Background: Depression is one of the most frequent and costly mental disorders. While there is increasing evidence for the efficacy of online self-help to improve depression or prevent relapse, there is little evidence in blended care settings, especially combined with inpatient face-to-face psychotherapy. Therefore, we evaluated whether an evidence-based online self-help program improves the efficacy of inpatient psychotherapy. Methods: A total of 229 depressed patients were randomly allocated either to an online self-help program (intervention group [IG]; Deprexis) or an active control group (CG; weekly online information on depression) in addition to inpatient psychodynamic psychotherapy. Both groups had access to their respective experimental intervention for 12 weeks, regardless of inpatient treatment duration. Reduction of depressive symptoms, as measured with the Beck Depression Inventory-II, was the primary outcome at the end of the intervention (T2). Results: Depressive symptoms were statistically significantly lower in the IG compared to the active CG at T2 with a moderate between-group effect size of d = 0.44. The same applied to anxiety (d = 0.33), quality of life (d = 0.34), and self-esteem (d = 0.38) at discharge from inpatient treatment (T1). No statistically significant differences were found regarding dysfunctional attitudes (d = 0.14) and work ability (d = 0.08) at T1. Conclusions: This is the first evidence for blended treatment combining online self-help with inpatient psychotherapy. The study opens new and promising avenues for increasing the efficacy of inpatient psychotherapy. Future studies should determine how integration of online self-help into the therapeutic process can be developed further.

Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jonsson B, Olesen J, Allgulander C, Alonso J, Faravelli C, Fratiglioni L, Jennum P, Lieb R, Maercker A, van Os J, Preisig M, Salvador-Carulla L, Simon R, Steinhausen HC: The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011;21:655-679.
Whiteford HA, Ferrari AJ, Degenhardt L, Feigin V, Vos T: The global burden of mental, neurological and substance use disorders: an analysis from the Global Burden of Disease Study 2010. PLoS One 2015;10:e0116820.
Smit F, Cuijpers P, Oostenbrink J, Batelaan N, de Graaf R, Beekman A: Costs of nine common mental disorders: implications for curative and preventive psychiatry. J Ment Health Policy Econ 2006;9:193-200.
Patel V, Maj M, Flisher AJ, de Silva MJ, Koschorke M, Prince M; WPA Zonal and Member Society Representatives: Reducing the treatment gap for mental disorders: a WPA survey. World Psychiatry 2010;9:169-176.
van Beljouw I, Verhaak P, Prins M, Cuijpers P, Penninx B, Bensing J: Reasons and determinants for not receiving treatment for common mental disorders. Psychiatr Serv 2010;61:250-257.
Cuijpers P, Donker T, Johansson R, Mohr DC, van Straten A, Andersson G: Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS One 2011;6: e21274.
Richards D, Richardson T: Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clin Psychol Rev 2012;32:329-342.
Cuijpers P, Marks IM, van Straten A, Cavanagh K, Gega L, Andersson G: Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cogn Behav Ther 2009;38:66-82.
Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, Mackinnon A, Meyer B, Botella C, Littlewood E, Andersson G, Christensen H, Klein JP, Schröder J, Bretón-López J, Scheider J, Griffiths K, Farrer L, Huibers MJH, Phillips R, Gilbody S, Moritz S, Berger T, Pop V, Spek V, Cuijpers P: Efficacy of self-guided internet-based cognitive behavioral therapy in the treatment of depressive symptoms. JAMA Psychiatry 2017;74:351.
Zhou T, Li X, Pei Y, Gao J, Kong J: Internet-based cognitive behavioural therapy for subthreshold depression: a systematic review and meta-analysis. BMC Psychiatry 2016;16:356.
Sander L, Rausch L, Baumeister H: Effectiveness of internet-based interventions for the prevention of mental disorders: a systematic review and meta-analysis. JMIR Mental Health 2016;3:e38.
Twomey C, O'Reilly G, Meyer B: Effectiveness of an individually-tailored computerised CBT programme (Deprexis) for depression: a meta-analysis. Psychiatry Res 2017;256:371-377.
So M, Yamaguchi S, Hashimoto S, Sado M, A FT, McCrone P: Is computerised CBT really helpful for adult depression? A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity. BMC Psychiatry 2013;13.
Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, Barkham M, Bower P, Cooper C, Gask L, Kessler D, Lester H, Lovell K, Parry G, Richards DA, Andersen P, Brabyn S, Knowles S, Shepherd C, Tallon D, White D; REEACT Team: Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large-scale pragmatic randomised controlled trial. BMJ 2015;351:h5627.
Clough BA, Casey LM: Technological adjuncts to enhance current psychotherapy practices: a review. Clin Psychol Rev 2011;31:279-292.
Clough BA, Casey LM: Technological adjuncts to increase adherence to therapy: a review. Clin Psychol Rev 2011;31:697-710.
Wright JH, Wright AS, Albano AM, Basco MR, Goldsmith LJ, Raffield T, Otto MW: Computer-assisted cognitive therapy for depression: maintaining efficacy while reducing therapist time. Am J Psychiatry 2005;1158-1164.
Romijn G, Riper H, Kok R, Donkert T, Goorden M, van Roijen LH, Kooistra L, van Balkom A, Koning J: Cost-effectiveness of blended vs. face-to- face cognitive behavioural therapy for severe anxiety disorders: study protocol of a randomized controlled trial. BMC Psychiatry 2015;15:311.
Kooistra LC, Wiersma JE, Ruwaard J, van Oppen P, Smit F, Lokkerbol J, Cuijpers P, Riper H: Blended versus face-to-face cognitive behavioural treatment for major depression in specialized mental health care: study protocol of a randomized controlled cost-effectiveness trial. BMC Psychiatry 2014;14:290.
Kok G, Burger H, Riper H, Cuijpers P, Dekker J, van Marwijk HW, Smit F, Beck A, Bockting C: The three-month effect of mobile internet-based cognitive therapy on the course of depressive symptoms in remitted recurrently depressed patients: results of a randomized controlled trial. Psychother Psychosom 2015;84:90-99.
Kok G, Bockting C, Burger H, Smit F, Riper H: Mobile cognitive therapy: adherence and acceptability of an online intervention in remitted recurrently depressed patients. Internet Interv 2014;1:65-73.
Hollandare F, Johnsson S, Randestad M, Tillfors M, Carlbring P, Andersson G, Engstrom I: Randomized trial of Internet-based relapse prevention for partially remitted depression. Acta Psychiatr Scand 2011;124:285-294.
Ebert D, Tarnowski T, Gollwitzer M, Sieland B, Berking M: A transdiagnostic internet-based maintenance treatment enhances the stability of outcome after inpatient cognitive behavioral therapy: a randomized controlled trial. Psychother Psychosom 2013;82:246-256.
Zwerenz R, Becker J, Gerzymisch K, Siepmann M, Holme M, Kiwus U, Sporl-Donch S, Beutel ME: Evaluation of a transdiagnostic psychodynamic online intervention to support return to work: a randomized controlled trial. PLoS One 2017;12:e0176513.
Härter M, Klesse C, Bermejo I, Schneider F, Berger M: Unipolar depression: diagnostic and therapeutic recommendations from the current S3/National Clinical Practice Guideline. Dtsch Arztebl Int 2010;107:700-708.
DGPPN, BÄK, KBV, AWMF, AkdÄ, BPtK, BApK, DAGSHG, DEGAM, DGPM, DGPs, DGRW: S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression - Langfassung, ed 2, version 3. 2015.
Zeeck A, Wietersheim J, Weisss H, Beutel ME, Hartmann A: The INDDEP study: inpatient and day hospital treatment for depression - symptom course and predictors of change. BMC Psychiatry 2013;13:100.
Franz M, Seidler D, Jenett Dr, Schäfer R, Wutzler U, Kämmerer W, Deters MA, Schauenburg H, Becher-Dortschy N, Frommhold K, Keller W, Gosda J, Tress W, Zeller A, Beutel ME, Langenbach M, Hoffmann T, Haberger R, Hartkamp N: Stationäre tiefenpsychologisch orientierte Psychotherapie bei depressiven Störungen (STOP-D) - Erste Befunde einer naturalistischen, multizentrischen Wirksamkeitsstudie. Z Psychosom Med Psychother 2015;61:19-35.
Schramm E, van Calker D, Dykierek P, Lieb K, Kech S, Zobel I, Leonhart R, Berger M: An intensive treatment program of interpersonal psychotherapy plus pharmacotherapy for depressed inpatients: acute and long-term results. Am J Psychiatry 2007;164:768-777.
Vittengl JR, Clark AL, Dunn TW, Jarrett RB: Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects. J Consult Clin Psychol 2007;75:475-488.
Rodriguez MR, Nuevo R, Chatterji S, Ayuso-Mateos JL: Definitions and factors associated with subthreshold depressive conditions: a systematic review. BMC Psychiatry 2012;12:181.
Zwerenz R, Becker J, Knickenberg RJ, Hagen K, Dreier M, Wölfling K, Beutel ME: Enhancing inpatient psychotherapeutic treatment with online self-help: study protocol for a randomized controlled trial. Trials 2015;16:98.
Meyer B, Berger T, Caspar F, Beevers CG, Andersson G, Weiss M: Effectiveness of a novel integrative online treatment for depression (Deprexis): randomized controlled trial. J Med Internet Res 2009;11:e15.
Ärztliches Zentrum für Qualität in der Medizin: Patientenleitlinie Depression. 2017.
Deutsches Bündnis gegen Depression e.V.: Deutsches Bündnis gegen Depression. 2017.
Leiner D: SoSci Survey (version 2.5.00-i) (computer software). 2014.
Beck AT, Steer RA, Brown GK: Manual for the Beck Depression Inventory-II. San Antonio, Psychological Corporation, 1996.
Wang YP, Gorenstein C: Psychometric properties of the Beck Depression Inventory-II: a comprehensive review. Rev Bras Psiquiatr 2013;35:416-431.
Kuhner C, Burger C, Keller F, Hautzinger M: Reliability and validity of the Revised Beck Depression Inventory (BDI-II). Results from German samples (in German). Nervenarzt 2007;78:651-656.
Kroenke K, Spitzer RL, Williams JB: The PHQ-9. Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-613.
Spitzer RL, Kroenke K, Williams JBW, Löwe B: A Brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-1097.
da Rocha NS, Power MJ, Bushnell DM, Fleck MP: The EUROHIS-QOL 8-item index: comparative psychometric properties to its parent WHOQOL-BREF. Value Health 2012;15:449-457.
von Collani G, Herzberg PY: Eine revidierte Fassung der deutschsprachigen Skala zum Selbstwertgefühl von Rosenberg. Z Diff Diagn Psychol 2003;24:3-7.
Nelson LD, Stern SL, Cicchetti DV: The Dysfunctional Attitude Scale - how well can it measure depressive thinking. J Psychopathol Behav 1992;14:217-223.
Tuomi K, Ilmarinen J, Jahkola A, Katajarinne L, Tulkki A: Arbeitsbewältigungsindex. Dortmund, Wirtschaftsverlag NW, 1998.
Radkiewicz P, Widerszal-Bazyl M: Psychometric properties of Work Ability Index in the light of comparative survey study. Int Congr Ser 2005;1280:304-309.
Bassler M, Potratz B, Krauthauser H: The “Helping Alliance Questionnaire” (HAQ) by Luborsky (in German). Psychotherapeut 1995;40:23-32.
Urbaniak GC, Plous S: Research Randomizer (version 3.0). 2011.
Dunlap WP, Cortina JM, Vaslow JB, Burke MJ: Meta-analysis of experiments with matched groups or repeated measures designs. Psychol Methods 1996;1:170-177.
IBM Corp: IBM SPSS Statistics for Windows, version 23.0. Armonk, IBM Corp, 2014.
Klein JP, Berger T, Schroder J, Spath C, Meyer B, Caspar F, Lutz W, Arndt A, Greiner W, Grafe V, Hautzinger M, Fuhr K, Rose M, Nolte S, Lowe B, Anderssoni G, Vettorazzi E, Moritz S, Hohagen F: Effects of a psychological internet intervention in the treatment of mild to moderate depressive symptoms: results of the EVIDENT Study, a randomized controlled trial. Psychother Psychosom 2016;85:218-228.
Kohler S, Unger T, Hoffmann S, Mackert A, Ross B, Fydrich T: Dysfunctional cognitions of depressive inpatients and their relationship with treatment outcome. Compr Psychiatry 2015;58:50-56.
Beutel ME, Zwerenz R, Bleichner F, Vorndran A, Gustson D, Knickenberg RJ: Vocational training integrated into inpatient psychosomatic rehabilitation - short and long-term results from a controlled study. Disabil Rehabil 2005;27:891-900.
Schneider J, Sarrami Foroushani P, Grime P, Thornicroft G: Acceptability of online self-help to people with depression: users' views of MoodGYM versus informational websites. J Med Internet Res 2014;16:e90.
Liebherz S, Rabung S: Do patients' symptoms and interpersonal problems improve in psychotherapeutic hospital treatment in Germany? - A systematic review and meta-analysis. PLoS One 2014;9:e105329.
Gieselmann A, Böckermann M, Sorbi M, Pietrowsky R: The effects of an internet-based imagery rehearsal intervention: a randomized controlled trial. Psychother Psychosom 2017;86:231-240.
Fava GA, Guidi J, Rafanelli C, Sonino N: The clinical inadequacy of evidence-based medicine and the need for a conceptual framework based on clinical judgment. Psychother Psychosom 2015;84:1-3.
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