Location-scale modeling as an integrative approach to symptom dynamics during psychotherapy: An illustration with depressive symptoms.

OBJECTIVE: Depressive symptom dynamics, including change trajectories and symptom variability, have been related to therapy outcomes. However, such dynamics have often been examined separately and related to outcomes of interest using two-step analyses, which are characterized by several limitations. Here, we show how to overcome these limitations using location-scale models in a dynamic structural equation modeling framework. METHOD: We introduce location-scale modeling in an accessible manner to pave the way for its use in research integrating within-person dynamics and intervention-related change in psychopathology, and we illustrate this modeling approach in a large-scale internet-based intervention for depression (N = 1,656). Using eight data points sampled across about 8 weeks, we predicted improvement across the intervention (50% symptom reduction) as a function of early change and symptom variability. RESULTS: Early symptom change was associated with a more likely improvement across therapy. Variability of symptoms beyond change trajectories during the intervention was associated with less likely improvement. CONCLUSIONS: Location-scale models, and dynamic structural equation modeling more generally, are well suited to modeling how patterns of symptom change during psychotherapy are related to important (e.g., therapy) outcomes. Our illustrative application of location-scale modeling showed that symptom variability was associated with less overall improvement in depressive symptoms. However, this finding requires replication with more intensive sampling of symptoms before final conclusions can be drawn on when and how to distinguish maladaptive from adaptive variability during psychotherapy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Uncovering Hidden Framings in Dark Triad Self-Ratings: What Frames-of-Reference Do People Use When Responding to Generic Dark Triad Items?

In typical Dark Triad (DT) questionnaires, generic items oftentimes refer to "others" or "people" in general. Hence, respondents have to mentally aggregate their behavior across several kinds of "others" (e.g., work colleagues, family members, and friends). It remains unknown if individuals consider different kinds of interaction partners equally or if their self-reports contain "hidden" interaction partner-specific tendencies. To shed light on this issue, we assessed generic and contextualized DT items (referring to family, friends, work, and strangers; N = 814 from the general population). The correlated trait-correlated (method - 1) model was used to investigate preregistered research questions. On average, generic DT items showed the strongest association with work-contextualized DT items and the weakest association with family-contextualized DT items. However, the associations varied considerably across DT items and traits. In sum, our results suggest that hidden framings exist in some DT items, which may impact their ability to predict relevant criteria due to contextual (a)symmetries. The generalizability of the findings to other DT instruments, items, and participant groups should be examined in future research.

Internet-based transdiagnostic treatment for emotional disorders in Arabic- and Farsi-speaking refugees: study protocol of a randomized controlled trial.

BACKGROUND: Refugee populations have an increased risk for mental disorders, such as depression, anxiety, and posttraumatic stress disorders. Comorbidity is common. At the same time, refugees face multiple barriers to accessing mental health treatment. Only a minority of them receive adequate help. The planned trial evaluates a low-threshold, transdiagnostic Internet-based treatment. The trial aims at establishing its efficacy and cost-effectiveness compared with no treatment. METHODS: N = 131 treatment-seeking Arabic- or Farsi-speaking patients, meeting diagnostic criteria for a depressive, anxiety, and/or posttraumatic stress disorder will be randomized to either the intervention or the waitlist control group. The intervention group receives an Internet-based treatment with weekly written guidance provided by Arabic- or Farsi-speaking professionals. The treatment is based on the Common Elements Treatment Approach (CETA), is tailored to the individual patient, and takes 6-16 weeks. The control group will wait for 3 months and then receive the Internet-based treatment. DISCUSSION: The planned trial will result in an estimate of the efficacy of a low-threshold and scalable treatment option for the most common mental disorders in refugees. TRIAL REGISTRATION: German Registry for Clinical Trials DRKS00024154. Registered on February 1, 2021.

Select or adjust? How information from early treatment stages boosts the prediction of non-response in internet-based depression treatment.

BACKGROUND: Internet-based interventions produce comparable effectiveness rates as face-to-face therapy in treating depression. Still, more than half of patients do not respond to treatment. Machine learning (ML) methods could help to overcome these low response rates by predicting therapy outcomes on an individual level and tailoring treatment accordingly. Few studies implemented ML algorithms in internet-based depression treatment using baseline self-report data, but differing results hinder inferences on clinical practicability. This work compares algorithms using features gathered at baseline or early in treatment in their capability to predict non-response to a 6-week online program targeting depression. METHODS: Our training and test sample encompassed 1270 and 318 individuals, respectively. We trained random forest algorithms on self-report and process features gathered at baseline and after 2 weeks of treatment. Non-responders were defined as participants not fulfilling the criteria for reliable and clinically significant change on PHQ-9 post-treatment. Our benchmark models were logistic regressions trained on baseline PHQ-9 sum or PHQ-9 early change, using 100 iterations of randomly sampled 80/20 train-test-splits. RESULTS: Best performances were reached by our models involving early treatment characteristics (recall: 0.75-0.76; AUC: 0.71-0.77). Therapeutic alliance and early symptom change constituted the most important predictors. Models trained on baseline data were not significantly better than our benchmark. CONCLUSIONS: Fair accuracies were only attainable by involving information from early treatment stages. In-treatment adaptation, instead of a priori selection, might constitute a more feasible approach for improving response when relying on easily accessible self-report features. Implementation trials are needed to determine clinical usefulness.

Sequencing effects of behavioral activation and cognitive restructuring in an Internet-based intervention for depressed adults are negligible: Results from a randomized controlled trial.

OBJECTIVE: Applying elements of cognitive behavioral therapy (CBT) in internet-based interventions (IBIs) is effective in treating depression. However, CBT-based IBIs differ in which kind of components are applied and the order of their application. Furthermore, it is as yet unknown whether such sequencing matters. Using an IBI for depression, we examined whether the sequence of two major CBT components, behavioral activation (BA) and cognitive restructuring (CR), affect patterns of symptom changes and dropout rates. METHOD: Individuals with moderate to mild depressive symptoms (N = 2,304, 59% female) were randomly assigned to two groups: one group that received BA in Modules 2 and 3 and CR in Modules 4 and 5, and another group with the opposite sequence. The component contents were identical. We investigated group differences in dropout rates, symptom changes, and change trajectories across the intervention. RESULTS: The groups had similar dropout rates and showed similar changes pre- to postassessment, and from pre- to 3-, 6-, and 12-month follow-up assessments. Between-group differences were small enough to be considered equivalent. Three classes of change trajectories emerged in both groups, but they did not differ in shape or size and did not show diverging associations with person-level characteristics. CONCLUSIONS: Results suggest that the sequence of the CBT components BA and CR in IBIs for depression does, on average, not systematically impact how individuals change during and after participation, which provides flexibility in designing CBT-based interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

On the Meaning of the "P Factor" in Symmetrical Bifactor Models of Psychopathology: Recommendations for Future Research From the Bifactor-(S-1) Perspective.

Symmetrical bifactor models are frequently applied to diverse symptoms of psychopathology to identify a general P factor. This factor is assumed to mark shared liability across all psychopathology dimensions and mental disorders. Despite their popularity, however, symmetrical bifactor models of P often yield anomalous results, including but not limited to nonsignificant or negative specific factor variances and nonsignificant or negative factor loadings. To date, these anomalies have often been treated as nuisances to be explained away. In this article, we demonstrate why these anomalies alter the substantive meaning of P such that it (a) does not reflect general liability to psychopathology and (b) differs in meaning across studies. We then describe an alternative modeling framework, the bifactor-(S-1) approach. This method avoids anomalous results, provides a framework for explaining unexpected findings in published symmetrical bifactor studies, and yields a well-defined general factor that can be compared across studies when researchers hypothesize what construct they consider "transdiagnostically meaningful" and measure it directly. We present an empirical example to illustrate these points and provide concrete recommendations to help researchers decide for or against specific variants of bifactor structure.

Increasing the effectiveness of psychotherapy in routine care through blended therapy with transdiagnostic online modules (PsyTOM): study protocol for a randomized controlled trial.

BACKGROUND: In blended therapy, face-to-face psychotherapy and Internet-based interventions are combined. Blended therapy may be advantageous for patients and psychotherapists. However, most blended interventions focus on cognitive behavioral therapy or single disorders, making them less suitable for routine care settings. METHODS: In a randomized controlled trial, we will compare blended therapy and face-to-face therapy in routine care. We intend to randomize 1152 patients nested in 231 psychotherapists in a 1:1 ratio. Patients in the blended therapy group will receive access to a therapeutic online intervention (TONI). TONI contains 12 transdiagnostic online modules suited for psychodynamic, cognitive behavioral, and systemic therapy. Psychotherapists decide which modules to assign and how to integrate TONI components into the psychotherapeutic process to tailor treatment to their patients' specific needs. We will assess patients at baseline, 6 weeks, 12 weeks, and 6 months. Patients enrolled early in the trial will also complete assessments at 12 months. The primary outcomes are depression and anxiety at 6-month post-randomization, as measured by PHQ-8 and GAD-7. The secondary outcomes include satisfaction with life, level of functioning, personality traits and functioning, eating pathology, sexual problems, alcohol/drug use, satisfaction with treatment, negative effects, and mental health care utilization. In addition, we will collect several potential moderators and mediators, including therapeutic alliance, agency, and self-efficacy. Psychotherapists will also report on changes in symptom severity and therapeutic alliance. Qualitative interviews with psychotherapists and patients will shed light on the barriers and benefits of the blended intervention. Furthermore, we will assess significant others of enrolled patients in a sub-study. DISCUSSION: The integration of online modules which use a common therapeutic language and address therapeutic principles shared across therapeutic approaches into regular psychotherapy has the potential to improve the effectiveness of psychotherapy and transfer it into everyday life as well help save therapists' resources and close treatment gaps. A modular and transdiagnostic setup of the blended intervention also enables psychotherapists to tailor their treatment optimally to the needs of their patients. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00028536. Registered on 07.06.2022.

Negative effects in internet-based interventions for depression: A qualitative content analysis.

An increasing number of studies is proving the efficacy of Internet-based interventions (IBI) for treating depression. While the focus of most studies is thereby lying on the potential of IBI to alleviate emotional distress and enhance well-being, few studies are investigating possible negative effects that might be encountered by participants. The current study was therefore exploring self-reported negative effects of participants undergoing a cognitive-behavioral IBI targeting mild to moderate depression over 6 weeks. Data from the client pool of a German insurance company (n = 814, 68% female) revealed that 8.6% of the participants reported the experience of negative effects. Qualitative content analysis yielded two broad categories and five subcategories for the nature of participants' experiences of negative effects: participant-related negative effects (insight and symptom) and program-related negative effects (online format, contact, and implementation). By using both, qualitative and quantitative methods, results did not only shed light on the characteristics of negative effects but analyses also found that working alliance was a predictor for the experience of negative effects. Monitoring the occurrences of negative effects as well as working alliance throughout treatment was considered essential to help prevent negative effects and attrition among participants undergoing IBI for depression.

Is only one cognitive technique also effective? Results from a randomized controlled trial of two different versions of an internet-based cognitive behavioural intervention for post-traumatic stress disorder in Arabic-speaking countries.

Background: Internet-based cognitive-behavioural interventions seem to be effective for the treatment of posttraumatic stress disorder (PTSD) in Arabic-speaking countries in the MENA region. However, due to high prevalence rates of trauma-related mental disorders in this region, it is important to scale up existing Internet-based interventions in order to increase the number of clients. Objective: The aim of the study was to examine whether a brief Internet-based intervention with one cognitive technique (TF-short, 6 assignments) results in the same PTSD symptom change and lower dropouts compared to a longer intervention with two cognitive techniques (TF-reg, 10 assignments). Method: A total of 224 Arab participants (67.4% female; M = 25.3 years old) with PTSD were randomly assigned to Internet-based CBT with either a TF-reg protocol (n = 110) or a TF-short protocol (n = 114). Symptoms of PTSD and secondary outcomes (anxiety, depression, somatic complaints, quality of life) were self-assessed online at baseline and post-treatment. Treatment-associated changes were estimated using multigroup latent difference score models. Results: The overall PTSD score assessed with the PDS decreased by about 15 points in both conditions. The between-group differences (TF-reg vs. TF-short) at post-assessment were non-significant, Δ = 0.29, p = .896, d = 0.02, 95% CI [-0.30, 0.34]. Like the primary outcome, all within-group changes for the secondary outcomes throughout the intervention were statistically significant and all between-group effects were non-significant. Overall, the dropout rates did not differ between the two conditions, χ2 (1/N = 175) = 0.83, p = .364. Conclusions: The findings suggest that the shorter condition results in the same symptom change and dropout rate as the longer condition. This highlights the potential of shorter, more scalable Internet-based interventions in socially restricted and (post-)conflict societies. ClinicalTrialsgov ID: NCT01508377.

Antecedentes: Las intervenciones cognitivo-conductuales basadas en Internet parecen ser efectivas para el tratamiento del trastorno de estrés postraumático (TEPT) en los países de habla árabe de la región MENA. Sin embargo, debido a las altas tasas de prevalencia de trastornos mentales relacionados con el trauma en esta región, es importante escalar las intervenciones existentes basadas en Internet para aumentar el número de clientes.Objetivo: El propósito del estudio fue examinar si una intervención breve basada en Internet con una técnica cognitiva (TF-corta, 6 asignaciones) da como resultado el mismo cambio sintomático del TEPT y menos abandonos en comparación con una intervención más prolongada con dos técnicas cognitivas (TF -reg, 10 asignaciones).Método: Un total de 224 participantes árabes (67,4% mujeres; M = 25,3 años) con TEPT fueron asignados aleatoriamente a TCC basada en Internet con un protocolo TF-reg (n = 110) o un protocolo TF-corta (n = 114). Los síntomas del TEPT y los resultados secundarios (ansiedad, depresión, quejas somáticas, calidad de vida) fueron autoevaluadas en línea al inicio y al finalizar el tratamiento. Los cambios asociados al tratamiento se estimaron utilizando modelos de puntuación de diferencia latente multigrupo.Resultados: El puntaje general de TEPT evaluado con la PDS disminuyó aproximadamente 15 puntos en ambas condiciones. Las diferencias entre grupos (TF-reg vs. TF-corta) en la evaluación posterior no fueron significativas, Δ = 0,29, p = .896, d = 0,02, IC del 95% [-0,30, 0,34]. Al igual que el resultado primario, todos los cambios dentro del grupo para los resultados secundarios a lo largo de la intervención fueron estadísticamente significativos y todos los efectos entre los grupos no fueron significativos. En general, las tasas de abandono no difirieron entre las dos condiciones, χ2 (1/N = 175) = 0.83, p = .364.Conclusiones: Los hallazgos sugieren que la condición más corta da como resultado el mismo cambio de síntomas y la misma tasa de abandono que la condición más larga. Esto resalta el potencial de intervenciones más breves y escalables basadas en Internet en sociedades socialmente restringidas y (post) conflicto.

Factors contributing to symptom change in standardized and individualized Internet-based interventions for depression: A randomized-controlled trial.

Research suggests 4 categories of outcome predictors in face-to-face therapy (i.e., treatment expectations, extratherapeutic factors, relationship factors, and factors specific to a treatment approach/technique). However, it is unclear whether these factors are relevant in standardized and individualized Internet-based interventions. To investigate this question, a secondary analysis of data from 1,089 mildly to moderately depressed adults undergoing 6 weeks of cognitive-behavioral Internet-based intervention for depression randomized to receive either weekly written feedback individualized by a counselor or automated and fully standardized feedback was performed. The following variables corresponding to the 4 categories were tested regarding associations with depressive symptom change during multiple treatment periods within a multigroup structural equation model: (a) outcome expectations, (b) extratherapeutic stressors and stress change during treatment, (c) midtreatment working alliance (task/goal and bond), and (d) uptake of treatment-specific components (logins and specific tool use). Results suggest similar regressive associations across treatment conditions: Previous symptom change was the most important predictor for subsequent symptom developments. Stress at baseline and the uptake of specific treatment components only played a minor role, and stronger task/goal ratings were associated with later symptom improvements. Early symptom improvements predicted stronger midtreatment task/goal and bond ratings, whereas only stronger task/goal ratings were associated with later symptom improvements. Outcome expectations were only indirectly related with symptom change mediated through goal/task ratings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Giving G a Meaning: An Application of the Bifactor-(S-1) Approach to Realize a More Symptom-Oriented Modeling of the Beck Depression Inventory-II.

The Beck Depression Inventory-II is one of the most frequently used scales to assess depressive burden. Despite many psychometric evaluations, its factor structure is still a topic of debate. An increasing number of articles using fully symmetrical bifactor models have been published recently. However, they all produce anomalous results, which lead to psychometric and interpretational difficulties. To avoid anomalous results, the bifactor-(S-1) approach has recently been proposed as alternative for fitting bifactor structures. The current article compares the applicability of fully symmetrical bifactor models and symptom-oriented bifactor-(S-1) and first-order confirmatory factor analysis models in a large clinical sample (N = 3,279) of adults. The results suggest that bifactor-(S-1) models are preferable when bifactor structures are of interest, since they reduce problematic results observed in fully symmetrical bifactor models and give the G factor an unambiguous meaning. Otherwise, symptom-oriented first-order confirmatory factor analysis models present a reasonable alternative.

How individuals change during internet-based interventions for depression: A randomized controlled trial comparing standardized and individualized feedback.

BACKGROUND: Standardized and individualized Internet-based interventions (IBI) for depression yield significant symptom improvements. However, change patterns during standardized or individualized IBI are unknown. Identifying subgroups that experience different symptom courses during IBI and their characteristics is vital for improving response. METHODS: Mildly to moderately depressed individuals according to self-report (N = 1,089) were randomized to receive module-wise feedback that was either standardized or individualized by a counselor within an otherwise identical cognitive-behavioral IBI for depression (seven modules over six weeks). Depressive symptoms were assessed at baseline and before each module (Patient Health Questionnaire; PHQ-9). Other individual characteristics (self-report) and the presence of an affective disorder (structured clinical interview) were assessed at baseline. Growth mixture modeling was used to identify and compare subgroups with discernable change patterns and associated client variables across conditions. RESULTS: Model comparisons suggest equal change patterns in both conditions. Across conditions, a group of immediate (62.5%) and a group of delayed improvers (37.5%) were identified. Immediate improvers decreased their PHQ-9 score by 5.5 points from pre to post, with 33% of improvement occurring before treatment commenced. Delayed improvers were characterized by stable symptom severity during the first two modules and smaller overall symptom decrease (3.4 points). Higher treatment expectations, a current major depressive disorder (interview), and lower social support were associated with delayed improvement. CONCLUSION: Internet-based interventions for depression with individualized and with standardized feedback lead to comparable patterns of change. Expectation management and bolstering of social support are promising strategies for individuals that are at risk for delayed improvement.

Developing a Diagnostic Algorithm for the Music-Based Scale for Autism Diagnostics (MUSAD) Assessing Adults with Intellectual Disability.

Initial studies have presented the Music-based Scale for Autism Diagnostics (MUSAD) as a promising DSM-5-based observational tool to identify autism spectrum disorder (ASD) in adults with intellectual disability (ID). The current study is the first to address its clinical utility in a new sample of 124 adults with ID (60.5% diagnosed with ASD). The derived diagnostic algorithm differentiated well between individuals with and without ASD (sensitivity 79%, specificity 74%, area under the curve = 0.81). Inter-rater reliability, assessed by the scorings of four independent experts in 22 consensus cases, was excellent (ICC = 0.92). Substantial correlations with scores from other ASD-specific measures indicated convergent validity. The MUSAD yields accurate and reliable scores, supporting comprehensive ASD diagnostics in adults with ID.

How is your mind-set? Proof of concept for the measurement of the level of emotional development.

BACKGROUND: In persons with intellectual and developmental disabilities, not only cognitive brain functions, but also socio-emotional processing networks may be impaired. This study aims to validate the Scale of Emotional Development-Short (SED-S) to provide an instrument for the assessment of socio-emotional brain functions. METHOD: The SED-S was applied in 160 children aged 0-12 years. Criterion validity was investigated at item and scale level in terms of the agreement between the scale classification and the child's chronological age. Additionally, interrater reliability and internal consistency were assessed. RESULTS: For the majority of items, the expected response pattern emerged, showing the highest response probabilities in the respective target age groups. Agreement between the classification of the different SED-S domains and chronological age was high (κw = 0.95; exact agreement = 80.6%). Interrater reliability at domain level ranged from κw = .98 to 1.00 and internal consistency was high (α = .99). CONCLUSION: The study normed the SED-S in a sample of typically developing children and provides evidence for criterion validity on item, domain and scale level.

The German Adaptation of the Therapist Beliefs about Exposure Scale: a Validation Study among Licensed Cognitive Behavioural Therapists in Germany.

BACKGROUND: Exposure is an effective intervention in the treatment of pathological anxiety, but it is insufficiently disseminated. Therapists' negative attitudes towards exposure might be of relevance when considering factors contributing to the non-application of this intervention. AIMS: In order to be able to measure concerns in German-speaking therapist populations, the study aimed at validating a German version of the Therapist Beliefs about Exposure Scale. METHOD: The scale was translated into the German language and validated in a sample of 330 German licensed cognitive behavioural therapists. RESULTS: In the present sample, the mean total score was significantly lower than in the original study including US-American therapists. Confirmatory factor analysis did not confirm the proposed one-factor model, while the exploratory factor analysis indicated that more than one factor is necessary to explain the structure of negative attitudes towards exposure. The internal consistency was high. Higher scores (more negative beliefs) were significantly correlated with older age, holding a master's degree (vs PhD), not being specialized in the treatment of anxiety disorders and with less experience with performance of exposure gained during clinical training. Negative beliefs about exposure were further associated with the self-reported average number of sessions spent on exposure in current treatment of post-traumatic stress disorder and panic disorder, and with negative attitudes towards application of exposure sessions presented in case vignettes. CONCLUSIONS: The German adaptation provides the opportunity of measuring concerns regarding application of exposure in German-speaking therapist populations. However, the presented data reveal suggestions for further scale development.

Efficacy of Cyberbullying Prevention on Somatic Symptoms-Randomized Controlled Trial Applying a Reasoned Action Approach.

The theory of reasoned action (ToRA) has been proposed as a framework for cyberbullying prevention design, targeting attitudes and norms. In this study effects of a long (10 weekly sessions) and a short (one day, four sessions) cyberbullying prevention program based on the ToRA were compared with a control group over 9 months. Longitudinal data from 722 students (mean age = 13.36) on cyberbullying, somatic symptoms, attitudes, and norms were analyzed within a structural equation model. Participation in the long intervention group significantly reduced cyberbullying (d = -0.584) and somatic symptoms (d = -0.316). No between-group differences emerged for attitudes and norms. Developmental trajectories and associations were found to be as suggested by ToRA in both cross-sectional and change-score analyses.

[Autism spectrum disorders in adults with intellectual disabilities : Frequencies and characteristics]. / Autismusspektrumstörungen bei Erwachsenen mit Intelligenzminderung : Häufigkeiten und Charakteristika.

OBJECTIVE: Collation of frequencies and clinical characteristics of autism spectrum disorders (ASD) in persons with intellectual disability (ID). METHODS: Cross-sectional analysis of a clinical psychiatric sample of 710 adults with ID and mental disorders. RESULTS: The frequency of ASD in an adult sample with ID was 19%. The occurrence of ASD was associated with a higher severity of ID, male gender (in mild to moderate ID), anticonvulsive therapy and reduced employment rates in workshops. CONCLUSION: The ASD are a frequent clinical diagnosis in adults with ID.

[Dementia in Adults with Down Syndrome: A Frequent Reason for Admission to Psychiatry]. / Demenz bei Down-Syndrom: Ein häufiger psychiatrischer Vorstellungsgrund.

INTRODUCTION: This study aimed to assess the prevalence and clinical characteristics of dementia in a clinical sample of adults with Down syndrome. Consequences for clinical practice were deduced. METHODS: Patient characteristics and prevalence rates of dementia were evaluated in adults with Down syndrome who were admitted to psychiatry from 2005 to 2012 (N = 75). RESULTS: In every third patient with Down syndrome, dementia was diagnosed in a second assessment 6 to 12 months after initial hospital admission. Patients with dementia were older and more often female, while no association was found with the level of intellectual disability. Thyroid function and calcium values were often abnormal in those with and without dementia. DISCUSSION: In persons with Down syndrome, dementia is a prevalent cause for admission to psychiatry, especially in females and those of advanced age. Services should be adapted to the increased demands.

Benefits of Individualized Feedback in Internet-Based Interventions for Depression: A Randomized Controlled Trial.

BACKGROUND: Even though there is an increasing number of studies on the efficacy of Internet-based interventions (IBI) for depression, experimental trials on the benefits of added guidance by clinicians are scarce and inconsistent. This study compared the efficacy of semistandardized feedback provided by psychologists with fully standardized feedback in IBI. METHODS: Participants with mild-to-moderate depression (n = 1,089, 66% female) from the client pool of a health insurance company participated in a cognitive-behavioral IBI targeting depression over 6 weeks. Individuals were randomized to weekly semistandardized e-mail feedback from psychologists (individual counseling; IC) or to automated, standardized feedback where a psychologist could be contacted on demand (CoD). The contents and tasks were identical across conditions. The primary outcome was depression; secondary outcomes included anxiety, rumination, and well-being. Outcomes were assessed before and after the intervention and 3, 6, and 12 months later. Changes in outcomes were evaluated using latent change score modeling. RESULTS: Both interventions yielded large pre-post effects on depression (Beck Depression Inventory-II: dIC = 1.53, dCoD = 1.37; Patient Health Questionnaire-9: dIC = 1.20, dCoD = 1.04), as well as significant improvements of all other outcome measures. The effects remained significant after 3, 6, and 12 months. The groups differed with regard to attrition (IC: 17.3%, CoD: 25.8%, p = 0.001). Between-group effects were statistically nonsignificant across outcomes and measurement occasions. CONCLUSION: Adding semistandardized guidance in IBI for depression did not prove to be more effective than fully standardized feedback on primary and secondary outcomes, but it had positive effects on attrition.