A recent study published in the Journal of Medical Internet Research explored the effectiveness of incorporating a stepped care model into internet-based cognitive behavioral therapy (i-CBT) for adults with major depressive disorder (MDD). The research, a single-blinded, randomized controlled trial, compared outcomes between an i-CBT-only group and an i-CBT with stepped care group, assessing changes in depressive symptoms and quality of life.
The study enrolled participants recruited from outpatient psychiatry clinics and health science centers. Eligible individuals, aged 18 years or older, met the criteria for MDD as determined by the Mini International Neuropsychiatric Interview (MINI) and had consistent internet access. Participants were excluded if they presented with active psychosis, acute mania, severe substance use disorder, or active suicidal ideation.
Study Design and Interventions
Participants were randomized into either the i-CBT group or the i-CBT with stepped care group. All participants received a 13-week i-CBT program designed for MDD, delivered through a secure online platform. The stepped care model involved four steps: (1) watchful waiting, (2) self-help psychotherapy (i-CBT with messaging), (3) face-to-face psychotherapy (i-CBT with telephone or video call), and (4) referral to a psychiatrist. The intervention that participants received was dictated by the participant’s care team based on changes in PHQ-9 scores, engagement with treatment, progress in weekly goals, and homework submission.
Key Findings
While both groups showed significant reductions in depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) and the Quick Inventory of Depressive Symptomatology (QIDS), there was no statistically significant difference between the two groups. However, participants in the stepped care group completed significantly more therapy sessions on average (9.41 sessions) compared to the i-CBT-only group (7 sessions; P=.03).
Implications and Future Directions
These findings suggest that while i-CBT is effective in reducing depressive symptoms, the addition of a stepped care model may primarily enhance treatment adherence. The study highlights the importance of exploring specific stepped care interventions and their long-term effects on diverse populations. Further research is needed to identify the optimal components of stepped care models and to understand how these interventions can be tailored to individual patient needs.
Limitations
The study acknowledges several limitations, including a relatively small sample size, a sex imbalance (more women), and the lack of long-term follow-up data (ongoing). The authors also note that the subjective nature of some criteria used to determine the stepped care intervention may have introduced variability. Additionally, the i-CBT group received support through homework feedback, which may have influenced the results.
Despite these limitations, the study provides valuable insights into the potential of stepped care models to improve engagement with i-CBT for depression. Future research should focus on addressing the identified limitations and exploring the mechanisms through which stepped care interventions can enhance treatment outcomes.
