headings for each database. In order to capture all relevant online interventions, additional free text words were identified by experts who have published in youth mental health online interventions and systematic review methodology. All studies retained for analysis needed to meet the study inclusion criteria outlined below. Further manual searching of reference lists was also undertaken, in addition to a “soft search” in the Google Scholar database for Section 1 for “Online interventions” and Section 2 for “Social networking and depression”. Search terms are listed in
Included studies had to meet each of the following criteria: (1) use a randomized controlled trial (RCT) design, (2) test any therapeutic modality delivered online, (3) use either an open access (not restricted) or referred (participation through invitation only and supplied with a password to access site) intervention, (4) focus on prevention (using a universal or targeted approach), treatment, or relapse prevention, and (5) include participants aged between 12 and 25 years.
Included studies met each of the following criteria: (1) focus on social networking services, defined as online interactions where the reader is also able to write, and where the social network is predefined, (2) either examine social networking websites that aim to prevent, treat, or provide relapse prevention for depression, or describe associations between the use of general social networking sites and depressive symptoms, and (3) include user-to-user contact. Given the early development stage of social networking interventions, no restrictions were placed on participant age or study design.
For each section, search results were independently screened by 2 researchers to establish their relevance for inclusion in the appropriate section. Any discrepancy between the researchers was referred to a third researcher involved in establishing the search strategy for the final decision. In order to assist the narrative synthesis of the included studies, a predefined data extraction template was designed for Sections 1 and 2.
We identified 101 articles, of which 15 studies met inclusion criteria (see
With the exception of the one combined prevention and intervention study [
The 15 identified studies reported on data from 10 separate trials. Of these, there were nine separate interventions tested: Cognitive Behavioral Analysis [
The included MoodGYM, Cognitive Behavioral Analysis, and SPARX interventions were delivered via computer in a group classroom setting, with supervision from a classroom teacher/tutor. The remaining interventions were designed to be delivered in a self-paced and self-directed manner. Studies varied in duration (eg, dose) both in terms of total length of intervention access, which ranged from 5 weeks (eg, MoodGYM) to 32 weeks (eg, Cognitive Behavioral Skills Training Program), and individual module length, which ranged from 20-40 minutes (MoodGYM) to 90 minutes (Master Your Mood).
The majority of included studies involved a fully automated intervention, with only two of the eight interventions including moderator involvement, or feedback to participants. Of the moderated interventions, the Internet Problem Solving Therapy intervention used email support from the moderator (with messages followed up within a 3-day period) [
Dropout rates were reported for 14 of the 15 studies and varied significantly, ranging from 3%-41%. The only study with a dropout rate of less than 5% used the SPARX avatar-based gaming intervention platform [
The prevention studies (Blues Blaster, Cognitive Behavioral Analysis, MoodGYM, and CATCH-IT) demonstrated intervention efficacy among university students [
The intervention studies demonstrated superiority of the online intervention to the comparison treatment. These involved the Cognitive Behavioral Skills Training Program, SPARX, Computerized CBT, and Master Your Mood. Comparison groups were either treatment as usual (pharmacotherapy and psychosocial services) [
The trial that targeted its Internet Problem Solving Therapy intervention to young people who were either at risk of depression or had depression showed no difference between the intervention group and the waitlist control. This trial recruited a relatively small (n=45) yet heterogeneous sample [
A total of 358 abstracts were screened, yielding 22 studies meeting inclusion criteria (see
The majority of included studies reported on data collected via online questionnaires. All but five of the identified SNS studies reported on participant data, with the remaining studies including one systematic review, one general literature review, two pieces discussing SNS in the context of clinical practice, and a descriptive networking study. Ages ranged between 12-85 years; however, with the exception of the systematic review paper [
Findings related to the benefits of SNS on depression were inconsistent. Eight of the SNS studies reported positive findings [
Direct one-to-one interactive communication (as opposed to passive SNS use) was associated with greatest well-being and least depression [
Identified risks included cyberbullying, harassment, sexting, privacy concerns, and SNS-induced depression in the association between young people’s use of SNS and depression [
The included systematic review of OSG use reported a lack of high-quality research examining the effects of OSGs on depression. The included systematic review reported that only two low-quality studies examined the effectiveness or efficacy of OSG use on depression with mixed results [
Of the included OSG studies in our review, three reported overall positive findings [
In contrast, one study reported that use of OSGs (but not SNS) was associated with increased suicidal ideation for young people 14-24 years over a 12-month period [
Young people are eager users of new technology, and online interventions offer an opportunity for mental health support that is immediate and cost-effective [
With the exception of Internet Problem Solving Therapy, all studies highlighted the benefits of online interventions for prevention and treatment of major depression in young people. However, caution is required in interpreting this finding given that few studies used blinded interviewer outcome assessments. General recommendations included the feasibility of widespread roll-out of online interventions across school-based populations [
Based on sample characteristics, studies were classified as prevention, intervention, or both. However, in practice, included studies tended to make little distinction regarding this and were broad in their disorder of focus. For example, the MoodGYM intervention is designed to both prevent and decrease depression symptoms [
Participant attrition is an important issue in the use of online interventions. Included studies that promoted greater engagement (either through use of motivational interviewing or content innovation) tended to report lower attrition rates. Automated self-help services require significant motivation and self-discipline [
Ongoing engagement is also an important factor for online interventions. The effect of high intervention adherence (relative to low intervention adherence) was found to improve treatment outcomes of the MoodGYM intervention [
The primary focus of the studies reviewed in Section 2 was the exploration of the relationship between engagement in SNS (including OSG use) and depressive symptomology. This is an emerging research area, and there was significant heterogeneity across study designs. Hence, results must be interpreted with caution.
Research suggests that some young people may be more willing to disclose information on an SNS than in person [
Given the early phase of mental health–related research on the use of SNS, significant knowledge gaps in research are to be expected. While some of the SNS studies reported positive findings, others identified adverse outcomes or no associations at all. It is possible that SNSs exert a bidirectional effect on depression symptoms or that the relationship is mediated by the intervention content, safety, and type of interaction. For example, positive online interactions may lead to increased social support and reduced depression, and negative online interactions (or with a negative focus) may lead to increased depression and perceived burden.
There may also be qualitative differences between young people who use particular websites for help seeking or discussion of mental health issues. For example, previous research has shown that those higher in hopelessness (a key predictor of suicidal ideation) may be more likely to engage in blogging type sites (eg, OSGs) versus sites focused on briefer posts and content [
Participation in online social networking has become ubiquitous and routine in the lives of young people. As such, there is both a great opportunity and an urgent need to identify and make use of the potential benefits of such sites for young people’s well-being. Provided that the SNS experience is primarily positive, time spent on SNSs has the potential to operate as a preventative or therapeutic medium for individuals with depression and may complement traditional therapy for more severe forms of the disorder.
Adherence and engagement are essential to effective and efficient delivery of online interventions [
The next generation of online interventions will include refinements and functionality not possible in previous technologies. There is significant scope for greater responsiveness and immediacy, including real-time clinician input and customized feedback. In addition, the next generation of online interventions offers an opportunity for better matching of intervention content to phase of illness, and the role of online social and peer support [
Literature searching for the present review was current at June 2013, and it is likely that higher-quality studies evaluating SNS use will start to soon appear in scholarly journals. Promising new lines of research are emerging for the treatment of depression in young people using mobile phone-based interventions [
The present review was limited by a lack of studies focusing on relapse prevention. Given that relapses in depression are high [
Mental health interventions will increasingly make use of online technologies. A key challenge for these interventions will be having broad appeal and engagement. There is clear evidence that online interventions using a cognitive behavioral focus are promising in reducing depression symptomology in young people. Further study is required to identify the effectiveness of online interventions delivering cognitive behavioral subcomponents, such as problem solving therapy or other therapeutic approaches. Although evidence for the use of online social networking is less robust, such interventions exist in a dynamic space with significant opportunity for methodological advancement and rigor.
Search terms.
Summary of studies, Sections 1 and 2.
cognitive behavioral therapy
major depressive disorder
online support group
randomized controlled trial
social networking site
The authors gratefully acknowledge the HCF Health and Medical Research Foundation for providing funding for this research. MA-J is supported by a CR Roper Fellowship, Faculty of Medicine, Dentistry, and Health Science, the University of Melbourne, Australia.
None declared.