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Given that relapse is common in patients in remission from anxiety and depressive disorders, relapse prevention is needed in the maintenance phase. Although existing psychological relapse prevention interventions have proven to be effective, they are not explicitly based on patients’ preferences. Hence, we developed a blended relapse prevention program based on patients’ preferences, which was delivered in primary care practices by mental health professionals (MHPs). This program comprises contact with MHPs, completion of core and optional online modules (including a relapse prevention plan), and keeping a mood and anxiety diary in which patients can monitor their symptoms.
The aims of this study were to provide insight into (1) usage intensity of the program (over time), (2) the course of symptoms during the 9 months of the study, and (3) the association between usage intensity and the course of symptoms.
The Guided E-healTh for RElapse prevention in Anxiety and Depression (GET READY) program was guided by 54 MHPs working in primary care practices. Patients in remission from anxiety and depressive disorders were included. Demographic and clinical characteristics, including anxiety and depressive symptoms, were collected via questionnaires at baseline and after 3, 6, and 9 months. Log data were collected to assess the usage intensity of the program.
A total of 113 patients participated in the study. Twenty-seven patients (23.9%) met the criteria for the minimal usage intensity measure. The core modules were used by ≥70% of the patients, while the optional modules were used by <40% of the patients. Usage decreased quickly over time. Anxiety and depressive symptoms remained stable across the total sample; a minority of 15% (12/79) of patients experienced a relapse in their anxiety symptoms, while 10% (8/79) experienced a relapse in their depressive symptoms. Generalized estimating equations analysis indicated a significant association between more frequent face-to-face contact with the MHPs and an increase in both anxiety symptoms (β=.84, 95% CI .39-1.29) and depressive symptoms (β=1.12, 95% CI 0.45-1.79). Diary entries and the number of completed modules were not significantly associated with the course of symptoms.
Although the core modules of the GET READY program were used by most of the patients and all patients saw an MHP at least once, usage decreased quickly over time. Most patients remained stable while participating in the study. The significant association between the frequency of contact and the course of symptoms most likely indicates that those who received more support had more symptoms, and thus, it is questionable whether the support offered by the program was sufficient to prevent these patients from relapsing.
RR2-10.1186/s12888-019-2034-6
Despite effective treatments for anxiety and depressive disorders [
In the Netherlands, relapse prevention is provided by mental health professionals (MHPs) in primary care practices. However, many MHPs are unfamiliar with relapse prevention interventions, and the tools to support MHPs in providing relapse prevention are lacking [
The GET READY study was a pre-post study for remitted patients with an anxiety or depressive disorder [
This study was conducted in 50 primary care practice settings across the Netherlands. In the Netherlands, most primary care physicians (PCPs) employ an MHP (ie, nurse, psychologist, or social worker) who provides support and treatment for patients with mild mental health problems. These MHPs were involved in the GET READY program. Alternatively, for those patients whose MHP was not participating in the study, the program was offered via an ambulatory mental health care center. Patients began with an FTF meeting with an MHP, whereby they started composing a personalized relapse prevention plan. Next, patients could access web-based modules and a weekly diary via their computer, tablet, or smartphone. They were able to send messages to their MHP, ask for feedback on completed modules, and schedule FTF meetings with their MHP. All MHPs received a 4-hour training course, in which background information on relapse prevention, strategies for relapse prevention, and practical advice on using the program was provided [
Patients were eligible to participate if they had received treatment in specialized mental health care centers for anxiety or depressive disorder in the previous 2 years. After receiving acute phase treatment, they were referred to primary care services. They had to be in full or partial remission according to their MHP or clinician (clinical judgment), have scored 50 or higher on the Global Assessment of Functioning scale [
We sought to recruit 50 MHPs and 126 patients for this study. Sample size calculations have been described elsewhere [
The Medical Ethics Committee of the Vrije Universiteit University Medical Center Amsterdam deemed that ethical approval was not required according to Dutch legislation (registration 2016.280) and thus gave their permission to conduct the study.
The central aim of the program was to prevent relapse via the promotion of self-management skills. In the field of mental health, strengthening self-management skills is increasingly important, insofar as it allows patients to self-manage their own mental health [
The web-based modules were divided into 2 core modules “relapse psychoeducation” and “relapse prevention plan” (see
Overview of eHealth modules.
Patients were invited to complete questionnaires at baseline (T0) and after 3 (T1), 6 (T2), and 9 months (T3). Completion of the questionnaires took 20-30 minutes. If necessary, patients received an email reminder after 1 week. As part of the treatment protocol, patients were also prompted to complete the mood and anxiety diary once a week for a period of 9 months (39 times). MHPs were requested to complete a case registration form after each FTF contact, in which the clinical status of patients and the duration and content of the FTF contacts were described. In order to assess the usage intensity of the program, log data from the web-based platform were collected.
Demographic and clinical variables of patients were assessed at baseline using the questionnaire. Moreover, in the baseline questionnaire, patients were asked to score their own perceived risk of relapse as well as their expectations about the effectiveness of the relapse prevention program (0%-100%). Anxiety severity was measured using the BAI, and symptoms in the past week were assessed. This questionnaire contains 21 items, all of which are rated on a 0- to 3-point scale, with a total score ranging from 0 to 63, with ≥30 indicating severe anxiety symptoms [
Log data from the web-based platform was used to assess the web-based usage intensity of the program. This included the number of messages from patients to MHPs or vice versa, the number of completed modules, and the number of diary entries. The frequency of FTF contact between patients and MHPs was registered with the TiC-P [
To explore the course of symptoms during the study, the severity of anxiety and depressive symptoms was measured at baseline and 3-month intervals (T1, T2, T3) using the BAI and the IDS-SR. Deterioration/relapse was defined as an increase of at least 1 SD on the IDS-SR or of an increase on the BAI between T0 and T3. If there was an increase of 1 SD on the IDS-SR and the BAI, this was also regarded as deterioration/relapse. Similarly, symptom improvement was defined as a decrease of at least 1 SD. The SD was calculated using data from the Netherlands Study of Depression and Anxiety [
Descriptive statistics were used to describe the characteristics of the participants to illustrate the extent to which patients used the program (over time) and to explore the course of symptoms. Explorative analyses were conducted to study the association between usage intensity and the course of symptoms. The course of symptoms was determined for both regular and low users in accordance with the “minimal usage intensity” measure as well as for the separate usage intensity measures. Differences in anxiety and depressive symptoms between regular and low users were tested using the Mann-Whitney
Time-lag model. T0: baseline assessment; T1: assessment after 3 months; T2: assessment after 6 months; T3: assessment after 9 months.
The demographic and clinical characteristics of the participants (N=113) are reported in
Demographic and clinical characteristics of the total sample (N=113).
Variables | Value | ||
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Age (years), mean (SD) | 42.9 (12.9) | |
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Sex (female), n (%) | 65 (57.5) | |
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Nationality (Dutch), n (%) | 105 (92.9) | |
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Single | 45 (39.8) |
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In relationship | 68 (60.2) |
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High school | 23 (20.3) |
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Secondary vocational education | 22 (19.5) |
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Higher professional education or university | 64 (56.6) |
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Unknown | 4 (3.6) |
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Employed | 79 (69.9) |
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Sick leave | 18 (15.9) |
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Other | 16 (14.2) |
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Treatment for depressive disorder | 41 (36.3) |
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Treatment for anxiety disorder | 27 (23.9) |
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Treatment for both depressive disorder and anxiety disorder | 45 (39.8) |
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Number of times received treatment for mental health problems, mean (SD) | 3.5 (3.3) | |
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Time passed since referral back to the primary care physician from specialized care (months), mean (SD) | 5.9 (6.3) | |
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Age of first onset (years), mean (SD) | 27.6 (13.8) | |
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Positive family history of anxiety or depressive disorder, n (%) | 60.0 (53.1) | |
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Anxiety sensitivity, mean (SD) | 10.7 (7.9) | |
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General functioning and disability, mean (SD) | 23.6 (15) | |
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Anxiety severity, mean (SD) | 10.2 (6.6) | |
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Depression severity, mean (SD) | 20.6 (9.5) |
The use of the program is described in 3 subcategories: (1) contact with MHP, (2) completed modules, and (3) diary entries.
The option to correspond with MHPs via the web-based platform was rarely exercised by participants. In total, the 113 patients sent 157 messages to their MHPs (median 0 [IQR 0.0-2.0]) and received 260 messages in return from their MHPs (median 1.0 [IQR 0.0-3.0]). Sixty-five patients (57.5%) never sent a message to their MHP, and 45 patients (39.8%) never received a single message from their MHP. All participants had initial FTF contact with their MHPs. During the 9 months of the study, there were 260 FTF follow-up meetings (median 1.0 [IQR 0.0-4.0]). Forty-nine participants (43.4%) did not have any follow-up meetings with their MHP. Forty-one participants (36.3%) met their MHP at least every 3 months, as prescribed in the research protocol. The number of FTF appointments ranged from 0 to 13.
A median of 4 modules were completed by the participants (IQR 2.0-8.0). Of the 113 participants, 1 (0.01%) completed all the 14 available modules, while 17 participants (15%) failed to complete any module. The 2 core modules were completed the most: 74.3% (84/113) of the participants completed the module “relapse psychoeducation” and 69.9% (79/113) completed the module “relapse prevention plan.” Approximately 46%-54% of the patients completed the other 3 psychoeducation modules, while less than 40% of patients completed the optional modules.
The number of diary entries varied substantially across the participants, ranging from 0 to 159, with a median of 4 (IQR 1.0-15.0). Seventeen participants (15%) never reported on their mood and anxiety. Only 12 participants (10.6%) completed the diary weekly for the entire duration of the study. Usage of the program decreased considerably over time, as can be seen in
Usage of the modules, diary, and face-to-face contacts over time. FTF: face-to-face; MHP: mental health professional.
In the overall sample, anxiety and depressive symptoms decreased slightly over time. For all 113 participants, the mean BAI score at baseline was 10.2 (SD 6.6). After 9 months, the mean BAI score of the remaining 79 participants was 9.3 (SD 8.2). The differences over time were not significant, as indicated by the overlapping error bars in Figure S1 in
Of the 113 patients, 27 (23.9%) met the criteria for the “minimal usage intensity” measure, and hence, these patients were defined as regular users. Figure S3 in
The mean BAI scores and IDS-SR scores for regular users (median use of usage variable or higher) and low users (below median of usage variable) on the separate usage intensity measures across all 4 time points are shown in
In the GEE analyses, all of the separate usage variables were used to model the course of anxiety and depressive symptoms in a multivariate analysis. GEE analyses indicated no significant association between module completion and number of diary entries and the course of anxiety or depressive symptoms (
Generalized estimating equations analysis of the longitudinal associations of separate usage intensity variables with anxiety and depressive symptoms.
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Anxiety symptoms | Depressive symptoms | ||||
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β (SE) | 95% CI | β (SE) | 95% CI | ||
Module completion | .12 (.13) | –.15 to .38 | .39 | .06 (.12) | –.18 to .30 | .65 |
Face-to-face contact with mental health professional | .84 (.23) | .39 to 1.29 |
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1.12 (.34) | .45 to 1.79 |
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Diary completion | –.05 (.03) | –.10 to .003 | .07 | –.04 (.03) | –.09 to .02 | .19 |
a
This study has shown the usage intensity of the GET READY relapse prevention program, explored the course of symptoms of participants across the duration of the study, and examined the association between usage intensity and the course of symptoms. The core modules were used by ≥70% of the patients, while optional modules were regarded as elective and used as such (<40% of the patients). Of the 113 patients, 27 (23.9%) were defined as regular users according to the minimal usage intensity measure. Usage of the self-management components of the program (the web-based modules and web-based mood and anxiety diary) decreased quickly over time. Although no causal effect of the GET READY intervention on the severity of psychopathology could be established owing to its pre-post design, it appeared that most patients remained stable or experienced symptom improvement while they engaged with the GET READY program. Having more FTF contact with MHPs was significantly associated with an increase in anxiety and depressive symptoms. The other usage intensity variables were not significantly associated with the course of symptoms. Overall, the participants were highly educated and employed. These results are consistent with those reported in other studies on web-based or eHealth interventions [
The core components of the program were used fairly well, as the 2 core modules “relapse psychoeducation” and “relapse prevention plan” were completed by 74.3% (84/113) and 69.9% (79/113) of patients, respectively. As expected, optional modules were used less frequently than the core modules, with less than 40% of patients completing them. This result is consistent with data from Hollandäre et al [
Usage of the program decreased rapidly over time, as most patients used the program for a median of 1 month after registering on the web-based platform. Although this finding has been reported in previous studies on (web-based) guided self-help programs [
Although all of the patients were in remission, they nevertheless appeared vulnerable to relapse: patients had already received an average of 3.5 treatments in specialized care, 53.1% (60/113) had a family history of anxiety/depression, and 39.8% (45/113) had received treatment for both an anxiety and a depressive disorder, while their baseline mean symptom levels showed mild residual anxiety and depressive symptoms. In the overall sample, anxiety and depressive symptoms decreased slightly over time. Most participants remained stable, while 19%-23% of patients experienced symptom improvement. Only 10%-15% of the patients experienced a relapse. In comparison to other studies, our results show lower relapse rates [
Patients who experienced a deterioration in symptoms more often used antidepressant medication than patients whose symptoms improved. However, this result should be interpreted with caution, as no causal pathway can be established. This study design is not feasible to investigate the influence of medication on the course of symptoms. Patients who had more FTF contact with MHPs had significantly higher anxiety and depressive scores than patients who had less FTF contact with MHPs. It is questionable whether the support they received by their MHP was sufficient to engender a subsequent decrease in symptoms. At the same time, this result might indicate that the web-based program in itself does not provide enough support to patients who experience a deterioration of symptoms. As aforesaid, this is a pre-post study; therefore, no causal pathway could be established [
There are several potential limitations in this study. First, attrition from the study was relatively high, with only 79 (69.9%) of the 113 participants completing the last follow-up questionnaire. Despite this, the statistical methods applied in this study, especially GEE analyses, are expedient for handling missing data. Second, self-selection bias and the fact that the patients were highly educated might restrict the generalizability of the results. However, Donkin et al’s [
This study highlights the importance of providing personalized and guided relapse prevention to remitted patients with anxiety and depressive disorders. Usage of the program decreased quickly over time, possibly indicating a rapid decrease in the motivation of patients. As aforesaid, this decrease in motivation can be explained by different causal factors. Therefore, MHPs have the important task of monitoring and motivating patients via personalized intervention strategies, thus ensuring that patients receive guidance when they need it the most. Further research in an RCT with a longer follow-up duration is necessary to establish the effectiveness of blended relapse prevention programs. Within the design of an RCT, greater insight can also be obtained into the association between usage intensity and the course of symptoms.
When relapse prevention was offered, most patients used the core modules, while optional modules were completed by a smaller sample. As indicated in an earlier study [
Home page for patients with core modules, namely, relapse psychoeducation and relapse prevention plan, and the mood and anxiety diary.
Course of symptoms specified by usage intensity.
Low and regular use of separate usage intensity measures.
Beck Anxiety Inventory
face-to-face
generalized estimating equations
Guided E-healTh for RElapse prevention in Anxiety and Depression
Inventory of Depressive Symptomatology Self-Report
mental health professional
primary care physician
randomized controlled trial
Trimbos/iMTA Questionnaire for Costs Associated with Psychiatric Illness
ADTM, NMB, AvS, and BvM obtained funding for this study. This study is funded by SIA-RAAK: The Taskforce for Applied Research, part of the Netherlands Organization for Scientific Research. The funder had no role in study design, data collection and analysis, interpretation of data, and preparation of the manuscript. The authors gratefully acknowledge the contribution of all patients, mental health professionals, primary care practices, research assistants, data managers, and all others who contributed to the study.
EKdB, ADTM, NMB, AvS, ORM, AJLMvB, and BvM contributed to the design of the study. EKdB, ADTM, and BvM coordinated the recruitment of mental health professionals and patients and the data collection. AH advised in data analysis. EMB participated in data analysis. EKdB analyzed the data and drafted the manuscript. All authors revised and commented on the manuscript. All authors read and approved the final manuscript.
None declared.