The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard

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54 Chapter 3. Online CBT of DepressionTable 3.5: Predictors of reduction of depressive symptoms after web-based CBT. aMeasure r post-test b r follow-upPretest depression severity .68 *** .42 **Gender −.07 .11Age .12 −.02Education −.01 −.04Treatment duration .06 .07Previous number of episodes −.14 −.02Antidepressant (at pretest) −.17 −.35 *Additional treatment .00 −.29Antidepressant −.12 −.49 **Psychotherapy −.03 −.24a Outcome is defined as the difference score (Pretest-Posttest, n = 47; Pretest-Follow-up, n = 39) on the Beck DepressionInventory (BDI-IA).b *: P < .05; **: P < .01; ***: P < .001.personal (78%) and stated that the relationship had grown during treatment (78%).Most participants (89%) indicated that they had not missed face-to-face contact.Predictors of outcome. As shown by Table 3.5, baseline BDI-IA scores correlatedpositively with posttreatment improvements. Further, the use of an antidepressant(either during or after treatment) correlated negatively with long-term improvements(see Figure 3.2). None of the other variables significantly predicted the improvements.Examination through multiple regression produced similar results.Baseline medication status correlated negatively with long-term improvements.Although the effect was absent at posttest, taking an antidepressant during treatment(n = 6), was associated with a less favourable outcome at 18 months. At follow-up,the severity of depression in the antidepressant group was equal to baseline severityof depression.Between the posttest and the 18-month follow-up, 16 (41%) of the 39 participantsreceived additional treatment (psychotherapy only: n = 7; medication only: n =1; both: n = 8). Although the overall association was not significant, participantsreceiving additional treatment showed a considerable higher level of symptoms at
3.4. Discussion 55follow-up (r p b = -.29). Further examination showed that participants, who startedtaking medication after treatment, clearly displayed more severe symptoms at followupcompared to those who did not [M = 16.8 vs. 8.0, t(36) = 3.0, P = .005]. Again,at pretest and posttest, the two groups reported similar depression levels.When medication usage both during and after treatment was considered, therewas a significant medication effect (r pb = -.52, P < .001). Figure 2C illustrates theeffect. On average, those who took medication during or after the trial (n = 13) didnot improve from pretest to follow-up (d = .04). In contrast, those who did not takeany medication (n = 26) reported large improvements (d = 1.6).3.4 DiscussionCompared with a waiting list control condition, standardised therapist-guided WebbasedCBT induced large and clinically relevant improvements in depression, anxietyand well-being in a community sample of adults with chronic symptoms of mild tomoderate depression. The follow-up indicated these effects to be persistent, althoughthe use of medication was highly predictive of a negative long-term outcome. Despitethe lack of face-to-face contact, participants were highly satisfied with the treatmentand their therapist.3.4.1 Primary resultsAfter controlling for improvements in the control group, web-CBT had an effect sizeof d = .9. This compares well with the effects found in meta-analyses of face-to-faceCT and CBT trials (d = .8: Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; d =.9: Cuijpers et al., 2007) and therapist-guided web-CBT (Spek et al., 2007: d = 1.0).Furthermore, the low drop-out rate of 10% in the present trial was encouraging, giventhat poor adherence has been identified as one of the major challenges of onlineintervention (Eysenbach, 2005).With regard to negative affect, results were less clear. Significant results werefound with the anxiety subscale of the DASS. The effects on DASS depression andDASS stress just fell short of statistical significance. However, given the magnitude ofobserved effects (.5 < d < 1.0), we expect future trials to find positive results.
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The Efficacy andEffectiveness ofOnl
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The studies in this thesis were sup
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Promotiecommissie:Promotores: Prof.
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6 Online CBT in Routine Clinical Pr
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Ruwaard, J., Lange, A., Schrieken,
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106 Chapter 6. Online CBT in Routin
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Chapter 7General DiscussionPrevious
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7.1. Key Findings 1277.1.2 The effe
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7.1. Key Findings 129Work−related
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7.2. Strengths and limitations 1317
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7.2. Strengths and limitations 133s
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7.3. Implications for clinical prac
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7.4. Suggestions for future researc
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7.5. Conclusion 139Post-treatment b
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142 Summaryof the introduction prov
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144 Summarythat face-to-face contac
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146 Summarycomplex, routine practic
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SamenvattingIn 1997 ontwikkelden on
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Samenvatting 151startten direct met
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Samenvatting 153up-metingen suggere
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Samenvatting 155ongeveer gelijk zou
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ReferencesAben, I., Verhey, F., Lou
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References 159Bickel, R. (2007). Mu
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References 161apy Research, 1(2), 8
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References 163Hay, P. P., Bacaltchu
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References 165for bulimia nervosa:
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References 167Mond, J. M., Hay, P.
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References 169(2003). The developme
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References 171of change in psycholo
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DankwoordAlleen mijn naam staat op
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Dankwoord 175en Janneke Broeksteeg
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178 Curriculum VitaeLange, A., & Ru
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