JMIR Publications

ABSTRACT

Background:

Background:

A considerable number of people with depression in Hong Kong are not diagnosed nor treated through traditional face-to-face psychotherapy. Internet-based cognitive behavioral therapy (iCBT) has emerged as a tool to enhance accessibility to mental health services. However, iCBT is under-developed in the Chinese communities, particularly in Hong Kong.

Objective:

Objective:

This study seeks to: (1) develop and test the effectiveness of a culturally and linguistically appropriate guided iCBT program for Hong Kong Chinese people with mild to moderate depressive symptoms, and (2) explore their treatment compliance.

Methods:

Methods:

An 11-week guided iCBT program called “Confront and Navigate Depression Online” (CANDO) with 8 online modules is developed and implemented for Hong Kong people. The program is accessible through either an online platform (web-based iCBT) or a smartphone application (app-based iCBT). A three-arm randomized controlled trial is conducted. The participants are recruited through open recruitment and referral by two local non-governmental organizations. A total of 402 eligible participants, with mild to moderate depressive symptoms, are recruited and randomly allocated into three groups: (1) web-based iCBT; (2) app-based iCBT; and (3) waitlist control (WLC), who transitioned to the app-based iCBT-group after 11 weeks. A clinical psychologist provides therapy support and weekly assignment feedback, and responds to inbox messages. The primary outcome is depressive symptoms, and the secondary outcomes are anxiety symptoms, psychological distress, positive/negative automatic thoughts and positive/negative emotions at the pre-, post-, 3-month and 6-month follow-up tests. The data are analyzed by using linear mixed-effects modeling with intent-to-treat principle.

Results:

Results:

Participants in both web-based and app-based iCBT are superior to those in the WLC in reducing their depression and anxiety symptoms, psychological distress, negative automatic thoughts and emotions, and enhancing positive automatic thoughts and emotions with median to large effect sizes at post-treatment. The positive effects are maintained at the 3- and 6-month follow-ups. The adherence rate in the two iCBT groups was 57.0% for all 8 online modules and 56.3% for all 4 counseling sessions. The percentage of completed sessions and assignments was 74.5% and 72.1%, respectively, for the web-based and app-based iCBT groups. The recovery rate, as measured by the Beck Depression Inventory-II (BDI-II) at post-treatment, was 38.9% and 38.5% for the web-based and app-based iCBT groups, respectively.

Conclusions:

Conclusions:

Culturally and linguistically adapted iCBT is an effective and feasible treatment approach for Hong Kong Chinese with mild to moderate levels of depressive symptoms with a satisfactory recovery rate and treatment adherence. The treatment can serve as an accessible and economic alternative to face-to-face treatment. The findings have policy implications; the Hong Kong government should allocate more resources and promote the use of iCBT to treat those with depression in Hong Kong. Clinical Trial: Trial Registration: ClinicalTrials.gov registration identifier: NCT04388800