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We recently showed in a randomized controlled trial that Web-based self-help as an adjunct improved the effectiveness of multimodal inpatient psychotherapy for depression.
The aims of this study were (1) to determine whether a Web-based self-help adjunctive to multimodal inpatient psychotherapeutic treatment could also improve the course of depressive symptoms and (2) to identify predictors of residual depressive symptoms at follow-up.
Overall, 229 patients were randomized either to the Web-based self-help intervention group (Deprexis) or an active control group (Web-based information about depression and depressive symptoms) in addition to multimodal inpatient psychotherapy. Participants in both groups were able to access their respective Web-based programs for 12 weeks, which meant that they typically had access after discharge from the inpatient unit (mean hospitalization duration: 40 days, T1). Follow-up was performed 6 months after study intake (T3).
At follow-up, participants of the Web-based self-help group had considerably lower symptom load regarding depressive symptoms (
Web-based self-help as an add-on to multimodal inpatient psychotherapy improved the short-term course of depressive symptoms beyond termination. Residual symptoms at discharge from inpatient treatment and utilization of the Web-based self-help were the major predictors of depressive symptoms at follow-up. Challenges and barriers (eg, costs, therapists’ concerns, or technical barriers) of adding Web-based interventions to inpatient treatment have to be addressed.
ClinicalTrials.gov NCT02196896; https://clinicaltrials.gov/ct2/show/NCT02196896.
Depression has been recognized as one of the leading health problems with a 12-month prevalence of 6.9% [
Deprexis is an interactive Web-based self-help program [
However, the challenge has remained how to integrate Web-based treatments into regular care [
In blended treatments, face-to-face interventions are combined with Web-based or mobile-based interventions and integrated in 1 treatment scheme [
Inpatient psychotherapy is indicated in severe, chronic and complex cases of depression, compounded by mental or somatic comorbid conditions according to German medical guidelines (DGPPN 2015) [
In an RCT with 229 depression inpatients [
The aim of this study was to determine whether the add-on of a Web-based self-help program to multimodal inpatient treatment of depressed patients also improves stability of remission and test postulated predictors of residual depression [
From July 2014 to February 2016, patients have been recruited in the Psychosomatic Clinic in Bad Neustadt/Saale, Germany. Eligible patients were aged between 18 to 65 years, had private internet access, sufficient German language skills, a score in the BDI-II above 13, and a clinical diagnosis of depression (International Statistical Classification of Diseases and Related Health Problems 10th revision: F32.x, F33.x, F34.1, and F43.2). Patients were excluded if a diagnosis of (1) psychosis (F20-F29); (2) current alcohol or drug addiction (F10-F19); (3) borderline (F60.3), antisocial (F60.2), schizoid (F60.1), and schizotypal (F21) personality disorders; (4) anorexia nervosa (F50.0); and (5) lifetime diagnoses of schizophrenia (F20-F29), schizoaffective (F25), bipolar (F31), or organic (F00-F09) mental disorder was present.
Eligible patients received oral and written information about the study and its requirements as part of a weekly information session. Therapists were introduced to the rationale of the intervention but had no active part in 1 of the add-on treatments.
After signing written informed consent, participants were coded and randomized to one of the groups (intervention group vs control group). Procedure and study protocol were conducted in accordance with the declaration of Helsinki and approved by the ethics committee of the Statutory Physician Board of the State of Rhineland Palatinate (Ref No 837.093.14 [9332-F]). The trial protocol was published elsewhere [
As described in more detail in the study by Zwerenz et al [
Participants were predominantly female (60.7%; 139/229) and had a mean age of 48 years (SD 9.79), ranging from 18 to 65 years. About half of the participants were married (50.2%; 115/229), graduated from middle or higher secondary level (58.1%; 133/229), and worked full-time (47.6%; 109/229), with 56.3% (129/229) being on sick leave at study intake. Mean inpatient treatment duration was 40 days (range 11-78; SD 7.51), with no difference between intervention group (mean 41, SD 7.43) and control group (mean 40, SD 7.58). Previous psychopharmacological and psychotherapeutic treatments were comparable in the intervention group and control group as well as the status of antidepressant medication during inpatient treatment [
In the Psychosomatic Clinic Bad Neustadt, multimodal inpatient psychodynamic psychotherapy entails individual and group psychotherapy, creative psychotherapy interventions, and adjunct treatments such as patient education and exercising. Insight-oriented group therapy was combined with nonverbal treatment methods, that is, body therapy to address difficulties in emotion modulation, interpersonal problems, core beliefs about oneself, deficits in self-esteem, and self-care that contributed to the depressive symptoms. In addition to multimodal inpatient psychodynamic psychotherapy, participants of the intervention group got access to the Web-based self-help program Deprexis for 12 weeks. It consists of 10 main modules plus an introductory and a summary module based on cognitive behavioral techniques, positive psychology, emotion-focused therapy, and dream work (for details, cf. Meyer et al [
For participants of the control group, an internet platform was accessible in addition to the inpatient psychotherapy (TAU), consisting of 12 weekly modules with specific topics regarding depression, for example, information on depressive disorders, treatment options (psychotherapeutic and medication), efficacy of different treatments, and prognostic factors. This information was mainly based on the official treatment guidelines for major depression in Germany [
In addition to sociodemographic variables and relevant treatment data (ie, previous treatment, diagnosis, medication, treatment duration, etc), standardized questionnaires were used. Primary and secondary outcome measures were collected by self-report using the Web-based survey platform SoSci Survey (SoSci Survey GmbH [
Depressive symptoms, our primary study outcome measured by the BDI-II [
Secondary outcomes were assessed by well-established, reliable, and valid measures. Depressive symptoms were additionally measured with the Patient Health Questionnaire-9 (PHQ-9 [
All analyses were performed on the basis of intention to treat. To replace missing values, we used a Markov Chain Monte Carlo multivariate imputation algorithm with IBM SPSS Statistics 23 and 5 imputations, 10 estimations per missing value, and a constraint of a maximum of 60% missing data.
Outcome measures were evaluated in both conditions by analyses of covariance with baseline scores as covariate. Remission rates, significant reliable change [
As described in the study protocol [
As delineated in the study by Zwerenz et al [
At follow-up (T3), intervention group and control group significantly improved regarding depressive symptoms assessed with the BDI-II (
Descriptive statistics of primary and secondary outcomes at 6-month follow-up (T3) of intervention (N=108) and control group (N=107), compared with study admission (T0).
Outcome criteria | Baseline (T0a), mean (SD) | Follow-Up (T3b), meanc (SD) | |
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IGe | 30.63 (9.39) | 18.52 (10.78) |
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CGf | 29.46 (9.50) | 24.75 (10.74) |
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IG | 14.86 (4.88) | 10.37 (5.54) |
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CG | 14.30 (5.23) | 13.13 (5.70) |
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IG | 11.59 (4.28) | 8.24 (4.68) |
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CG | 11.57 (5.08) | 10.38 (4.68) |
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IG | 1.62 (0.57) | 2.13 (0.68) |
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CG | 1.68 (0.59) | 1.84 (0.66) |
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IG | 15.11 (6.68) | 17.78 (6.60) |
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CG | 15.40 (6.80) | 15.75 (6.60) |
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IG | 149.96 (37.05) | 139.78 (34.26) |
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CG | 158.42 (38.26) | 145.82 (34.78) |
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IG | 25.41 (2.87) | 26.47 (3.73) |
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CG | 25.28 (2.60) | 26.30 (4.55) |
aT0: allocation to intervention (baseline).
bT3: follow-up 6 months after baseline.
cEstimated means.
dBDI-II: Beck Depression Inventory.
eIG: intervention group.
fCG: control group.
gPHQ-9: Patient Health Questionnaire-9.
hGAD-7: Generalized Anxiety Disorder-7.
iEUROHIS: European Health Interview Survey.
jRSE: Rosenberg Self-Esteem Scale.
kDAS: Dysfunctional Attitude Scale.
lWAI: Work Ability Index.
Primary outcome (BDI-II) in the course of time. BDI-II: Beck Depression Inventory II; CG: control group; IG: intervention group; T0: allocation to intervention (baseline); T3: follow-up 6 months after baseline.
There were no significant differences at baseline (T0) between intervention group and control group for any of the secondary outcome measures. A lower symptom load at follow-up (T3) in the intervention group in comparison with the control group could also be observed for the secondary outcomes. Analyses revealed statistically significant between group differences and low-to-moderate effect sizes for depressive symptoms assessed with the PHQ-9 (
Between-group and within-group comparisons for primary and secondary outcomes.
Outcome criteria | T3a | T0b-T3 | |||||
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Between-group comparisonsc | Within-group comparisonsd | |||||
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18.87 (1,212) | <.001 | 0.58 | —g | — | — | |
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IGh | — | — | — | 10.21 (1665); 0.42 | <.001 | 1.06 |
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CGi | — | — | — | 4.94 (1671); 0.57 | <.001 | 0.44 |
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13.733 (1,212) | <.001 | 0.49 | — | — | — | |
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IG | — | — | — | 7.488 (13863); 0.38 | <.001 | 0.80 |
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CG | — | — | — | 2.136 (1088); 0.42 | <.001 | 0.23 |
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12.802 (1,212) | <.001 | 0.46 | — | — | — | |
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IG | — | — | — | 6.497 (6851); 0.39 | <.001 | 0.69 |
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CG | — | — | — | 2.252 (19067); 0.38 | <.001 | 0.24 |
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9.557 (1,212) | <.001 | 0.43 | — | — | — | |
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IG | — | — | — | 6.895 (1095); 0.43 | <.001 | 0.71 |
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CG | — | — | — | 2.488 (866); 0.48 | <.001 | 0.25 |
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5.427 (1,212) | .02 | 0.31 | — | — | — | |
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IG | — | — | — | 3.585 (7165); 0.44 | <.001 | 0.37 |
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CG | — | — | — | 0.589 (4437), 0.45 | .55 | 0.06 |
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0.955 (1,212) | .34 | 0.18 | — | — | — | |
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IG | — | — | — | 3.917 (34211); 0.62 | <.001 | 0.33 |
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CG | — | — | — | 2.558 (7731); 0.52 | .01 | 0.24 |
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0.676 (1,212) | .45 | 0.04 | — | — | — | |
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IG | — | — | — | 2.558 (99); 0.22 | .01 | 0.31 |
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CG | — | — | — | 1.948 (31); 0.04 | .06 | 0.26 |
aT3: Follow-up 6 months after baseline.
bT0: Allocation to intervention (baseline).
cAnalyses of covariance with baseline as covariate.
dPaired samples
eLevel of significance .05.
fBDI-II: Beck Depression Inventory II.
gNot applicable.
hIG: intervention group.
iCG: control group.
jPHQ-9: Patient Health Questionnaire-9.
kGAD-7: Generalized Anxiety Disorde-7.
lEUROHIS: European Health Interview Survey.
mRSE: Rosenberg Self-Esteem Scale.
nDAS: Dysfunctional Attitude Scale.
oWAI: Work Ability Index.
Comparisons between intervention group and control group are shown in
Recovery, improvement, and deterioration in the course of time. BDI-II: Beck Depression Inventory II; CG: control group; IG: intervention group; T1: discharge; T2: end of intervention; T3: follow-up 6 months after baseline.
Following the study protocol, multivariate analyses were performed to test the effects of postulated predictors on depressive symptoms at follow-up 6 months later (T3). These were depressive symptoms at study intake and at discharge, utilization of other treatments at follow-up, childhood trauma, and structural characteristics. GLM (R²=0.688;
Predictors of depressive symptoms at 6-month follow-up (T3) based on generalized linear model (N=200).
Predictors |
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Age | 0.460 (1) | .25 | 0.004 |
Sex | 0.316 (1) | .28 | 0.003 |
CTQc at T0d | 0.991 (1) | .16 | 0.008 |
OPD-SFKe at T0 | 0.454 (1) | .25 | 0.004 |
Utilization of other treatments at follow-up | 0.294 (1) | .30 | 0.002 |
BDI-IIf at T0 | 1.285 (1) | .26 | 0.011 |
BDI-II at T1g | 2.630 (46) | <.001 | 0.506 |
Group | 3.243 (1) | .04 | 0.027 |
BDI-II at T1 X Group | 1.267 (28) | .10 | 0.231 |
aLevel of significance .05, 1-tailed test.
bPartial eta square.
cCTQ: Childhood Trauma Questionnaire.
dT0: Study admission (baseline).
eOPD-SFK: Operationalized Psychodynamic Diagnosis.
fBDI-II: Beck Depression Inventory.
gT1: Discharge of inpatient treatment.
Following our first publication to the efficacy of Deprexis offered as an add-on to inpatient psychotherapy [
Additional and moderate improvements were found in Deprexis compared with the control group regarding the PHQ-9 measure of depressive symptoms, generalized anxiety (GAD-7), and quality of life (EUROHIS-QOL), all of which also improved in the control group. Self-esteem (RSE) only improved moderately in the intervention group but not the control group. Dysfunctional attitudes (DAS) improved in both groups, whereas WAI was significant in the intervention (trend in the control group), and there were no differential benefits.
Consistent with previous studies [
Inpatient treatment usually applies to complex cases of depression with different mental and somatic comorbidities [
The high effects of our adjunct to inpatient multimodal psychotherapy are consistent with a recent review, in which evidence was shown that Web-based interventions are efficacious for maintaining treatment gains and prevent relapse [
In view of chronic trajectories of depressive symptoms, the short follow-up interval of about 3 months (mean 96.59 days, SD 20.21 days) following termination of the program must be considered a drawback. However, our data underline that even the brief time period of the first months after discharge sets the stage for deterioration for many patients—notwithstanding continued outpatient care. Although the study raises important economic issues, health economic data were not collected. Another limitation is that we mainly relied on self-reports and have no clinical diagnostics after discharge from inpatient treatment. Furthermore, we do not know exactly what kind of treatment and what treatment intensity patients received after discharge from the hospital and of course this could have an influence on the course of depressive symptoms. But after all, we could control for the 1 item that asked if any kind of treatment followed inpatient treatment (yes/no), which was not a significant predictor of depressive symptoms at follow-up.
Although the Web-based self-help program Deprexis has been demonstrated to be efficacious [
Tapping into self-help resources of patients by adding Web-based self-help is a promising way to improve long-term outcomes. There is a need for more studies, but if other studies also conclude that Web-based interventions as an add-on or blended treatment are effective, the challenge will be to implement them in the health care system so that reimbursement is possible. An ongoing development, regular updating, and securing of the latest technical standards are associated with corresponding costs. Therefore, it must be investigated who can bear these costs and how much they are. However, if that succeeds, efficacious Web-based interventions could be implemented on a broader basis to improve the benefits and sustainability of face-to-face treatments.
Beck Depression Inventory-II
Dysfunctional Attitude Scale
European Health Interview Survey Quality of Life 8-Item Index
generalized anxiety disorder-7
generalized linear model
number needed to treat
Patient Health Questionnaire-9
Reliable Change Index
randomized controlled trial
Rosenberg Self-Esteem Scale
Treatment as Usual
Work Ability Index
The authors are grateful to all the participating patients and the staff in the cooperating clinic for their support in patient recruitment without whom this study would not be possible (in alphabetical order), especially Johanna Kraus, Dipl-Sozpäd Annerose Vorndran, Dipl-Sozpäd Hiltrud Zajac, as well as our student research assistants Svenja Bidmon (BSc Psych), Tanja Darwiesh (MSc Psych), and Hanna Merz (BSc Psych). The study was funded by Rhön-Klinikum AG Bad Neustadt/Saale.
MEB and RZ did the first draft of the manuscript. RZ, CB, AT, JB, and MS did the final draft of the manuscript and revised it critically for its intellectual content. RZ, JB, MS, RJK, and MEB substantially contributed to the conception and the design of the study. All authors read and approved the final manuscript.
None declared.