Internet-based intervention effective in the treatment of depression in people living with HIV

An online self-help intervention is effective in the treatment of mild to moderate depressive symptoms in people with HIV, according to a randomised clinical trial conducted in the Netherlands and published in the September issue of The Lancet HIV.

The trial compared the outcomes in a group who received the online self-help intervention and a control group. The internet-based intervention, available in Dutch and English, consisted of a cognitive behavioural therapy programme called “Living Positive with HIV” and developed from a self-help booklet that had previously proved effective in decreasing depressive symptoms. Participants also received minimal telephone coaching by a Masters student in psychology. The control group received the telephone coaching and could access the online intervention after the trial was completed.

Sanne van Leunen and colleagues randomly assigned 188 eligible participants to the intervention (97) or the control group (91) in 2015. Depression was assessed at baseline, Month 2, Month 5 and Month 8 (the control group did not take the last assessment).

As detailed below, results show that more participants in the intervention group than in the control group demonstrated significant change in their symptoms and that this effect was maintained for six months. Anxiety symptoms were also decreased. No adverse events were reported, the rate of satisfaction with the intervention was high, and most participants reported that they would recommend “Living Positive with HIV” to others.

“Living Positive with HIV”

There were four main components in the self-help intervention, which were covered in eight lessons:

• Activation, where participants were encouraged to engage in pleasant activities (identify a small activity, such as a short walk; perform this activity in the following weeks and expand this stimulation exercise to other activities)
• Relaxation exercises
• Identification and change of irrational cognitions, where participants were taught to challenge negative thoughts and evoke a strong and positive feeling when they experienced negative ones
• Goal setting, where participants were guided to formulate a new, realistic, concrete goal (such as quit smoking) and work on achieving this goal.

Support and motivation were provided by a coach, through prescheduled weekly telephone calls of an average of fifteen minutes. Participants worked on the intervention from one to two hours a week, for a total period of eight weeks.

Outcome measurements

The primary outcome of the study was the severity of depressive symptoms. It was measured with the Patient Health Questionnaire-9 (PHQ-9) and the Center of Epidemiologic Studies Depression Scale (CES-D).

The PHQ-9 is a nine-item depression scale, with questions that explore people’s self-perception, sleep, appetite, energy, capacity to concentrate, moods, etc. People self-report how often they have been bothered by specific problems in the two previous weeks, such as:

• Feeling bad about yourself – or that you are a failure or have let yourself or your family down?
• Trouble falling or staying asleep, or sleeping too much?
• Poor appetite or overeating?
• Feeling tired or having little energy?
• Trouble concentrating on things, such as reading the newspaper or watching television?

Possible responses range from “Not at all” to “Nearly every day”. A total score of 4 or less suggests no depression; a 5 to 9 score, mild depression; 10-14 moderate depression; 15-19, moderately severe depression; and 20-27 severe depression. Of note, one of the eligibility criteria for participation in this study was a PHQ-9 score over 4 and below 20.

The CES-D is a 20-item scale that reflects the major dimensions of depression: depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, appetite loss and sleep disturbance.

Patients self-report on how often they have felt in certain ways in the previous week or so, for example:

• I felt depressed
• I felt like a bad person
• I wish I were dead
• I felt like I was moving too slowly
• My appetite was poor
• My sleep was restless.

Responses range from “rarely or none of the time” to “most or all of the time”. The total score ranges from 0 to 60. No or mild depressive symptoms are suggested by a score below 16; moderate depressive symptoms by a score between 16 and 23; and severe symptoms by a score between 24 and 60.

The equivalence of CES-D and PHQ-9 has been demonstrated. Both were used in the study to confirm the outcomes on depressive symptoms.

Secondary outcomes included a decrease of anxiety symptoms, measured by the Generalised Anxiety Disorder 7 (GAD-7). This is a seven-item, self-report questionnaire that measures the severity of generalised anxiety disorder. A person is asked: “Over the last two weeks, how often have you been bothered by the following problems: feeling nervous, anxious or on edge; not being able to stop or control worrying; worrying too much about different things; having trouble relaxing; being so restless that it is hard to sit still; becoming easily annoyed, or irritable; and feeling afraid as if something awful might happen”.

Total scores of 5, 10 and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. A score above 10 should encourage further evaluation.  

All assessments in the study were self-reports conducted online, except for the screening that was performed at the HIV clinics or by telephone.  

More detailed results

Regarding depressive symptoms, at baseline, mean scores for the two depression scores were equivalent in both study groups (11.74 in the intervention group vs 11.11 in the control group for PHQ-9; 24.91 vs 22.94 for CES-D).

But as early as Month 2, a difference between the groups was observed, for both PHQ-9 (6.73 vs 8.60) and CES-D (13.94 vs 19.09), showing the better efficacy of the online intervention. This trend was confirmed at Month 5: 6.62 vs 8.06 for PHQ-9; 15.71 vs 18.43 for CES-D.

In other words, from baseline to Month 5, the severity of depressive symptoms declined from moderate to mild, when measured with PHQ-9, and from the lower end of the severe range to mild when measured with CES-D, thanks to the online intervention.

Regarding anxiety disorders, the impact of the intervention was also significant. GAD-7 scores decreased from 9.44 (just below the cut-off for moderate symptoms) at baseline, to 5.12 and 5.55 at Months 2 and 5 (mild symptoms). The change in the control group was not so large.

Critical study against a grim background

The positive outcomes of this trial are more than welcome in the HIV community. In a linked comment article, Eirini Karyotaki highlights that the researchers are the first to demonstrate that ehealth (health practice supported by electronic processes and communication) interventions may have an important role to play in depression treatment and care for people with HIV. These outcomes are consistent with several studies of self-help interventions in people with other chronic diseases (multiple sclerosis, epilepsy and diabetes) and with somatic and mental health problems.

Around a third of people with HIV have depression or depressive symptoms, with potential detrimental consequences such as a reduced access to care and adherence to therapy, accelerated disease progression and an increased risk of suicide. The provision of effective depression treatment is therefore essential, but it is known that many people do not seek treatment when they feel depressed, often due to perceived stigma.

Eirini Karyotaki suggests that internet-guided psychotherapeutic interventions might represent a low-cost, easy to access, flexible and confidential treatment option – an approach to “fill the gap between treatment supply and demand in people with HIV and depression”.

Sanne Van Leunen and colleagues, the authors of the study, recommend that internet interventions for people with HIV and depression should now be tested in regular HIV care.