JMIR Publications

ABSTRACT

Background:

Behavioral Activation is an effective treatment for reducing depression. As depressive disorders affect many people worldwide, internet-based behavioral activation (iBA) could provide enhanced treatment access.

Objective:

To investigate whether iBA is effective in reducing depressive symptoms and to assess the impact on secondary outcomes.

Methods:

We systematically searched MEDLINE, PsycINFO, PSYNDEX, and CENTRAL up to December 2021 for eligible randomized controlled trials. A reference search was conducted supplementary. Title- and abstract screening, as well as full-text screening was conducted by two independent reviewers. Randomized controlled trials that investigated the effectiveness of iBA for depression as a treatment or main component were included. Randomized controlled trials had to report depressive symptoms with a quantitative outcome measure and assess an adult population with depressive symptoms above cut-off. Two independent reviewers performed the data extraction, and risk of bias assessment. Data were pooled in random-effects meta-analyses. The primary outcome was self-reported depressive symptoms at post-treatment. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines (PRISMA).

Results:

A total of 12 randomized controlled trials with 3274 participants (88% female, 43.61 years) were included. IBA was more effective in reducing depressive symptom severity at post-treatment than passive control groups (standardized mean difference, -0.49 [95% CI, -0.63 to -0.34; P < .001]). The overall level of heterogeneity was moderate (I2 = 53 %). No significant effect of iBA on depressive symptoms could be found at the 6-months follow-up. Participants assigned to iBA also experienced a significant reduction of anxiety, and a significant increase in quality of life and activation compared to passive control groups. Results remained robust in multiple sensitivity analyses. The risk of bias assessment revealed at least some concerns for all studies and there was evidence of slight publication bias.

Conclusions:

This systematic review and meta-analysis indicates, that iBA is effective in reducing depressive symptoms. It represents a promising treatment option providing treatment access where no treatment is available yet. Clinical Trial: This systematic review and meta-analysis was preregistered in the International Prospective Register of Systematic Reviews (CRD42021236822).