Major depression is the world’s leading cause of disability. It accounts for the greatest burden of all diseases globally, with serious potential negative effects, including heart disease and suicide.

Typically manifesting during young adulthood, depression tends to worsen with subsequent episodes. Some 350 million people worldwide suffer from depression, but fewer than half of those affected receive treatment.

Cognitive Behavioural Therapy (CBT) is usually recommended as the first step in the treatment of depression but research suggests that it may only be modestly effective in treating depression in young people. Additionally, despite discussion of mental health issues becoming part of public discourse, mental health problems remain heavily stigmatised. This impacts upon help seeking behaviour in those suffering from depression and results in low engagement with mental health services, particularly amongst young people. As a result, there is an increased need to develop alternative effective treatment strategies.

Researchers have taken advantage of young people’s high use of web-based communication and social networking sites in order to improve treatment acceptability and engagement. A range of online interventions (both prevention and intervention) have been developed successfully; as these interventions differ in content, clinician input and modality, it is important to identify key features associated with treatment outcomes.

The aim of this study was to systematically review the relevant literature of online approaches to depression treatment in young people. Two separate strategies were used to identify:

• Studies of standard online interventions (section 1)
• Second-generation interventions using social networking functions (section 2)

Methods

Two specific literature searches were conducted in June 2013 of multiple electronic databases. The Section 1 search focused on randomised controlled trials that included only young people (12-25 years) and yielded 101 study abstracts, of which 15 met the review inclusion criteria. The Section 2 search included all study design types and was not age restricted; it yielded 358 abstracts, of which 22 studies met the inclusion criteria.

Results

Section 1 (standard online interventions):

• 15 studies described 10 trials testing eight different online interventions, all of which were based on a cognitive behavioural approach
• Studies were categorised as: prevention (n=9); intervention (n=5); combined prevention-intervention (n=1)
• Two studies included moderator or clinician input
• With the exception of the one combined prevention-intervention study, all included trials reported positive findings
• However, the majority (n=9) of trials used participant self-report data as outcome variables
• Studies varied significantly in presentation of intervention content, treatment dose, and dropout

Section 2 (interventions using social networking functions):

• Articles were categorised as: social networking sites (n=16); online support groups (n=4); general commentary (n=1)
• None of the Section 2 studies reported controlled or randomised designs
• The majority of included studies reported on data collected via online questionnaires
• Eight of the 16 social networking studies reported positive results for depression-related outcomes. The remaining studies were either mixed or negative
• Findings for online support groups tended to be positive; however, results from the studies were mixed and noteworthy risks were identified by some studies, including increased suicidal ideation and excessive reliance on online support

Discussion

There is no doubt that online interventions offer an opportunity to both prevent and treat mental health problems in a cost-effective and immediate way. Current UK health policy and financial priorities strongly indicate the need to develop innovative ways of encouraging patients to engage with and adhere to novel treatment approaches and this review demonstrates that online interventions with a broad cognitive behavioural focus may be effective in reducing depression symptomology in young people.

This unpacking of the components of effective online interventions is crucial: although the potential reach of online interventions makes them attractive, simply placing an established face-to-face approach into an online context is insufficient. The reviewers are keen to point out that further research is required into the effectiveness of online interventions delivering cognitive behavioural subcomponents, such as problem-solving therapy. In addition, further work is needed in order to better understand the problems of participant engagement, adherence and attrition, important issues in the use of online interventions.

The evidence for the use of social networking is less compelling, limited by a significant heterogeneity across study designs. As an emerging field, gaps in the research are to be expected and the reviewers urge others to take advantage of the ubiquitous and routine use of social networking sites, in order to better understand the potential role of social networking as an effective therapeutic medium.

The widespread roll-out of online interventions for the prevention and treatment of depression in young people is an attractive prospect but the reviewers underline the fact that future interventions must consider features that encourage engagement and offer increased opportunity for tailored and dynamic content. The evidence suggests that real-time moderator input is likely to be vital, to assuage risk issues associated with unmonitored suicidal ideation or symptom deterioration.

This is an exciting time for digital health. Emerging models which incorporate immediacy of responsiveness and utilise evidence gathered from the fast moving research fields of sentiment analysis, qualitative methodologies and insights gained from other forms of digital health intervention are best placed to contribute to the development of effective and rigorous online interventions.

Links

Rice SM, Goodall J, Hetrick SE, Parker AG, Gilbertson T, Amminger GP, Davey CG, McGorry PD, Gleeson J, Alvarez-Jimenez M. (2014) Online and Social Networking Interventions for the Treatment of Depression in Young People: A Systematic Review (PDF). J Med Internet Res 2014;16(9):e206 DOI: 10.2196/jmir.3304

Other links

Depression in children and young people: information for young people. Mental Health and Growing Up Factsheet, Royal College of Psychiatrists, 2012.

YoungMinds is the UK’s leading charity committed to improving the emotional wellbeing and mental health of children and young people. http://www.youngminds.org.uk/

NICE (2005) ‘Depression in children and young people’ Clinical Guidelines CG28.