Internet-Based Psychodynamic Therapy vs. CBT for Depression
In this pilot study, we investigated differences between psychodynamic and cognitive-behavioral psychotherapy delivered via the Internet in a sample of participants with major depression, where groups were formed based on preference. We also investigated the predictive value of the strength of preference. The main finding regarding efficacy was that there were indications that those choosing ICBT may have had some larger long-term benefits in terms of quality of life. Another finding was that completion of the entire program was higher among participants who chose the psychodynamic treatment. We also found indications that strength of preference could predict adherence. Among participants choosing psychodynamic treatment, completion of the program was predicted by strength of preference. Moreover, participants preferred ICBT over IPDT as significantly more participants chose ICBT.
Despite a significantly larger rate of completion in the psychodynamic treatment group, we found no indications of differential efficacy during the treatment phase. However, indications of treatment differences were found at the 7-month follow-up in favor of ICBT. This is somewhat in line with results which show that participants having received ICBT may benefit from it 3.5 years after completion. It is important to notice that all participants who did not complete the entire treatment, did receive the remaining modules after post-measurement. As data on post-treatment use of treatment modules were not available, we could not perform any analyses to investigate if continued work with the modules were related to continued symptom reduction. While the two programs had a similar amount of text, the ICBT treatment had homework in the classical sense (completing exercises) and the IPDT treatment had encouragements for working with the material. The work that the ICBT group was doing was known to the participants as "homework" while it in the IPDT group was called "reflections". The latter was more of writing about experiences than completing tasks. This could have made a difference for how the participants worked with the material and it could potentially be related to how many participants completed the entire treatment. While we in this study did not measure the amount of work done by each participant, this could potentially also have been affected by this difference in how the work was presented to and handled by the participants.
This study also explored preferences, as all participants had been allocated to their preferred choice of treatment and had stated their strength of preference. The preference literature suggest that an extra effect of having received one's preferred treatment should be expected. This study can only speculate about this, as all preferences were matched. However, the within-group effect size on the primary outcome measure in this study was around d = 1.0, which seems quite low when compared to d = 2.18 from the original trial. Importantly, all participants from this study had previously taken part of a support intervention for 10 weeks, with substantial within-group effects. Still, based on this comparison, data from this pilot study do not seem to give any support for an extra effect of preference matching. Importantly, the effect of preference matching seems to be less important when comparing two psychotherapies, than when comparing psychotherapy and pharmacotherapy.
We also considered preference strength in this study. Our indications that strength of preference could predict adherence and completion of treatment are similar to the results presented by Raue et al.. In contrast to the two previous studies we found that strength of preference could predict long-term treatment outcome in the ICBT group. In summary, results regarding preference strength are mixed. However, this study indicates that strength of preference for treatment has some predictive value and that further research is warranted.
There are limitations to this study that need to be addressed. First, as one of the aims was to explore differences in efficacy between treatments, the study is underpowered. If this question is to be further explored, a larger sample needs to be used. Second, as all participants received their preferred treatment, we could only explore the effect of preference matching in an open study design. A preferable design would be to randomize participants to either a preferred or non preferred treatment arm. Third, we did not explore therapist preferences, i.e. allegiance effects. We do not rule out that therapist preferences could have potentially made impact in this study and acknowledge the effect of allegiance as an important area for further research. Fourth, we did not measure factors that could potentially explain differences in completion rates, e.g. treatment satisfaction and perceived effort of taking part of treatment.
The findings from this pilot study suggest several research issues. A larger, adequately powered, randomized trial comparing the two treatments head-to-head could investigate differences in efficacy and the predictive value of preference strength regarding treatment outcome and adherence to treatment. If designed as a four-armed trial (randomized to being given the choice or not, and if not, randomized to treatment arm), as described by Howard and Thornicroft, the trial could also investigate the preference matching effect. This design would be a solution to all of the limitations mentioned above. Furthermore, as the effect of preference strength are largely unexplored, one implication of this study is that we have shown that strength of preference indeed may have some predictive value and further inclusion of this in treatment studies is warranted. Research on the effect of treatment preference and strength of preference could potentially be useful in dissemination of Internet-delivered psychological treatments, where these factors could be taken into consideration.
Discussion
In this pilot study, we investigated differences between psychodynamic and cognitive-behavioral psychotherapy delivered via the Internet in a sample of participants with major depression, where groups were formed based on preference. We also investigated the predictive value of the strength of preference. The main finding regarding efficacy was that there were indications that those choosing ICBT may have had some larger long-term benefits in terms of quality of life. Another finding was that completion of the entire program was higher among participants who chose the psychodynamic treatment. We also found indications that strength of preference could predict adherence. Among participants choosing psychodynamic treatment, completion of the program was predicted by strength of preference. Moreover, participants preferred ICBT over IPDT as significantly more participants chose ICBT.
Despite a significantly larger rate of completion in the psychodynamic treatment group, we found no indications of differential efficacy during the treatment phase. However, indications of treatment differences were found at the 7-month follow-up in favor of ICBT. This is somewhat in line with results which show that participants having received ICBT may benefit from it 3.5 years after completion. It is important to notice that all participants who did not complete the entire treatment, did receive the remaining modules after post-measurement. As data on post-treatment use of treatment modules were not available, we could not perform any analyses to investigate if continued work with the modules were related to continued symptom reduction. While the two programs had a similar amount of text, the ICBT treatment had homework in the classical sense (completing exercises) and the IPDT treatment had encouragements for working with the material. The work that the ICBT group was doing was known to the participants as "homework" while it in the IPDT group was called "reflections". The latter was more of writing about experiences than completing tasks. This could have made a difference for how the participants worked with the material and it could potentially be related to how many participants completed the entire treatment. While we in this study did not measure the amount of work done by each participant, this could potentially also have been affected by this difference in how the work was presented to and handled by the participants.
This study also explored preferences, as all participants had been allocated to their preferred choice of treatment and had stated their strength of preference. The preference literature suggest that an extra effect of having received one's preferred treatment should be expected. This study can only speculate about this, as all preferences were matched. However, the within-group effect size on the primary outcome measure in this study was around d = 1.0, which seems quite low when compared to d = 2.18 from the original trial. Importantly, all participants from this study had previously taken part of a support intervention for 10 weeks, with substantial within-group effects. Still, based on this comparison, data from this pilot study do not seem to give any support for an extra effect of preference matching. Importantly, the effect of preference matching seems to be less important when comparing two psychotherapies, than when comparing psychotherapy and pharmacotherapy.
We also considered preference strength in this study. Our indications that strength of preference could predict adherence and completion of treatment are similar to the results presented by Raue et al.. In contrast to the two previous studies we found that strength of preference could predict long-term treatment outcome in the ICBT group. In summary, results regarding preference strength are mixed. However, this study indicates that strength of preference for treatment has some predictive value and that further research is warranted.
There are limitations to this study that need to be addressed. First, as one of the aims was to explore differences in efficacy between treatments, the study is underpowered. If this question is to be further explored, a larger sample needs to be used. Second, as all participants received their preferred treatment, we could only explore the effect of preference matching in an open study design. A preferable design would be to randomize participants to either a preferred or non preferred treatment arm. Third, we did not explore therapist preferences, i.e. allegiance effects. We do not rule out that therapist preferences could have potentially made impact in this study and acknowledge the effect of allegiance as an important area for further research. Fourth, we did not measure factors that could potentially explain differences in completion rates, e.g. treatment satisfaction and perceived effort of taking part of treatment.
The findings from this pilot study suggest several research issues. A larger, adequately powered, randomized trial comparing the two treatments head-to-head could investigate differences in efficacy and the predictive value of preference strength regarding treatment outcome and adherence to treatment. If designed as a four-armed trial (randomized to being given the choice or not, and if not, randomized to treatment arm), as described by Howard and Thornicroft, the trial could also investigate the preference matching effect. This design would be a solution to all of the limitations mentioned above. Furthermore, as the effect of preference strength are largely unexplored, one implication of this study is that we have shown that strength of preference indeed may have some predictive value and further inclusion of this in treatment studies is warranted. Research on the effect of treatment preference and strength of preference could potentially be useful in dissemination of Internet-delivered psychological treatments, where these factors could be taken into consideration.