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Although depression is known to affect millions of people worldwide, individuals seeking aid from qualified health care professionals are faced with a number of barriers to treatment including a lack of treatment resources, limited number of qualified service providers, stigma associated with diagnosis and treatment, prolonged wait times, cost, and barriers to accessibility such as transportation and clinic locations. The delivery of depression interventions through the Internet may provide a practical solution to addressing some of these barriers.
The purpose of this scoping review was to answer the following questions: (1) What Web-delivered programs are currently available that offer an interactive treatment component for depression?, (2) What are the contents, accessibility, and usability of each identified program?, and (3) What tools, supports, and research evidence are available for each identified program?
Using the popular search engines Google, Yahoo, and Bing (Canadian platforms), two reviewers independently searched for interactive Web-based interventions targeting the treatment of depression. The Beacon website, an information portal for online health applications, was also consulted. For each identified program, accessibility, usability, tools, support, and research evidence were evaluated and programs were categorized as evidence-based versus non-evidence-based if they had been the subject of at least one randomized controlled trial. Programs were scored using a 28-point rating system, and evidence- versus non-evidence-based programs were compared and contrasted. Although this review included all programs meeting exclusion and inclusion criteria found using the described search method, only English language Web-delivered depression programs were awarded an evaluation score.
The review identified 32 programs meeting inclusion criteria. There was a great deal of variability among the programs captured in this evaluation. Many of the programs were developed for general adolescent or adult audiences, with few (n=2) focusing on special populations (eg, military personnel, older adults). Cognitive behavioral therapy was the most common therapeutic approach used in the programs described. Program interactive components included mood assessments and supplementary homework sheets such as activity planning and goal setting. Only 12 of the programs had published evidence in support of their efficacy and treatment of depressive symptoms.
There are a number of interactive depression interventions available through the Internet. Recommendations for future programs, or the adaptation of existing programs include offering a greater selection of alternative languages, removing registration restrictions, free trial periods for programs requiring user fees, and amending programs to meet the needs of special populations (eg, those with cognitive and/or visual impairments). Furthermore, discussion of specific and relevant topics to the target audience while also enhancing overall user control would contribute to a more accessible intervention tool.
In October 2012, the World Health Organization estimated that 350 million people worldwide suffer from depression [
Not all individuals face the same risk. Certain populations are more susceptible to depression relative to others. For example, it is estimated that 14%-77% of traumatic brain injury survivors suffer from depression post injury, which is a much higher than the general population [
There are a number of depression treatment options available including medication, lifestyle, and psychological interventions. Unfortunately, many therapies are unavailable to patients due to a lack of qualified service providers. In Canada, it is estimated that only 33% of individuals seeking mental health services actually receive treatment [
Not only are individuals hindered by accessibility issues but also by the stigma associated with a mental illness diagnosis such as depression. Only 42% of Canadians said that they would socialize with a friend suffering from a significant mental health issue [
Recent advances in computer technology offer potential alternative treatment options. The percentage of the global population that had access to the Internet nearly doubled from 18% in 2006 to 35% in 2011 [
Regarding Web-based intervention treatments for depression specifically, the Canadian Network for Mood and Anxiety Treatments suggested computer-assisted cognitive behavioral therapy (CBT) programs as a second line treatment in cases “where first line treatments are not indicated or cannot be used or when first line treatments have not worked” [
Reviews of existing Web-based programs for the treatment of depression are available on the Beacon website [
We conducted a scoping review of interactive Web-based treatment programs for depression to answer the following questions: (1) What Web-based programs are currently available that offer an interactive treatment component for depression?, (2) What are the contents, accessibility, and usability of each identified program?, and (3) What tools, supports, and research evidence are available for each identified program? Unlike the systematic reviews that have been published to date, our review included publicly available Web-based programs with and without supporting research trials. In addition, we have compared and contrasted those with and without supporting evidence on predetermined evaluation criteria.
A search for interactive programs targeting depression was conducted in April 2014 using Google, Yahoo, and Bing (Canadian versions)—popular and comprehensive search engines easily accessible to many individuals. A list of the search terms used is included in
For the purposes of this scoping review, interactive was defined as a program requiring user engagement and input (eg, mood assessments, user worksheets, and integrated program requirements for mandatory user feedback). If a program provided only reading materials on the symptoms of depression, treatments, and relapse prevention, it was classified as psychoeducational and did not meet the “interactive” inclusion criterion.
Online depression treatment
CBT depression online treatment
Depression and CBT online programs
Online methods of depression treatment
Computerized cognitive behavior therapy programs for treatment of depression
Online cognitive behavior therapy programs treating depression
Computer based depression treatment programs
Internet delivered depression treatment programs
E-therapy for depression
Each of the terms in
The Beacon website [
In order to systematically evaluate each identified program, we used criteria adapted from previously published guidelines [
Categories of investigation used to evaluate each program.
Category | Investigation | Evaluation focus |
Accessibility | Fee/Referral | Was there a fee or physician referral required to access the program? |
Language | Was the program available in alternative languages? | |
Registration Requirement | Was personal information required to access the program? Were details provided regarding the registration process? | |
Target Audience | Who was the program designed for? | |
Usability | Statistics | Registered users, completion rates, and attrition data (if available). |
Therapeutic Approach | What therapies/treatment approach(es) were offered? | |
Mode of Delivery | How was the content delivered: size of text, audio or video offered, use of character examples, and case scenarios? | |
Tools | Additional Features | What additional features were available (eg, if users could monitor their progress/modules completion and mood over time)? Were email reminders and follow-up offered? |
Worksheets | Did the program offer worksheets (printable for offline use or integrated throughout program)? Indicated whether worksheets were mandatory or optional. | |
Assessments | Were assessments offered within the program? Indicated whether assessments were mandatory for completion of program. | |
Support | Clinician Support | Did the program offer linking with a clinician (either user’s own clinician or program specific clinician) and type of linkage (eg, telephone monitoring)? |
Peer Support | Did the program offer peer support (eg, forum, personal story sharing, or blogs)? | |
Crisis Links | Did the program offer crisis or emergency contacts? | |
Evidence | Randomized Controlled Trial | Had the program been evaluated for efficacy with at least one randomized controlled trial? |
A program evaluation scoring system was also created based on the above mentioned article [
Two reviewers independently examined each program and scored them using the evaluation criteria outlined in
An identified program was categorized as an evidence-based program (EBP) if it was the intervention in at least one published randomized controlled trial (RCT). All other programs were categorized as non-evidence-based programs (NBP).
Facets and adapted evaluation criteria.
Facet # and description | Adapted evaluation description and # |
1. Focus and target population | 1. Were the primary focus/ goals/ objectives of the intervention stated? |
2. Was an initial assessment conducted for program/user suitability purposes? | |
3. Was the target audience or age group defined? | |
2. Authorship details | 4. Were the names and credentials of authors present? |
5. Was the ownership or developer name provided? | |
6. Were links to the developer website provided? | |
7. Was date of program/site update provided? | |
8. Was country of origin stated? | |
3. Model of change | 9. Was the model of change (ie, type of therapy utilized) defined/stated? |
4. Type and dose of intervention | 10. Were the number of modules or time to complete each module stated? |
11. Was the program structured/guided (ie, modules to be completed in a restricted and specific order =1) or unstructured/unguided (ie, modules could be accessed freely =0)? | |
12. Was the intervention tailored to the user or was it generic for all users? | |
13. Did users receive feedback? | |
14. Could users track their progress throughout the program? | |
15. Were the assessments validated/reliable? | |
5. Ethical issues | 16. Were the risks of the program stated/benefits of program were stated? |
17. Were safe guards provided (ie, crisis links /telephone hotline numbers provided)? | |
18. Was a unique user name or password provided to users? | |
19. Was the site secure? | |
20. Were the rights and use of user personal information provided? | |
6. Professional support | 21. Was there a statement of professional support (ie, therapist integrated into the intervention)? |
22. For programs utilizing therapist support: were the credentials of the therapist provided? | |
7. Other support | 23. Was support provided from additional sources (ie, peer discussion forums or blogs)? |
24. Was this type of support monitored by an overseeing authority? | |
8. Program interactivity | 25. Was the interactivity of the program described and accurate (ie, how much time needing to be spent on module/homework assignments)? |
9. Multimedia channel of delivery | 26. Did the program offer a multimedia content delivery (ie, a combination use of text, video, graphics, and audio formats)? |
10. Degree of synchronicity | This evaluation point was combined with point 13. |
11. Audience reach | This evaluation point is available in |
12. Program evaluation | 27. Was evidence for the program provided to the user (ie, attrition data/ success rate/ completion rate/ # of users in the program/ testimonials)? |
28. Was a randomized controlled trial completed for the program? |
We identified 27 websites collectively offering 32 programs in accordance with inclusion and exclusion criteria (see
Three programs meeting inclusion criteria were not found using the searches conducted but were previously known to authors: After Deployment, Dealing With Depression, and Students Against Depression. Three programs (Interapy, Kleur Je Leven, and Internetpsykiatri) included in
A summary of the countries where programs were developed is provided in
Program development by country of origin.
Four of the EBP were offered in alternative languages (Deprexis: Swedish and German; eCentre Clinic: Wellbeing Course: Arabic; MoodGYM: Simplified Chinese, Dutch, and Norwegian; and MoodHelper: Spanish). Two programs were available only in Dutch (Interapy and Kleur je Leven). Only one NBP was offered in another language and was not available in English (Internetpsykiatri: Swedish only). The remaining 19 programs were offered exclusively in English.
The registration processes and fee structures varied by program for both the EBP and NBP and included those that were freely available (n=12), those with a fee required (n=8), those with an access code required (n=4), those for which an application to the course was required (n=4), those with multiple registration criteria (n=1), and those with unknown registration criteria (n=3). See
Eight programs had an associated fee ranging from AUD $55 (This Way Up, Clinic Course) for five/six lessons to US $400 for eight sessions (The National Stress Clinic). Most programs offered a free trial period, allowing users to interact with the program prior to paying the fee.
Most programs (n=21) required the input of personal information to access course material. Registration was restricted to certain countries for five programs (eCentre Clinic: The Wellbeing Course,The Mood Mechanic Course, The Wellbeing Plus Course, and The UniWellbeing Course, restricted to Australia; MoodHelper, restricted to the United States). Registration was not required for three programs, and registration requirements were unknown for three programs.
The programs that did not mandate registration allowed users to access program content without entering any personal information. However, users could not track their progress through these programs without registration. Programs with mandatory registration required users to input basic personal information before gaining access to program content, allowing for sessional data storage. For example, registration allowed users to create personal profiles through which mood assessments, worksheets, and module progression were recorded.
Fees and referrals required for program access.
Registration required for program access.
The identified programs predominantly targeted adult audiences (n=19), with a few programs developed for adolescents or students (n=3), combined populations (ie, adolescent and adult population; n=5), a specified special population (n=2), or unknown audiences (n=3) (see
The majority of programs contained content that was specific to the adult end-user. Sessions varied by program and offered an array of materials targeting adult concerns surrounding depression. Topics included but were not limited to problem solving, goal setting and planning, tackling financial issues, workplace stress, in addition to challenging negative thoughts. Programs targeting adolescents were mainly focused on academic life and the stressors associated with the learning environment. Topics included time management, stress associated with exams, relationships, confidence and self-esteem, as well as other social issues faced by youth.
Two NBP were developed for specific target populations: After Deployment (discharged military personnel) and eCentre Clinic Wellbeing Plus Course (older adults). Sessions covered many issues faced by these individuals including post-traumatic stress syndrome, insomnia, depression, and anxiety.
Target audience(s) of the programs.
Evaluation scores for EBP ranged from 68%-92%, with an average score of 80%. Evaluation scores for NBP ranged from 39%-92%, with an average score of 73%. A detailed breakdown of scores per program is provided in
A number of programs (n=17) provided user statistics and/or user reviews. Varying by program, statistics aimed to demonstrate overall program efficacy and effectiveness using program completion rates, number of registered users, number of users completing the course, and reductions in validated measure scores from pre- to post-intervention. See
Usability of the programs evaluated.
Ref. # | Statistics available (# of users registered, number of unique visitors, attrition data, stated completion rate) | Therapeutic orientation/Intervention offereda | Content deliveryb |
1 | 89% of users rated the program as useful, 70% of users (mild to moderate depression) who completed the program required no further treatment | CBT | ANI/TXT++/VID |
2 | — | PE/CBT | AUD/TXT/VID/ANI |
3 | 7000 patients currently enrolled in trials | CBT/PP | AUD/TXT++ |
4 | Have offered free treatment to more than 4000 Australians | CBT/IPT | TXT++ |
5 | — | CBT | ANI/TXT++ |
6 | 10,804 new registrations, 71,113 unique visitors, 9,199,943 Internet hits | CBT/IPT/PS/RX/PA | TXT++/VID |
7 | — | UNK | UNK |
8 | — | UNK | UNK |
9 | 750,000 registered users | CBT | TXT++/ANI |
10 | Over 2500 users registered | CBT | TXT+/ANI |
11 | 75% of users complete the course and require no further treatment, 6000 patients enrolled and 2400 clinicians as of Dec. 2012 | CBT | ANI/TXT+ |
12 | — | CBT | ANI/TXT+ |
13 | — | UNK | AUD/TXT+/VID |
14 | 54% average reduction in Patient Health Questionnaire (PHQ)-9 Score | MD/CBT | AUD/TXT+/VID |
15 | Reported decreases in Beck Depression Index scores and reportedly 60% of individuals who finish program will be “cured” of their depression/ testimonials | CBT | TXT++/ANI |
16 | — | CBT | VID/TXT++ |
17 | — | UNK | AUD/TXT++/VID |
18 | Have offered free treatment to more than 4000 Australians | CBT/IPT | TXT++ |
19 | Have offered free treatment to more than 4000 Australians | CBT/IPT | TXT++ |
20 | Have offered free treatment to more than 4000 Australians | CBT/IPT | TXT++ |
21 | — | UNK | UNK |
22 | 222,078 registered users | CBT | ANI/TXT++ |
23 | — | CBT/PP | VID/TXT++/AUD |
24 | 600,000 users registered, 437,507 unique visitors, 79,607,184 Internet hits. | CBT/IPT | TXT++/ANI |
25 | — | CBT/IPT/PS/PP | TXT++ |
26 | — | CBT | TXT+++ |
27 | Testimonials and user reviews | CBT | UNK |
28 | User reviews | CBT | TXT++/ VID |
29 | — | CBT | AUD/TXT+++ |
30 | User reviews | CBT | TXT++ |
31 | — | UNK | VID (subtitles avail.)/TXT+++/AUD |
32 | — | CBT | TXT+/ANI |
aMD:mindfulness, PA: physical activity, PE: psychoeducation, PP: positive psychology, PS: problem solving, RX: relaxation, UNK: unknown.
bANI: animations/graphics, AUD: audio files, TXT: text based (+=small text blocks, ++=medium text blocks, +++=large text blocks), VID: video files.
Programs delivered their interventions through various therapeutic techniques. The majority of the EBP (n=6) delivered CBT-focused treatments, four offered integrated therapies (eg, CBT, Intrapersonal Therapy [IPT], psychoeducation, relaxation therapy, problem solving, and physical activity), and two did not define their therapeutic approach. Nine NBP provided CBT-based materials, seven offered combination therapy models, and four NBP were categorized as unknown as they did not define their therapeutic approach. See
Therapeutic approach offered in programs evaluated.
Treatment interventions were delivered in a number of ways for both EBP and NBP. Nine EBP contained a multimodal format (ie, combination of text, video, and audio) with only one delivered in a text-only format. Two EBP were unknown (could not be evaluated). The majority of the NBP (n=12) were offered in a multimodal format. Six NBP were offered in a text-only format, and two programs were categorized as unknown. See
Method of content delivery.
Tools associated with the programs evaluated.
Ref. # | Additional featuresa | Worksheetsb | Assessmentsc |
1 | PT | W | UNK |
2 | PTP | W | A[V] |
3 | RE/MT/PTP/PT/F | W | A[V] |
4 | PT/F | W | A[V] |
5 | PT/F/MT | W | A |
6 | PT/MT/F | W | A[V] |
7 | UNK | UNK | UNK |
8 | UNK | UNK | UNK |
9 | PT/MT/F | W | A[V] |
10 | MT/PT/F | W | A |
11 | CA/PT/F | W | A[V] |
12 | CA/PT/F | W | A |
13 | PT/F/MT | W | A[V] |
14 | JOUR/PT/F/MT | W | A[V] |
15 | PTP/F/PT | UNK | A[V] |
16 | PT/F | W | A[V] |
17 | — | — | — |
18 | PT/F | W | A[V] |
19 | PT/F | W | A[V] |
20 | PT/F | W | A[V] |
21 | UNK | UNK | UNK |
22 | MT/PT/PTP/F | W | A[V] |
23 | PT/F | W | A |
24 | MT/PT/JOUR/PTP/F | W | A |
25 | PTP/F | W | A |
26 | PT/F/RE | W | A |
27 | PT/F/MT | W | A |
28 | MT/CA/PT/F/JOUR | — | A[V] |
29 | — | W | — |
30 | MT/PT/F | W | A[V] |
31 | PT/CA/F | W | A[V] |
32 | PT/F | W | A[V] |
aCA: calendar application, JOUR: journal application, MT: mood tracking, F: feedback provided, PT: progress tracking, PTP: personalized treatment plan, RE: reminder emails.
bUNK, unknown, W: worksheets available.
cA: assessments available, A[V]: assessment validated.
Support associated with the programs evaluated.
Ref. # | Peer supporta | Clinician supportb | Crisis linksc |
1 | — | TC | UNK |
2 | — | — | UNK |
3 | — | TC | EC |
4 | — | TC | EC |
5 | — | — | EC |
6 | UNK | TC/— | UNK |
7 | UNK | UNK | UNK |
8 | UNK | UNK | UNK |
9 | — | — | EC |
10 | — | TC | EC |
11 | — | TC | EC |
12 | — | — | EC |
13 | PSF | — | EC |
14 | UNK | TC | — |
15 | — | — | — |
16 | — | — | EC |
17 | — | — | — |
18 | — | TC | EC |
19 | — | TC | EC |
20 | — | TC | EC |
21 | UNK | UNK | UNK |
22 | PSF | TC | EC |
23 | PSF | — | — |
24 | — | — | EC |
25 | PSF | — | — |
26 | PSF | TC | EC |
27 | PSF | TC | EC |
28 | — | — | EC |
29 | PSF | — | EC |
30 | PSF | — | — |
31 | — | TC | EC |
32 | — | — | EC |
aPSF: peer support forum.
bTC: therapist contact via telephone/email and/or therapist linking to program, UNK: unknown.
cEC: emergency contact information provided.
Many programs included additional features such as email reminders, calendar applications, journal space, progress tracking reports as well as mood tracking. EBP and NBP both offered a number of support tool options, with most programs offering multiple features (EBP=7, NBP=10). See
Additional features offered to program users.
Many programs provided lesson reinforcement activities and worksheets (EBP: n=10, NBP: n=16). Worksheets covered topics discussed in current or previous modules and encouraged user engagement. Many worksheets incorporated activity planning, goal setting, problem solving, and thought evaluation. Self-reflection activities further identified troublesome areas and encouraged corrective action.
Most programs incorporated mood or depression assessment tools (EBP: n=8, NBP: n=17). Assessments were delivered prior to user registration, integrated into module content and/or independent of session programming. Programs administering assessments provided feedback and results immediately upon user completion. When evaluating some programs (EBP: n=3, NBP: n=1), it was unclear whether assessments were administered. In total, 17 programs used validated measures: Patient Health Questionnaire (PHQ)-9, Beck Depression Inventory (BDI), and Center for Epidemiologic Studies Depression Scale (CES-D).
None of the EBP offered a peer-support forum (three programs were categorized as unknown). The majority (n=11) of NBP did not include a peer-support forum (one program was categorized as unknown). Only eight NBP were found to have this service available to its users. See
Support available from peers.
Six EBP offered clinician support, four offered no clinician support, and two programs were unknown. Eight NBP offered clinician support, 11 programs did not offer clinician support, and one program was not evaluated. See
Support available from clinicians.
Crisis links were defined as email addresses, phone numbers, and/or hotlines connected to distress centers providing counseling services to at-risk users. If present, telephone numbers and distress centers were from within the program’s country of origin. In total, 20 programs (both EBP and NBP) had a crisis link with contact information and phone numbers. Most EBP provided this service (five programs were unknown); however, six NBP did not (one program unknown). See
Crisis link information provided.
Only 12 of the 32 programs had at least one published RCT evaluating their efficacy. It was beyond the scope of the current review to summarize the results of these trials and the reader is directed to recently published systematic reviews and meta-analyses [
Use and wide spread dissemination of Web-based mental health care interventions is expanding and reflected by the number of currently available depression treatment programs captured in this scoping review. Web-based approaches may have several benefits beyond those of conventional psychotherapy [
We have identified 32 existing interactive Web-based programs and have found varying degrees of accessibility, quality, and evidence supporting their efficacy. Only 12 of the 32 programs had at least one peer-reviewed, published article describing the results of an efficacy study. In examining the programs, authors noted a number of similarities and differences when comparing EBP to NBP by each evaluation point (see
While Web-based programs can generally improve access to mental health care, some aspects of existing programs may present users with alternative access barriers. For example, some programs were available only in one language (eg, Interapy and Kleur je Leven in Dutch, and Internetpsykiatri in Swedish), with the majority of NBP available only in English. The addition of alternative languages could promote open accessibility to any user seeking treatment. Furthermore, some programs had accessibility restrictions based on country of residence (see
While a higher proportion of the NBP (9/19a; 47%) were freely available (no fees or referrals required to access) as compared to the EBP (3/10a; 30%), a higher proportion of the NBP (6/19a; 32%) than the EBP (3/10a; 30%) had a fee for accessing the program. Requirements such as therapist referral, administrator acceptance for registration, and/or user fees may act as deterrents to use as they necessitate additional motivation and resources on the part of the user. The need to obtain a referral, enter personal information to register, and/or wait for access negates the benefits of anonymity and convenience afforded by Web-based tools. Conversely, registration requirements enable the user to track their progress and build on previously completed modules. In addition, the registration of personal information would allow the program deliverers to contact the user when in need, such as when increases in depression symptoms or suicide risk (which are more prevalent among depressed individuals as compared to other mental health disorders) are reported. Also, referral-based programs often allowed for integrated therapist contact. For fee-based programs, free demonstration/trial modules could be provided to allow users to assess the program prior to making a financial commitment.
In examining the programs captured in the review, CBT was the most commonly incorporated therapeutic approach (EBP=6, NBP=9; see
Many of the programs captured in this review delivered treatment specifically for adolescents, adults, or both. A limited number of programs catered to special populations (eg, military personnel, older adults). Future programs could be geared toward the needs of special populations such as individuals with cognitive impairments or persons in a caregiving role. Accommodations for cognitively impaired individuals may include larger text sizing, multimodal delivery (audio and video files), in addition to programming specific to their impairments (eg, memory games, goal setting and problem solving). Caregivers of chronically ill patients also demonstrate increased psychological distress and burden [
Although a target audience was identified for each of the programs (ie, adults, students, special population), course content was often generic for all users within the targeted population. Personalized treatment plans (ie, generic programs vs individual treatment plans; evaluation point 12) were offered in only a few programs: 22% of EBP (2/9a) and NBP (4/18a). Personalized treatment plans may enhance user engagement by appealing to their specific treatment needs and offering relevant treatment information. Take for example a user suffering from only a mild form of depression; they may not have found additional anxiety information useful causing them to lose interest in continuing with the program despite its potential benefit. In programs offering a personalized treatment plan, program suggestions were based on an initial assessment. All but a few EBP and NBP offered assessments; however, not all of the assessment tools used were validated (evaluation point 15). Of EBP, 75% (6/8a) relative to 67% (12/18a) of NBP employed validated assessment tools (ie, BDI, PHQ-9, or CES-D). Programs should strive to offer validated assessment tools to provide users with accurate feedback in regards to their depressive and anxiety symptoms. During this emotionally sensitive time period, individuals could be heavily influenced by program feedback and results, necessitating accurate and valid depictions of depression symptoms over time.
In addition to worksheets and assessments, some programs offered additional features that may help enhance usage and retention including emails offering encouragement, helpful quotes or testimonials, and reminders to complete modules; completion trackers for each session and/or the program overall; supplementary worksheets and mood assessments delivered during or after each session to assess and monitor progress; and automated feedback to the user. The majority of both EBP (7/10a; 70%) and NBP (10/20; 50%) offered three or more of these additional features (see
Many of the programs included additional integrated therapist contact, peer support discussion forums, and crisis links. Programs offering therapist support (evaluation point 21) were delivered via telephone, video conference, or live chat (ie, instant messaging): 60% (6/10a) of EBP and 50% (8/19a) of NBP offered therapist support. Similarly, 60% (6/10a) of EBP and 50% (8/19a) of NBP provided a therapist name and their credentials (evaluation point 22). Providing users with this information may provide them peace of mind that they are being cared for and monitored by an accredited individual capable of intervening if required. A recent study using MoodGYM plus brief face-to-face therapist support indicated positive results in the reduction of symptoms of depression in a primary care setting [
Other avenues of support offered within the evaluated programs included peer discussion forums, blogs, and shared user spaces (evaluation point 23). Unlike EBP, none of which provided peer-support forums, 44% (8/18a) of NBP offered this feature. However, only 24% (4/17a) of NBP offered forums that were monitored by an overseeing authority, facilitating safe user interaction and positive constructive topics of conversation (evaluation point 24). Peer support offers a level of familiarity not offered with clinician support. The need for relatedness to others enduring similar emotional issues can be both comforting and motivating; however, the effectiveness of peer support upon symptom resolution has yet to be evaluated in this context.
In addition to peer and clinician support, some programs offered crisis links via telephone hotlines, email, or chat functions. Hotlines provided support to users under distress when therapists or other social support options were unavailable. Safeguards (evaluation point 17) were available in all the evaluated EBP; however, only 68% (13/19a) of NBP offered this feature. Due to the sensitive nature of the treatment and topics discussed, all programs should offer or provide information for available crisis links.
To evaluate program usability, we contacted each of the program’s administrators. Many were unable or did not wish to disclose user statistics in regards to registration, attrition, and program completion. Those that responded to inquiry emails or posted statistics on their program websites are listed in
Although not included in this review (as they did not meet the inclusion and exclusion criteria), three novel and noteworthy Web-based treatment programs for depression were identified: Depression Quest [
In summary, many interactive treatment programs for depression are available on the Web; however, the efficacy and validity of most of these programs (20/32, 63%) have not been evaluated using RCTs. When comparing those programs that are evidence-based to those that have not been empirically evaluated, more of the EBP programs seemed to use a guided approach, employ validated assessment tools, offer additional features, incorporate safeguards, and provide user statistics. More of the NBP programs were available without fees or referrals (however, a higher proportion did request a user fee than the EBP) and offered peer-support forums. Based on our review, several programs emerged that are easily accessible, free to use, and have supporting evidence for their efficacy including E Couch, MoodGYM, and This Way Up (Self Help Course, Worry and Sadness; see
Although there is a strong and growing body of evidence in support of Web-based interventions, some perceive that the uptake and dissemination of such programs have not been commensurate with their potential to improve health-related outcomes. With respect to Web-based interventions for depression, potential barriers have been cited such as negative clinician and patient attitudes [
Mood Gym introduction page.
E Couch navigation page.
This Way Up welcome page.
While we aimed to be comprehensive, systematic, and thorough in our review and evaluation, some information could not be ascertained due to referral and cost restrictions limiting program accessibility. We used the Canadian version of common search engines (Google, Yahoo, and Bing) to identify programs conforming to evaluation inclusion criteria. Searches were repeated until results became redundant; however, it is possible that despite our efforts to be inclusive, some programs were missed. It is also important to note that searches conducted in other countries (using the above mentioned search engines) may not yield the same search results. Provided that many search engines suggest local websites and may also receive funding from local advertisers, our search results may be highly specific to our proximity (Toronto, Canada). Moreover, the rapidly evolving nature of the Internet means that the same search conducted several months from now could yield a different set of results and conclusions. New programs may be developed, existing programs may be discontinued, adapted, or amalgamated, and new research trials could support or refute the efficacy of these programs.
It should also be noted that programs were evaluated from the perspective of a researcher and not of an end-user. A person with depression, for example, may have different opinions regarding the usability and quality of the identified programs. The intended end-user would likely provide developers with a more subjective opinion. Programs may also be biased to the type of user they capture, that is, individuals with less severe forms of depression. Individuals suffering from more severe forms of depression may face greater decreases in motivation and are less likely to access and participate in an intervention program. Consequently, users with severe forms of depression may be underrepresented in RCTs and in collected user feedback and data. Feedback is necessary to facilitate change as well as outline likes and dislikes for various features. Overall, end-user input should be sought as it is crucial to improving treatment delivery and program functionality.
At this time, there are few programs available for special populations (eg, caregivers, individuals with cognitive deficits, older adults). It is important that program functionality accommodate accessibility of varying populations to ensure adequate treatment is delivered. Studies investigating the needs of these special populations could inform the development of new programs and the adaptation of existing ones. Future programs could also aim for increased accessibility. This could entail multilanguage delivery, elimination of residency restrictions, elimination of registration fees or referrals, flexibility in module timing, and minimization of mandatory user response (eg, mandatory worksheets and mood assessments).
With respect to research, although the minority of the identified programs were evidence-based as defined by the presence of at least one evaluative RCT, the trials that have been completed to date have been generally of strong quality with adequate sample sizes [
In this review, we identified 27 websites offering 32 programs with interactive components aimed at reducing symptoms of depression among users. The programs varied widely in terms of content, accessibility, usability, method of delivery (eg, text, audio, or video), and supplementary tools. A minority of the programs identified had empiric evidence to support their efficacy for the treatment of depressive symptoms.
In choosing to use or refer a Web-based treatment program for depression, the user may wish to consider the following factors: ease of use and accessibility, availability of additional features and support needs, and most critically, programs that have been validated with good quality research. Users are encouraged to critically evaluate their program choice and should investigate research supporting program claims.
Web-delivered interventions afford many potential advantages to individuals. Users can log on to their preferred program in the comfort of their own home 24 hours a day, 365 days a year. This may help to increase accessibility, reduce prolonged wait times, and address privacy concerns. Furthermore, it is potentially cost-efficient and convenient, allowing users to seek treatment when desired. Developers should continue to create such programs and tailor additional sites to the needs of specialty groups.
Search log.
Accessibility of the programs evaluated.
Program evaluation log.
Randomized controlled trial citations for evidence-based programs.
Program screenshots.
cognitive behavioral therapy
evidence-based program
interpersonal therapy
non-evidence-based program
randomized controlled trial
Authors wish to thank Karthik Natarajan for his additional support conducting searches and program evaluations. We also wish to thank Herman Tang for generously providing us a cover graphic reflective of the manuscript topic.
None declared.