Self-Help Books, Web Sites First-Line Depression Treatment?

Deborah Brauser

February 27, 2013

Low-intensity interventions, including self-help books, interactive Web sites, and limited professional support, may help patients with severe depression, especially if offered as part of a stepped care model, new research suggests.

A meta-analysis of almost 2500 adults with depression showed that after undergoing these types of treatments, patients deemed severely depressed had greater improvement in symptom scores than participants who were not as depressed. However, the magnitude of this superior interaction was small and was not deemed clinically significant.

Still, "the data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients," researchers led by Peter Bower, PhD, professor of health services research at the National Institute of Health Research (NIHR) School for Primary Care Research at the University of Manchester, United Kingdom, write.

This means that rather than jumping first to high-cost/high-intensity interventions for patients with severe depression, clinicians should perhaps consider starting with low-intensity alternatives, suggest the investigators.

However, they also note the importance of ongoing assessments to monitor patient progress and the need for further research.

The study was published online February 26 in BMJ.

Stepped Care

The researchers note that healthcare systems face serious challenges when it comes to effectively managing patient depression. Therefore, many organizations in the UK have adopted a stepped care approach.

"Stepped care is a system of delivering health technologies, where the most effective yet least resource intensive treatment is delivered to patients first."

This means that only patients deemed severely depressed or who fail to respond to low-intensity interventions are offered high-intensity treatment, including therapist-led cognitive-behavioral therapy.

"However, the thresholds used in decision making vary," report the investigators.

For this analysis, they evaluated data on 2470 adult patients with depression from 16 studies conducted after the year 2000. Most of the studies measured depression using either the Beck Depression Inventory (BDI) or the Epidemiologic Studies Depression Scale (CES-D).

A BDI baseline score of 10 to 29 (out of 63) indicated mild or moderate depression, whereas a score of 30 or greater indicated severe depression. In addition, a CES-D baseline score of 16 or greater (out of 60) indicated probable depression.

All of the patients had been referred to low-intensity interventions.

Possible First Step

Results showed a significant interaction between baseline severity and treatment effect (interaction coefficient, -0.1; 95% confidence interval, -0.19 to -0.002).

This suggested that "patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed," write the investigators.

However, the interaction was equivalent to only a 1-point additional drop on the BDI and CES-D "for a one standard deviation increase in initial severity."

Although the effect of initial depression severity was larger for patients who underwent Internet-based interventions than for those who used written interventions, this difference was not statistically significant.

Overall, the findings suggest that "it is legitimate to include low intensity interventions in the first step of a stepped care system...even when initial severity of depression is high," write the researchers.

They note, however, that because some patients will not find these types of interventions useful, "it would seem sensible to continue to refer severe cases to more intense psychological intervention or pharmacological management until further evidence is generated confirming our findings."

The study was funded by the NIHR School for Primary Care Research. Dr. Bower reports having been a paid scientific consultant to the British Association of Counseling and Psychotherapy, and a coinvestigator reports being a full-time employee of GAIA AG, which owns and developed 1 of the interventions assessed in this analysis. The other study authors have reported no relevant financial relationships.

BMJ. Published online February 26, 2013. Full article