Effectiveness of a Web-Based Cognitive-Behavioral Tool to Improve Mental Well-Being in the General Population: Randomized Controlled Trial

Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom. .
Journal of Medical Internet Research (Impact Factor: 3.43). 11/2012; 15(1):e2. DOI: 10.2196/jmir.2240
Source: PubMed


Interventions to promote mental well-being can bring benefits to the individual and to society. The Internet can facilitate the large-scale and low-cost delivery of individually targeted health promoting interventions.
To evaluate the effectiveness of a self-directed Internet-delivered cognitive-behavioral skills training tool in improving mental well-being in a population sample.
This was a randomized trial with a waiting-list control. Using advertisements on a national health portal and through its mailing list, we recruited 3070 participants aged 18 or over, resident in England, and willing to give their email address and access a fully automated Web-based intervention. The intervention (MoodGYM) consisted of 5 interactive modules that teach cognitive-behavioral principles. Participants in the intervention arm received weekly email reminders to access the intervention. The control group received access to the intervention after the trial was completed and received no specific intervention or email reminders. Outcomes were assessed by using self-completion questionnaires. The primary outcome was mental well-being measured with the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes were Center for Epidemiologic Studies Depression scale (CES-D) depression scores, Generalized Anxiety Disorder 7-item scale (GAD-7) anxiety scores, EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) quality of life scores, physical activity, and health service use. All outcomes were measured at baseline, and at 6- and 12-week follow-ups.
A total of 1529 (49.80%) participants completed final follow-up at 12 weeks. Retention was 73.11% (1123/1536) in the control arm and 26.47% (406/1534) in the intervention arm. No relationship between baseline measures and withdrawal could be established. The analysis of WEMWBS mental well-being scores using a linear mixed model for repeated measures showed no difference between intervention and control group at baseline (difference -0.124 points, 95% CI -0.814 to 0.566), and significant improvements for the intervention group at 6 weeks (2.542 points, 95% CI 1.693-3.390) and at 12 weeks (2.876 points, 95% CI 1.933-3.819). The model showed a highly significant (P<.001) intervention by time interaction effect. There were also significant improvements in self-rated scores of depression and anxiety. Given the high level of attrition, a sensitivity analysis with imputed missing values was undertaken that also showed a significant positive effect of the intervention.
Participants allocated to the intervention arm had an average increase of approximately 3 points on the WEMWBS scale compared to no increase for participants in the control group. Three points on this scale is approximately one-third of a standard deviation. In a low-cost automated intervention designed to shift the population distribution of mental well-being, a small difference per individual could yield a major benefit in population terms. In common with other Web-based interventions, there were high rates of attrition. Further work is needed to improve acceptability, to evaluate against placebo effect, and to disaggregate the effect on mental well-being from the effect on depression and anxiety.
International Standard Randomised Controlled Trial Number Register ISRCTN 48134476; (Archived by WebCite® at

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    • "There is some emerging evidence that e-health technologies may be able to assist in meeting some of these practical challenges [57]. Internet-based CBT has been shown to be effective as a treatment for depression and anxiety and is able to enhance mental well-being in a community setting [58,59]. While there are some early indications that computer-aided interventions are well received in the workplace [55], the effectiveness of universal work-based e-health prevention strategies remains unknown. "
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    ABSTRACT: Background Depression is a major public health problem among working-age adults. The workplace is potentially an important location for interventions aimed at preventing the development of depression, but to date, the mental health impact of universal interventions in the workplace has been unclear. Method A systematic search was conducted in relevant databases to identify randomized controlled trials of workplace interventions aimed at universal prevention of depression. The quality of studies was assessed using the Downs and Black checklist. A meta-analysis was performed using results from studies of adequate methodological quality, with pooled effect size estimates obtained from a random effects model. Results Nine workplace-based randomized controlled trials (RCT) were identified. The majority of the included studies utilized cognitive behavioral therapy (CBT) techniques. The overall standardized mean difference (SMD) between the intervention and control groups was 0.16 (95% confidence interval (CI): 0.07, 0.24, P = 0.0002), indicating a small positive effect. A separate analysis using only CBT-based interventions yielded a significant SMD of 0.12 (95% CI: 0.02, 0.22, P = 0.01). Conclusions There is good quality evidence that universally delivered workplace mental health interventions can reduce the level of depression symptoms among workers. There is more evidence for the effectiveness of CBT-based programs than other interventions. Evidence-based workplace interventions should be a key component of efforts to prevent the development of depression among adults.
    Full-text · Article · Dec 2014 · BMC Medicine
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    • "). The scalability and cost-effectiveness of unsupported interventions allow them to be both evaluated in and distributed to populations that do not usually participate in randomized trials, such as individuals with sub-syndromal symptoms (Powell et al., 2013). Thus, although interventions that are supported/guided by a clinician or a coach may yield somewhat greater improvement as compared to unguided interventions (Andersson and Cuijpers, 2009; Johansson and Andersson, 2012; Newman et al., 2011), these additional benefits are limited in scope given logistical challenges and costs of scaling such guidance to a larger population (Johansson and Andersson, 2012). "
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    ABSTRACT: Internet interventions provide an option for those who either cannot or choose not to engage with traditional treatments. Most research on internet interventions involves guided or supported interventions. However, unsupported interventions offer considerably more scalability and cost-effectiveness, which makes them attractive for large-scale implementation. In this study, 309 participants recruited via Google AdWords entered an unsupported cognitive-behavioral internet intervention for depressive symptoms. To maximize the ecological validity of the study, participants received no incentives or live contact with study personnel. Furthermore, the study was open to individuals at any level of depressive symptoms, and all participants received the active intervention. The main outcome measures were depressive symptom level and self-efficacy in managing depressive symptoms. At follow-up, depression scores were significantly lower than baseline scores at each follow-up point (1, 2, 4, and 7 months), with pre-post effect sizes ranging from medium to large. Follow-up depression self-efficacy scores were significantly higher than baseline scores at each follow-up point, with pre-post effect sizes in the medium range. The results remained significant when analyzing only participants with depression scores indicative of a presence of a major depressive episode; results likewise remained significant when employing the conservative last observation carried forward convention, even in the presence of high attrition observed in this study. The results illustrate the potential of unsupported internet intervention to address the health needs of the global community.
    Full-text · Article · Sep 2014 · Internet Interventions
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    • "The majority of e-mental health treatment programs provide cognitive behavioral therapy (CBT) skills (38), and there is increasing evidence that self-help interventions are effective for reducing symptoms of anxiety disorders (39). Recent studies have shown that therapist-guided web-based treatment programs can be effective compared to conventional care (28, 34, 40, 41), and a randomized controlled trial in Australia suggested that unguided web-based interventions can be effective in reducing depressive symptoms (42). However, in a meta-analysis, Spek and colleagues (43) analyzed 12 such trials examining the effectiveness of computerized cognitive behavioral therapy (c-CBT) interventions, and found that they showed little evidence that un-guided Internet-based self-help services improved mental well-being. "
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    ABSTRACT: Mental disorders are common in almost all industrialized countries and many emerging economies. While several trials have shown that effective treatments exist for mental disorders, such as pharmacotherapy, psychological interventions, and self-help programs, the treatment gap in mental health care remains pervasive. Unrestricted access to adequate medical care for people with mental disorders will be one of the pressing public mental health tasks in the near future. In addition, scarcity of financial resources across the public mental health sector is a powerful argument for investigating innovative alternatives of delivering mental health care. Thus, one challenge that arises in modern mental health care is the development of innovative treatment concepts. One possibility for improving mental health care services is to deliver them via the Internet. Online-based mental health services have the potential to address the unmet need for mental health care.
    Full-text · Article · Jun 2014 · Frontiers in Public Health
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