This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.
This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.
The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.
IPDT was significantly more effective than the control condition in reducing depression (
IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.
International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254
According to the World Health Organization [
Internet-based interventions may address some of the barriers to seeking and receiving treatment. For example, people living in rural areas may access care in their home rather than travelling potentially long distances to services [
To date, the literature on internet-based treatments for adolescent depression is lagging behind the research on adult populations [
One such treatment alternative is psychodynamic psychotherapy (PDT). Albeit not as extensively researched as cognitive behavioral therapy (CBT), several meta-analyses support the efficacy of PDT as a treatment for adults suffering from psychopathology [
Thus, this RCT aimed to evaluate a newly developed, affect-focused IPDT program for adolescent depression. The treatment was given as a guided self-help program with therapist support and weekly chat sessions and was compared to a control condition in which participants were given online therapist support. It was hypothesized that the treatment would be significantly more effective than the control condition for depression as well as for secondary outcomes, such as anxiety, emotion regulation, and self-compassion. Furthermore, treatment effects on depression and anxiety were investigated at a 6-month follow-up after treatment completion. As this was a trial of a newly developed treatment, acceptability and attitudes toward the treatment were also investigated.
This study was carried out in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement for clinical trials [
Adolescents were recruited via social media as well as through information via schools, youth centers, youth mental health care providers, and other similar locations during January and February 2019. Eligibility criteria were being aged 15-18 years; fulfilling a diagnosis of unipolar major depressive disorder according to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria, as established by scoring at least 10 points on the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR) [
Potential participants were directed to a study website with information about the project and online registration. Informed consent was given upon registration. After applying for the study, participants were given access to an online screening survey consisting of demographic questions as well as online versions of the screening and outcome measures. If initial inclusion criteria were met (ie, scoring ≥10 on the QIDS-A17-SR and not meeting any of the exclusion criteria), participants were contacted within the following few days for a diagnostic interview (ie, MINI 7.0) over the phone with study therapists or clinical psychologists in the research group. During this interview, each participant’s identity was confirmed through full name, social security number, and address. If the interview confirmed a current major depressive episode and no exclusion criteria were fulfilled, patients were included. All cases were discussed with the principal investigator and coordinators of the study as well as with a senior psychiatrist to determine inclusion or exclusion. Included participants were randomized to either the treatment or control condition in a 1:1 ratio, the process of which was conducted by an independent researcher using an online randomization tool [
CONSORT (Consolidated Standards of Reporting Trials) flowchart. IPDT: internet-based psychodynamic therapy; ITT: intention-to-treat.
The IPDT intervention consisted of eight therapist-supported self-help modules delivered over 8 weeks on a secure online platform [
The IPDT program was developed specifically for this project (by the first and second author) and was based on similar principles as a treatment program with efficacy for adults in several RCTs (eg, Johansson et al [
Malan's (1979) triangle of conflict.
Module 1: Introducing theory on the interplay between basic emotions and attachment. Emphasis lies on how attachment needs are given priority above our emotions, thus leading to affect phobias (illustrated using the “triangle of conflict”).
Module 2: Superego, shame, and self-compassion. Focus on building the capacity for self-observation and differentiating between old habits of self-neglect and self-criticizing versus more healthy parts of the ego.
Module 3: Differentiation between optimal and too-high levels of anxiety. Anxiety regulation through an increased capacity for self-observation and breathing exercises.
Module 4: Affect theory and the visceral experience of affect. Exposure to warded-off feelings through an expressive writing exercise.
Module 5: Identifying and understanding defensive patterns. Identifying different defensive maneuvers and the long-term negative consequences connected to them.
Module 6: Especially problematic feelings: anger, sadness, and guilt. Mixed and complex emotions. How to notice, accept, and experience them viscerally.
Module 7: Interpersonal patterns of relatedness and self-definition. Identifying one’s predominant relationship patterns according to Sidney Blatt’s theory on anaclitic and introjective polarities of personality [
Module 8: Communicating and expressing affects appropriately and identifying and repairing relationship ruptures. Moving forward and maintaining gains.
The control condition consisted of supportive contact over the internet with weekly monitoring of symptoms and well-being. Each week, participants were contacted with a text message by their personally assigned therapist—both licensed clinical psychologists (JM and KL)—typically containing questions regarding their well-being during the previous week. All messages from participants were responded to, typically within 24 hours. Participants could also contact their therapist at any time via the integrated message system on the platform. Therapists provided basic support, expressed empathy and validated emotions and experiences, and encouraged participants to describe and discuss distressing life events but used no psychotherapeutic techniques or interventions. Participants who expressed suicidality, either in weekly ratings or verbally through text, were immediately contacted via phone or text message for an in-depth assessment and were offered appropriate support.
The control condition did not include any treatment material or chat sessions. After 10 weeks, participants in the control condition were offered the IPDT program without chat sessions (not presented in this study).
A total of 11 therapists were included in the project and were either licensed psychologists (n=2) or students of clinical psychology in the last semesters of their psychologist training (n=9). All therapists had chosen to specialize in PDT for their clinical training and, thus, had taken courses in PDT theory and practice. Student therapists received a 1-day training by the treatment developers (JM and KL) and treated the majority of participants in the treatment (n=32). All therapists were supervised in group (n = 5-6) during 90-minute weekly sessions by an experienced psychotherapist (PL) specialized in experiential psychodynamic psychotherapies.
Psychiatric diagnoses at inclusion were assessed during telephone interviews using the MINI 7.0 [
The diagnostic interviews were conducted by licensed psychologists (n=3) from the research team as well as psychology students (n=3) who received training in both the MINI 7.0 and the C-SSRS.
The primary outcome was self-reported depressive symptoms, measured with the QIDS-A17-SR, a reliable self-rated measure of depressive symptoms validated for both adults and adolescents [
Secondary outcomes were measured using the Generalized Anxiety Disorder 7-item scale (GAD-7) [
Sample size was determined a priori based on an expected between-group effect size of
Since the primary outcome was measured weekly within subjects, we applied multilevel modeling (MLM) [
For all secondary outcome measures, missing data at posttreatment (n=3) were addressed using multiple imputation in R, version 1.7 (The R Foundation), packages Mice [
Between-group effect size for the primary outcome was calculated using model-estimated means at posttreatment and the observed pretreatment sample SD, as recommended by Feingold [
Response to treatment was calculated using the Reliable Change Index (RCI) [
A total of 76 participants were included in the study (IPDT 38/76, 50%; control 38/76, 50%). Out of 76 participants, 61 (80%) were female and the sample had a mean age of 16.6 years (SD 1.1). A total of 4 participants randomized to IPDT never entered treatment, meaning that they never participated in any of the exercises or chat sessions and had no contact with the therapist, except in 2 cases to say that they wanted to drop out. A total of 3 of these participants never opened the initial study message, meaning that they dropped out without knowing their allocation (ie, treatment or control). These 4 nonstarters were still included in the ITT analysis for the primary outcome measure, but not for the secondary outcome measures.
Patients’ characteristics for the full ITT sample are presented in
Demographic data at baselinea.
Characteristic | IPDTb group (n=38) | Control group (n=38) | |
|
|
|
|
|
Female | 31 (82) | 30 (79) |
|
Uncertain or other | 4 (11) | 0 (0) |
Age (years), mean (SD) | 16.6 (1.11) | 16.5 (1.13) | |
|
|
|
|
|
Major depressive disorderc | 38 (100) | 38 (100) |
|
Any anxiety disorderc | 22 (58) | 23 (62) |
|
Posttraumatic stress disorderc | 4 (11) | 1 (3) |
|
Eating disorderc,d | 2 (5) | 1 (3) |
|
|
|
|
|
Ever | 20 (53) | 10 (26) |
|
Current | 9 (24) | 4 (11) |
Currently on psychotropic medication, n (%) | 2 (5) | 2 (5) |
aThere were no significant between-group differences on any of the data at baseline.
bIPDT: internet-based psychodynamic therapy.
cConfirmed by the Mini International Neuropsychiatric Interview 7.0 (MINI 7.0).
dBulimia nervosa and binge-eating disorder.
Fixed-effect estimates from our MLM analysis for QIDS-A17-SR are displayed in
The ANCOVAs revealed that improvements on all secondary measures were significantly greater in the treatment group. Detailed results and effect sizes are presented in
Multilevel models estimating changes over time in the primary outcome measure, QIDS-A17-SRa.
Model estimates | Estimate | 95% CI | ||
|
|
|
|
|
|
Intercept | 15.62 | 14.57 to 16.68 | <.001 |
|
IPDTb | –0.32 | –1.76 to 1.13 | .67 |
|
|
|
|
|
|
Slope | –0.73 | –1.01 to –0.46 | <.001 |
|
Time × time | 0.05 | 0.02 to 0.07 | <.001 |
|
IPDT versus control | –0.29 | –0.51 to –0.07 | .01 |
|
|
|
|
|
|
Residual variance | 6.10 | 5.40 to 6.89 | <.001 |
|
Intercept | 7.61 | 5.04 to 11.50 | <.001 |
|
Slope | 0.13 | 0.08 to 0.23 | <.001 |
|
Correlation | –0.05 | –0.29 to 0.38 | .78 |
Between-group effect size (Cohen |
0.82 | 0.35 to 1.29 |
|
aQIDS-A17-SR: Quick Inventory of Depressive Symptomatology for Adolescents.
bIPDT: internet-based psychodynamic therapy.
Weekly mean scores on the QIDS-A17-SR (Quick Inventory of Depressive Symptomatology for Adolescents). IPDT: internet-based psychodynamic therapy.
Secondary outcome results.
Measure | Pretreatment, mean (SD) | Posttreatment, mean (SD) | Follow-up, mean (SD) | Posttreatment, between-group Cohen |
||
|
|
|
|
|
|
|
|
IPDTb | 24.97 (7.06) | 18.97 (7.53) | N/Ac | 0.80 (0.32-1.28) | <.001 |
|
Controld | 26.21 (6.93) | 25.84 (8.51) |
|
|
|
|
|
|
|
|
|
|
|
IPDT | 12.35 (4.11) | 8.18 (4.62) | 8.41 (5.54) | 0.78 (0.30-1.26) | <.001 |
|
Control | 10.45 (3.88) | 10.42 (4.65) |
|
|
|
|
|
|
|
|
|
|
|
IPDT | 55.44 (12.12) | 41.53 (14.47) | N/A | 0.97 (0.48-1.46) | <.001 |
|
Control | 56.42 (10.64) | 53.0 (14.41) |
|
|
|
|
|
|
|
|
|
|
|
IPDT | 25.91 (5.68) | 31.06 (7.31) | N/A | 0.65 (0.18-1.12) | .003 |
|
Control | 26.87 (5.65) | 27.08 (7.69) |
|
|
|
aMADRS-S: Montgomery Åsberg Depression Rating Scale–self-rated.
bIPDT: internet-based psychodynamic therapy, n=34.
cNot applicable.
dControl, n=38.
eGAD-7: Generalized Anxiety Disorder 7-item scale.
fDERS: Difficulties in Emotion Regulation Scale.
gSCS-SF: Self-Compassion Scale short-form.
In all analyses of response and remission rates, missing cases (n=2, 1 in each group) were categorized as not improved. Using fulfillment of RCI and scoring 2 SDs below the pretreatment mean as criteria for response, 56% (19/34) of the treatment group compared to 21% (8/38) of the control group were categorized as responders. There was a significant difference between the groups in favor of the treatment group (χ24=10.9,
Follow-up assessments at 6 months posttreatment were conducted using the QIDS-A17-SR and GAD-7. Data were obtained from all participants who entered the treatment (n=34). Pairwise
Posttreatment QIDS-A17-SR scores and an open-ended question concerning negative effects [
When responding to the open-ended question regarding negative effects, the vast majority did not report any (28/34, 82%). Out of 34 participants, 1 (3%) participant described that online text-based interactions were not optimal due to feelings of loneliness, and another participant (3%) described increased awareness of feelings of anger and that this was painful and distressing in the short term; however, the same participant then described the mastery of these angry feelings gained through the treatment as positive in the long term. Out of 34 participants, 2 (6%) described feelings of distress in connection with facing previously avoided thoughts and feelings, and 2 (6%) participants found the treatment format stressful; 1 (3%) of these participants also described feelings of shame in connection with not completing exercises on time. Thus, 6 patients in total out of 34 (18%) reported negative effects of the treatment. No serious adverse events were reported during the trial.
Of the 34 participants that entered treatment, 4 (12%) dropped out of treatment, meaning that they stopped opening modules, attending chat sessions, or responding to messages before week 7. The completion of modules was defined as completing at least one exercise in the module. The mean number of completed modules was 5.8 (SD 2.4) of the 8 that were available. Excluding the 4 dropouts, the mean number was 6.2 (SD 1.9) and the median was 7. The mean number of chat sessions attended was 6.6 (SD 2.1) of the 8 available. Excluding the 4 dropouts, the mean number of chat sessions attended was 7.1 (SD 1.4). Of the 34 participants, 1 (3%) who did not drop out completed zero modules but continued attending chat sessions throughout the treatment period. Spearman correlations showed no dose-response relationship.
This RCT aimed to evaluate an affect-focused psychodynamic internet-based treatment for depression in a sample of adolescents (15-18 years of age). The results indicated that the IPDT treatment was effective in reducing depression and anxiety, as well as in enhancing emotion regulation and self-compassion, compared to a supportive contact control condition. Results indicated that the treatment facilitated clinically significant changes [
Between-group effect sizes were similar to those found in previous trials on IPDT targeting adult psychopathology [
Although some of the more classical ingredients of psychodynamic therapy are lost in the translation to a guided self-help program, being significantly more directive and not including transference work to the same extent, the treatment is clearly based on a psychodynamic model. This is an important point since this distinguishes the treatment from ones that have been previously developed and assessed for adolescent depression. The model for understanding depression, which was also presented to the participants, is the triangle of conflict [
This study did not comprise an evaluation of adding synchronous chat sessions to the standard guided self-help format, so it is not possible to separate out the impact of each element to the overall effectiveness of the intervention. However, some aspect of the positive results may be related to the text-chat component, as it might have increased motivation and hence continued participation in the treatment. In order to minimize the workload, therapists were permitted to have two parallel chat sessions at the same time. The added value of synchronous chat sessions is an area for further research in the future.
While the chat sessions make the treatment format more time-consuming compared to internet-based interventions targeting adult depression, it is comparable to some other internet-based treatment protocols targeting adolescents [
The sample of the study is predominantly female. This is in line with other psychotherapy trials on face-to-face treatment (eg, Abbass et al [
Apart from the randomized design, a considerable strength is that a “pure” wait list was not used [
Limitations of the study include the fact that no diagnostic interviews were conducted after the treatment and that 6-month follow-up data were only collected for two of the outcome measures. The reason for this was to avoid burdening the young people with too many measures and interviews, as it might have heightened the risk of missing data. Therefore, the most relevant instruments were prioritized for both postassessment and follow-up measurements. Also, although all interviewers were trained in the application of the MINI 7.0 and the C-SSRS, no measures of interrater reliability were conducted as interviews were not recorded. All measures in the study have been validated in adolescent populations and official translations were used. However, except for the MADRS-S [
This RCT’s results provide preliminary support for affect-focused IPDT for adolescent depression. This study furthers the evidence that psychodynamic models can be translated into internet-based treatments and strengthens the evidence for the effectiveness of psychodynamic treatments in general.
Future research could aim to explore whether this treatment, in an adapted format, would be suitable for a transdiagnostic sample or to target adolescent anxiety. This study is preceding a noninferiority trial comparing IPDT to the already-proven effective ICBT program for depression in adolescents [
CONSORT eHEALTH checklist (V 1.6.1).
analysis of covariance
cognitive behavioral therapy
Consolidated Standards of Reporting Trials
Columbia-Suicide Severity Rating Scale
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Generalized Anxiety Disorder 7-item scale
internet-based cognitive behavioral therapy
internet-based psychodynamic therapy
International Standard Randomised Controlled Trial Number
intention-to-treat
Montgomery Åsberg Depression Rating Scale–self-rated
Mini International Neuropsychiatric Interview 7.0
Mini International Neuropsychiatric Interview for Children and Adolescents
multilevel modelling
psychodynamic psychotherapy
Quick Inventory of Depressive Symptomatology for Adolescents
Reliable Change Index
randomized controlled trial
selective serotonin reuptake inhibitor
This research is supported by the Kavli Trust. We thank the participating adolescents, and the study therapists: Anna Carrascosa Molin, Henrik Hallberg, Isak Jansmyr, Pontus Kinnmark, Therese Lindgren, Charlotta Olerud, Per-Åke Olsson, Katarina Streberg Carstorp, and Fredrik Strid. We also thank George Vlaescu for platform development and support and Anna Steen, MD, for psychiatric consultations.
None declared.