RESUMO
BACKGROUND: Depression is undertreated in Brazil. Deprexis is a self-guided internet-based program used to treat depressive symptoms based on empirically supported integrative and cognitive behavioral therapy. Evidence from a meta-analysis supports Deprexis' efficacy in German-speaking countries and the United States, but no study has been conducted using this program in countries with low literacy rates and large social disparities. Furthermore, few studies have investigated whether internet-based interventions ameliorate the psychological processes that might underlie depressive symptomatology, such as low perceived self-efficacy. OBJECTIVE: The main objective of this study was to replicate in Brazil previously reported effects of Deprexis on depressive symptom reduction. Therefore, the main research question was whether Deprexis is effective in reducing depressive symptoms and the general psychological state in Brazilian users with moderate and severe depression in comparison with a control group that does not receive access to Deprexis. A secondary research question was whether the use of Deprexis affects perceptions of self-efficacy. METHODS: We interviewed 312 participants recruited over the internet and randomized 189 participants with moderate to severe depression (according to the Patient Health Questionnaire-9 and a semistructured interview) to an intervention condition (treatment as usual plus immediate access to Deprexis for 90 days, n=94) or to a control condition (treatment as usual and delayed access to Deprexis, after 8 weeks, n=95). RESULTS: Participants from the immediate access group logged in at Deprexis an average of 14.81 (SD 12.16) times. The intention-to-treat analysis using a linear mixed model showed that participants who received Deprexis improved significantly more than participants assigned to the delayed access control group on the primary depression self-assessment measure (Patient Health Questionnaire-9; Cohen d=0.80; P<.001) and secondary outcomes, such as general psychological state measure (Clinical Outcome in Routine Evaluation-Outcome Measurement; Cohen d=0.82; P<.001) and the perceived self-efficacy measure (Cohen d=0.63; P<.001). The intention-to-treat analyses showed that 21% (20/94) of the participants achieved remission compared with 7% (7/95) in the control group (P<.001). The deterioration rates were lower in the immediate access control group. The dropout rate was high, but no differences in demographic and clinical variables were found. Participants reported a medium to high level of satisfaction with Deprexis. CONCLUSIONS: These results replicate previous findings by showing that Deprexis can facilitate symptomatic improvement over 3 months in depressed samples of Brazilian users. From a public health perspective, this is important information to expand the reach of internet-based interventions for those who really need them, especially in countries with less access to mental health care. This extends previous research by showing significant effects on perceived self-efficacy. TRIAL REGISTRATION: Registro Brasileiro de Ensaios Clíncos (ReBec) RBR-6kk3bx UTN U1111-1212-8998; https://ensaiosclinicos.gov.br/rg/RBR-6kk3bx/. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1590/1516-4446-2019-0582.
RESUMO
Specific psychological treatments for depressive disorders delivered on the Internet have shown effectiveness and presented advantages over face-to-face treatments (potentially less expensive, flexible schedules, available in remote areas). This paper aims to describe the characteristics of those who sought help from an online self-guided intervention for depression and to explore hypotheses about predictors of enrollment to the program. Based on a sample of 282 of individuals who filled in screening questionnaires, we verified that the respondents were mainly female, were on average 34.36 years old, were primarily recruited through Facebook, had been previously diagnosed by mental health professionals, presented moderate self-efficacy perception, and had moderately severe symptoms of depression. Respondents who reported comorbid conditions were more likely to attend enrollment interviews, and being in treatment or not did not influence attendance. Such characterization may provide strategies to reach more people and to optimize the design of interventions targeting help-seeking depressed individuals in Brazil.
Alguns tratamentos para a depressão baseados na Internet se mostraram efetivos e apresentaram vantagens em relação a tratamentos presenciais (potencialmente menos caros, com horários mais flexíveis e com disponibilidade em áreas remotas). Este artigo descreve as características de indivíduos que procuraram ajuda de uma intervenção autoguiada on-line e explora hipóteses sobre preditores de adesão ao programa. Baseado em uma amostra de 282 indivíduos que preencheram questionários de triagem, verificou-se que os participantes eram majoritariamente mulheres, tinham em média 34,36 anos, foram recrutados em sua maioria pelo Facebook, apresentaram diagnóstico psiquiátrico prévio feito por algum profissional de saúde mental, apresentaram percepção de autoeficácia moderada e sintomas depressivos moderadamente severos. Os respondentes que relataram condições comórbidas apresentaram mais chances de avançar para as entrevistas diagnósticas, e estar ou não em tratamento não influenciou a chegada às entrevistas. Estas descrições podem auxiliar na identificação de estratégias para se atingir mais indivíduos e para otimizar o desenho das intervenções on-line para brasileiros que as buscam.
Assuntos
Terapêutica , Estratégias de Saúde , Depressão , Transtornos MentaisRESUMO
O estudo apresenta o protocolo de acolhimento do Calma Nessa Hora, um serviço de e-health via chat, de apoio a pessoas em sofrimento psicológico diante da COVID-19. Foi elaborado um diagrama de fluxo de atendimento com previsão de início e fim em uma sessão, contendo três etapas: avaliação, acolhimento e finalização. Cada etapa possuía marcos de tomada de decisão sobre o fluxo diante do conteúdo e do grau de risco da demanda. Na etapa de acolhimento foram priorizadas demandas de baixo e médio risco associadas à COVID-19, como questões sociais e de saúde; ansiedade, depressão ou luto; conflitos familiares e de trabalho. Situações de elevado risco, como intenção suicida e violência, seguiram fluxo específico de encaminhamento para a rede de saúde. O artigo descreve cada etapa e os diferentes fluxos a partir de casos-exemplo. O protocolo é interdisciplinar, com potencial aplicação em serviços de atenção à saúde e serviços-escola nas universidades
This paper presents the protocol of support from Keep Calm, an e-health service via chat for people suffering from psychological distress related to COVID-19. A flowchart diagram of one-session chats was developed. Each session consisted of three steps: evaluation, support and conclusion. For each stage, decision-making milestones on what to do next were taken according to content and risk degree of the demand. At the support step, demands related toCOVID-19 that did not involve high-risk situations were prioritized, that is, social and health issues, anxiety, depression symptoms or grief, and family or work conflicts. High-risk situations such as suicidal intention and violence, followed a specific referral flow to healthcare services. The article describes each step in detail and exemplifies the different flows according to case examples. The protocol is interdisciplinary and has the potential to be applied in health care services and school care services in universities
El estudio presenta el protocolo del apoyo del Calma En Esta Hora, un servicio de e-health via chat de apoyo para personas con problemas psicológicos como consecuencia de COVID-19. Se preparó un flujograma con inicio y fin en una sesión, en tres etapas: evaluación, acogimiento y finalización. Para cada etapa se definieron hitos de decisión sobre el flujo en función del contenido y el grado de riesgo de la demanda. En la etapa de acogida, se priorizaron las demandas de bajo y medio riesgo asociadas a Covid-19, como problemas sociales y de salud; ansiedad, depresión o duelo; conflictos familiares y laborales. Las situaciones de alto riesgo, como intención de suicídio y violencia, siguieron un flujo específico a la red sanitaria. El artículo describe cada paso y los flujos basándose en casos de ejemplo. El protocolo es interdisciplinario con potencial aplicación en los servicios de salud y en las universidades
