Using a cognitive behavioral therapy (CBT) framework, the web-based Sadness Program was developed to treat depression in adults.
The Sadness Program has four key components: psychoeducation, homework assignments, online discussion forum participation, and regular email contact with a clinician. Over six lessons, users are taught behavioral activation, cognitive restructuring, problem solving, and assertiveness skills. Each lesson includes a cartoon narrative illustrating the story of a female with depression. A clinician is also available to moderate the discussion forum and contact participants after the completion of each lesson. The goal of the clinician contact is to encourage continued participation, answer questions about the program, and reinforce skills learned in the lessons. For patients referred from primary care or psychiatric providers, the program can send automatic updates on progress, or alerts if a user expresses suicidal ideation.
Cognitive Behavioral Therapy (CBT)
Young Adults (18-30)
Clinician-assisted internet-based treatment is effective for depression: Randomized controlled trial.
Perini S, Titov N, Andrews G. Australian and New Zealand Journal of Psychiatry. 2009. 43(6): 571-578. PMID: 19440890.
Summary: A randomized controlled trial compared the Sadness Program with no treatment for adults with depression. Adults with mild to moderate depression were recruited through a research website. Forty-eight participants were enrolled and randomized to the Sadness Program or to a waitlist control group. Psychiatric symptoms were measured pre- and post-intervention. In total, 74% of participants assigned to the Sadness Program completed all modules within eight weeks. The majority of participants reported being “very” or “mostly” satisfied with the Sadness Program. The intervention group had significantly larger improvements in depression and overall health than the waitlist control. Additionally, 41% of the group receiving the Sadness Program met clinical criteria for recovery from depression, while only 6% of the control group met criteria.
Take Away: The Sadness Program demonstrated short-term efficacy for reducing mild and moderate depression symptoms. Future research to evaluate the relative usage and impact of the module components (i.e., psychoeducation, skill building, online discussion forum, clinician support) could yield important information regarding mechanisms of effect.
Internet treatment for depression: A randomized controlled trial comparing clinician vs. technician assistance.
Titov N, Andrews G, Davies M, McIntyre K, Robinson E, Solley K. PLOS One. 2010. 5(6): e10939. PMCID: PMC2882336.
Summary: In this randomized controlled trial, the clinician-assisted version of the Sadness Program was compared to a technician-assisted version. Australian adults with depression (n=141) were recruited through a research website and randomized to either a waitlist control group, the Sadness Program plus Clinician-Assistance (CA), or the Sadness program plus Technician-Assistance (TA). In the CA version, clinicians gave clinical advice through an online discussion forum, email, or telephone. Clinicians helped participants set goals, solve problems, and overcome hurdles to progress. In the TA version, participants had no access to clinician assistance. Instead, technicians called each participant weekly and provided encouragement and support. Unlike the clinician assistance, the technicians offered no clinical advice and used no therapeutic techniques. Both the technicians and clinicians spent less than one hour with each participant every week. Depression and psychological distress were assessed at baseline, an 11 week follow-up, and a four month follow-up.
Eighty-percent of participants in the TA group and 70% of participants in the CA group completed treatment. At 11 weeks, participants in both the TA and CA groups had greater improvements in depression than participants in the control group. 56% of the TA group and 61% of the CA group were classified as in recovery from depression, compared to 8% of the control group. By the four months, the TA group had significantly lower depression severity and psychiatric distress than the CA group. Despite that, effect sizes for both the TA and CA groups were large.
Take Away: Technician-assisted and clinician-assisted versions of the Sadness Program were equally effective in reducing depression and psychiatric distress in adults.
The effectiveness of internet cognitive behavioural therapy (iCBT) for depression in primary care: A quality assurance study.
Williams AD, Andrews G. PLOS One. 2013. 8(2): e57447. PMCID: PMC3579844.
Summary: Patients with depression were referred to this cohort study of the Sadness Program by their primary care or psychiatric providers. All 359 participants had access to the Sadness Program. Depressive symptoms were assessed prior to beginning the program and after each weekly lesson. Overall, 54% of participants completed the program. Depression and psychiatric distress decreased significantly throughout the program. After program completion, 63% of participants did not meet criteria for a current depressive episode. The program was also effective in reducing depressive symptoms among patients with severe depression or suicidal ideation.
Take Away: Results of this uncontrolled study support the previous randomized controlled trials demonstrating the efficacy of the Sadness Program in reducing psychiatric distress and depression.
CBT for depression: A pilot RCT comparing mobile phone vs. computer.
Watts S, Mackenzie A, Thomas C, Griskaitis A, Mewton L, Williams A, Andrews G. BMC Psychiatry. 2013. 13: 49. PMCID: PMC3571935.
Summary: The computer version of the Sadness Program was converted to a mobile phone application, and renamed “The Get Happy Program”. This randomized controlled trial compared the web-based and mobile application version of the Sadness Program. Adults with mild to moderate depression (n=52) were recruited through a research website and randomized to get either the mobile phone or computer version. Depression was measured pre-treatment, post-treatment, and at a 3-month follow-up. Sixty-nine percent of participants completed either the computer or mobile version of the program. All participants had significant decreases in depression at the post-treatment and 3-month follow-ups. Changes in depression were comparable between the mobile phone and computer groups. Participants in both groups also had similar decreases in the days of work lost.
Take Away: For adults with mild to moderate depression, both the mobile phone and computer versions of the Sadness Program improve depressive symptoms.
Follow-up of previous study
The impact of psychological distress tolerance in the treatment of depression
Williams AD, Thompson J, Andrews G. Behaviour Research and Therapy. 2013. 51(8): 469-475. PMID: 23787227.
Summary: To examine the impact of distress tolerance on depression treatment outcomes, the authors conducted secondary analyses of data collected in the Williams et al (2013) cohort study, and the Watts et al (2013) randomized controlled trial. The authors wondered how distress tolerance impacts the outcomes of depression treatment. The results showed that participants who completed the Sadness Program had increased ability to tolerate and regulate their responses to upsetting situations. Additionally, participants with lower distress tolerance at baseline also had higher depressive symptoms both before and after completing the Sadness Program.
Take Away: Distress tolerance may impact patients’ response to depression treatment.
Transdiagnostic internet treatment for anxiety and depression: A randomized controlled trial.
Titov N, Dear BF, Schwencke G, Andrews G, Johnston L, Craske MG, McEvoy P. Behaviour Research and Therapy. 2011. 49(8): 441-452. PMID: 21679925.
Summary: This study describes the results of a randomized controlled trial of an earlier version of the Wellbeing Course, previously entitled the Wellbeing Program. Adults in Australia were recruited online and screened for depression and anxiety disorders. Those meeting criteria (n=78) for either depression, panic disorder, generalized anxiety disorder (GAD), and/or social phobia were randomized to a waitlist control, or the Wellbeing Program. Depressive and anxiety symptoms were assessed pre-, mid-, and post-treatment. Participants getting the Wellbeing Program also completed a 3-month follow-up. At baseline, all participants met criteria for at least one depressive or anxiety disorder, while 81% met criteria for two or more diagnoses. Results at post-treatment showed that participants getting the Wellbeing Program had significantly lower scores on depression, GAD, and panic disorder measures than those in the control group. A greater proportion of participants in the Wellbeing Program group were in remission post-treatment (43-51%), while only 16-19% of controls were in remission. This improvement was sustained at the 3-month follow-up.
Take Away: The Wellbeing Program is effective at reducing depression and anxiety symptoms in adults.
An open trial of a brief transdiagnostic internet treatment for anxiety and depression.
Dear BF, Titov N, Schwencke G, Andrews G, Johnston L, Craske MG, McEvoy P. Behavior Research and Therapy. 2011. 49(12): 830-837. PMID: 21993153.
Summary: The authors modified the original Wellness Program to create a shorter, five-module version. This single group open trial study tested the efficacy of that brief version of the Wellness Program. Participants in the control group of the original randomized controlled trial of the Wellness Program (Titov et al, 2011) were asked to participate. After 4 declined, 36 participants were enrolled. All met criteria for depression, generalized anxiety disorder (GAD), panic disorder, and/or social phobia. As there was no control group, all participants received the brief Wellness Program. Participants completed assessments pre-treatment, post-treatment, and 3-months post-treatment. Depression and anxiety symptoms were significantly decreased at the post-treatment and 3-month follow-ups. At 3 months, 78% of participants no longer met criteria for their primary diagnosis. In addition, the percent of participants with comorbid diagnoses decreased from 78% pre-treatment to 12% at 3 months.
Take Away: A brief version of the Wellness Program appears to decrease depression and anxiety in adults.
Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: Randomised controlled trial.
Titov N, Dear BF, Johnston L, Lorian C, Zou J, Wootton B, Spence J, McEvoy PM, Rapee RM. PLOS One. 2013. 8(7): e62873. PMCID: PMC3701078.
Summary: This study presents the results of the first randomized controlled trial of the Wellness Course, which was adapted from the Wellbeing Program tested by Titov et al (2011). Australian adults with depression, generalized anxiety disorder (GAD), social phobia, and/or panic disorder were enrolled in this study. Participants (n=257) were randomly assigned to: 1) the treatment (Wellness Course) plus automated email group (TEG); 2) the treatment (Wellness Course) only (TG) group; or 3) the control group. The TEG group received weekly emails with reminders, reinforcement, and skills promotion messages. The control group participants accessed the Wellness Course after completing the post-treatment assessment. All participants completed pre-treatment, post-treatment, and 3-month follow-up assessments. At the post-treatment assessments, participants getting the Wellness Course had lower depression and anxiety symptoms than participants in the control group. Among the entire sample, no significant differences in depression and anxiety were detected between participants in the TEG and TG groups. Among participants with comorbid disorders, the TEG group had lower anxiety and depression than the TG group at the post-treatment and 3-month assessments. The automated emails also improved program completion rates. While 57% of the TEG group completed the Wellness Course, only 30% of the TG group completed.
Take Away: The Wellness Course is effective in reducing anxiety and depressive symptoms in adults. For users with comorbid disorders, adding weekly automated emails improved outcomes.
Follow Up of Previous Study: Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: A 12-month follow-up of a randomized controlled trial.
Titov N, Dear BF, Johnston L, McEvoy PM, Wootton B, Terides MD, Gandy M, Fogliati V, Kayrouz R, Rapee RM. PLOS One. 2014. 9(2): e89591. PMCID: PMC3934918.
Summary: This study presents results from the final follow-up of participants from the Titov et al (2013) randomized controlled trial. A final assessment was conducted with all participants 12 months post-treatment. Results showed depressive and anxiety symptoms were comparable in the treatment only (TG) group and the treatment plus automated email group (TEG) at 12 months. Although the groups did not show further improvement from the 3-month follow-up, reductions in anxiety and depression were maintained. Unlike the 3-month follow-up, depression and anxiety symptoms were not different for participants with comorbid diagnoses in the TEG and TG groups.
Take Away: Improvements in depression and anxiety from the Wellness Course are maintained at one year post-treatment.
A feasibility open trial of internet-delivered cognitive behavioural therapy (iCBT) among consumers of a non-governmental mental health organization with anxiety.
Kirkpatrick T, Manoukian L, Dear BF, Johnston L, Titov N. PeerJ. 2013. 1: e210. PMCID: PMC3845869.
Summary: Using a single group, open trial design, this study assessed the feasibility of using the Wellness Course for consumers receiving care from a mental health agency. The mental health agency typically provided telephone, email, and face-to-face services to consumers. Ten consumers with anxiety were enrolled and referred to the Wellness Course. Anxiety symptoms were assessed pre-treatment, post-treatment, and 2-months post-treatment. All 10 participants completed the Wellness Course, 100% reported being “very satisfied” with the course, and none reported adverse events. Statistically significant improvement in anxiety was seen from pre- to post-treatment. Those improvements were maintained 2-months post-treatment.
Take Away: The Wellness Course is an acceptable and potentially feasible treatment for consumers with anxiety seeking treatment at mental health agencies.
A feasibility open trial of guided internet-delivered cognitive behavioural therapy for anxiety and depression amongst Arab Australians.
Kayrouz R, Dear BF, Johnston L, Gandy M, Fogliati VJ, Sheehan J, Titov N. Internet Interventions. 2015. 2(1): 32-38. PMCID: PMC6096118
Summary: The authors modified the Wellness Course for Arab Australians and tested its feasibility in this single group, open trial. The Wellness Course was altered by translating key words and phrases into Arabic, changing names and demographics to be culturally relevant, and editing case examples to reflect the experiences of Arab Australians. The updated program was called the Arab Wellbeing Course. Eleven Arab Australians with depression and anxiety were enrolled to test the feasibility and efficacy of the program. Depressive and anxiety symptoms were measured at pre-, post-, and 3-month follow-up assessments. Ultimately, 91% of participants completed the program. Most were satisfied and 100% reported that the program was worth completing. Additionally, 89% would recommend the program to friends and family with depression. Large pre- and post-treatment effects were found for depressive and anxiety symptoms. From the pre- to post-treatment assessments, depression and anxiety decreased significantly. These changes were maintained at the 3-month follow-up.
Take Away: The Arab Wellness Course is acceptable and feasible for Arab Australians with depression and anxiety. Further research is needed to test the program’s efficacy.