Bret S. Stetka, MD; Jan Philipp Klein, MD

Editor's Note: While browsing a poster session at the American Psychiatric Association's 168th Annual Meeting in Toronto, Ontario, Canada, Medscape spoke with Dr Jan Philipp Klein of the Lübeck University (Lübeck, Germany) Department of Psychiatry and Psychotherapy about the efficacy of a new Internet-based depression therapy.

Medscape: What was the objective of your study[1]?
Dr Klein: We were interested in studying Internet-based psychological interventions for depression, in part due to the large treatment gap associated with the condition. Many patients don't get adequate treatment for depression. Prior to starting the study we knew that there is an evidence base for psychological Internet interventions in treating depressive symptoms. However, in previous studies, the sample size was much smaller, and depressive symptoms were only self-rated. This was the first study to also include clinician ratings over time.

Medscape: How big was the study?
Dr Klein: We recruited over 1000 participants with mild to moderate depressive symptoms, and we chose this population given that guidelines say that Internet interventions might be most effective in this group. We randomly assigned participants to two groups: the care-as-usual group, defined as patients being free to use any psychopharmacologic or psychotherapeutic treatment that they desired; and the intervention group, which received the Internet intervention for 12 weeks on top of care as usual. Those in the treatment group could use the intervention as much and as long as they wanted. Our main outcome measure was PHQ9 score, which measures self-rated depression, and clinician ratings, including the MINI interview and the Hamilton Rating Scale for Depression.

Medscape: Tell us about how the intervention works.
Dr Klein: The Internet intervention was developed by a company based in Hamburg, Germany, and is called Deprexis. It consists of mainly cognitive-behavioral–based materials, including acceptance, mindfulness, and interpersonal work. The material is presented in an interactive fashion. The program incorporates feedback from the user, including disapproval or skepticism related to the material presented, and then customizes the intervention on the basis of user responses.

Medscape: What did you find?
Dr Klein: As in most depression studies, both groups showed a response. But the intervention group improved much more than the control group, with a small to moderate between-group effect. Also, the effect was stable at 3-month follow-up. It also had a small to medium effect on clinician-rated symptoms.
These effect sizes compare favorably with effect sizes for other depression therapies, like antidepressants and psychotherapy. So, really, we can say that Internet-based psychological interventions are evidence-based, now with the additional advantage of having clinician ratings data.

Medscape: It's Not a Drug, It's Not a Device; Who Will Cover It?
Dr Klein: The next step is implementing the treatment into actual clinical practice. We have to deal with reimbursement issues. Our study was sponsored by the German Federal Ministry of Health, and they are really interested in this. What is uncertain is what this therapy is, from a regulatory perspective. There's not much in the way of precedent here. Some software is considered a device by the German government, but it's mostly software that controls interventions like anesthesia—software controlling something that physically interacts with the body.

Medscape: Do you see this as an adjunct therapy to pharmacotherapy and psychotherapy?
Dr Klein: it depends on the patient. There are patients who are skeptical and afraid of stigmatization and don't want to go into the therapist's office, or who might not have a therapist available, like in the Nevada desert. It could be helpful in cases like this, as an easier-to-access alternative treatment, or it could be used temporarily while waiting for psychotherapy. This also could be beneficial for immigrants who may not speak the language well, which precludes psychotherapy. I think there will be a lot of uses for this.