Centre for Youth Mental Health - Theses
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ItemPromotion of self-help strategies for sub-threshold depression: an e-mental health randomised controlled trial( 2012)Background: Sub-threshold depression refers to clinically relevant depressive symptoms that fall short of a diagnosis of major depression. Sub-threshold depression is very common in the general population, impairs functioning, increases the risk of developing major depression, and poses a significant burden at the population level. Public promotion of greater use of effective self-help strategies for depression has been proposed as one technique to reduce this population burden. Improving self-help strategies could reduce symptoms of sub-threshold depression and prevent major depression. Depression experts have identified several self-help strategies that are helpful for sub-threshold depression. The aim of the study was to develop messages based on these strategies that could be promoted to members of the public with sub-threshold depression, and to test whether their promotion was effective. Method: Twelve email messages (‘Mood Memos’) were developed, based on self-help strategies endorsed as effective and feasible by depression experts. The email messages were developed with reference to theories of behaviour change, persuasion, and health communication, in order to persuade recipients to engage in the self-help behaviours. The effectiveness of these emails was evaluated in a randomised controlled trial. Recruitment was via internet-based sources and participants joined the study by visiting the website www.moodmemos.com. Adults aged 18+ with sub-threshold depression who were not receiving professional treatment for depression were eligible to participate. Participants were randomly allocated to receive emails twice weekly for six weeks in a fully automated intervention. The active group received emails based on the effective self-help strategies and the control group received emails containing general information about depressive disorders. Assessment points were at baseline, midway through the intervention and at the end of the intervention (6 weeks post-baseline). The primary outcome was depression symptom score on the Patient Health Questionnaire-9 (PHQ-9). Secondary outcomes were psychological distress, assessed with the ten-item Kessler Psychological Distress Scale (K10), and level of functioning, assessed with the Work and Social Adjustment Scale. The primary hypotheses were that the emails containing self-help strategies would reduce depression symptoms and reduce the incidence of major depression more than the control emails post-intervention. Results: The study recruited an international sample of 1,326 adults with sub-threshold depression. There was a small, significant difference in depression symptoms post-intervention, favouring the active group (Cohen’s d = 0.17, 95% CI: 0.01 to 0.34). There was also a higher, though non-significant, risk of major depression in the control group (Relative Risk = 1.32, 95% CI: 0.89 to 1.98). A similar effect was found for psychological distress (d = 0.22, 95% CI: 0.05 to 0.38), but effects on functioning were less strong, with no significant difference between the active and control groups (d = 0.12, 95% CI: -0.05 to 0.28). A mediation analysis indicated that the effect of the emails on depression symptoms was completely mediated by the use of the self-help strategies promoted in the emails. Discussion: Overall, the results indicate that promoting effective self-help strategies to the public via automated emails was effective for sub-threshold depression. The improvement in depression was associated with use of the self-help strategies promoted in the emails. The delivery of self-help messages via email is a scalable, easily disseminated intervention. The study is a novel contribution with potential to reduce the large population burden of depression.