A Self-Help Preventive Intervention for Major Depressive Disorder: Promising Findings

The global burden of depressive illness is already staggering, and by 2030, major depressive disorder (MDD) is expected to become the leading cause of premature disability and mortality in higher-income countries (Mathers & Loncar, 2006). This prediction is surely a call to action by psychiatric clinicians. What preventive interventions could be delivered to individuals at high risk of developing MDD? What, if any, self-help interventions could be employed by laypersons to prevent the ultimate onset of full-blown MDD?

Some empirical evidence is already available indicating that depressive symptoms can be decreased by psychological therapies delivered via the Internet (Ebert et al., 2015; Spek et al., 2007). A newer study out of Germany has demonstrated that a Web-based self-help intervention can prevent the development of MDD (Buntrock et al., 2016). The intriguing results of the study by Buntrock et al. (2016) deserve careful attention.

In a randomized clinical trial involving 406 German adults, potential participants who self-identified as having “lower mood” were recruited through print, on-air, and online media (Buntrock et al., 2016). First, they completed an online screening questionnaire to ensure that they had sub-threshold depression (defined as score of 16 or less on the Centre for Epidemiological Studies Depression Scale [CES-D]); were not receiving psychotherapy and had not received it within the past 6 months; were not suicidal; and had Internet access. Potential participants who achieved eligibility through this initial screening were then interviewed to ensure that they did not meet diagnostic criteria for MDD, bipolar disorder, or psychotic disorder. Then, the randomization took place, either to the intervention group (Web-based interactive exercises based on psychoeducation, behavior therapy and problem-solving therapy, guided by on online trainer who gave feedback regarding each completed exercise) or the control group (psychoeducation alone, with no online trainer). It should be noted that all study participants were permitted to receive antidepressant medication, if prescribed, and primary care office visits, as necessary, but not therapies delivered by psychiatric clinicians.

Participants in the study by Buntrock et al. (2016) were predominately female (73.9%), white (83.5%), middle-aged (mean of 45 years), and employed full-time (52%) or part-time (30.5%). The self-help intervention they received was relatively brief. For the intervention group, mean treatment duration was 5.84 weeks, and the participants completed an average of 4.93 out of the six 30-minute interactive sessions. Trainers spent approximately 2–3 hours providing “semi-standardized feedback” to the study participants but were specifically instructed not to employ individualized psychotherapeutic strategies; trainer adherence to this restriction was assured through supervisory fidelity checks (Ebert, Buntrock, & Cuijpers, 2016).

Self-report measures of depression symptoms, anxiety, problem-solving, and other outcome variables were administered at 6- and 12-month follow-up, but the primary outcome variable was time to onset of MDD (assessed by psychologists blinded to group assignment). Not only were fewer participants diagnosed with MDD in the intervention group (27% compared to 41% in the control group) but also the time of onset of MDD was delayed compared to that of the control group (Buntrock et al., 2016).

These study findings, especially if replicated with more ethnically diverse adults in countries other than Germany, are encouraging. Advantages of a self-help intervention such as this to people with sub-threshold depression are many, including the convenience of working through modules in one's own home, the availability of an online trainer for guidance, and the lack of need (or delay in need) for costly inpatient or face-to-face outpatient treatment for full-blown depressive illness.

Implications of this study for nursing readily come to mind. Family nurse practitioners diagnosing subthreshold depression could recommend Web-based self-help sessions to their clinic patients in addition to other health-promoting measures such as increased exercise and improved sleep hygiene. Clearly, the “online trainers” in replications of the study could be mental health nurses. Buntrock and colleagues (2016, p. 1856) did not specify the disciplines of the trainers who provided feedback to their study participants, referring to them only as “trained graduate students and health care professionals supervised by clinical psychologists.” Psychiatric nurse researchers could be instrumental in further testing of the self-help modules and making modifications for cultural appropriateness for populations other than middle-aged German women. Replications of the research should address some of the limitations of the Buntrock study, such as including assessment of lifetime history of MDD and chronic medical conditions.

Development of Web-based interventions for many mental health conditions beyond depression will undoubtedly continue at a rapid pace. Such interventions can be delivered to individuals in remote locales who have limited (or no) access to traditional psychiatric services. Unless online trainers (such as graduate students) require payment for their work, there is no cost associated with provision of self-help interventions such as that described by Buntrock et al. (2016). I invite manuscripts from psychiatric mental health nurse clinicians and researchers that will enrich this burgeoning literature.