Web-based self-intervention may prevent depression in patients with persistent back pain

A guided web-based self-intervention, adapted from elements of cognitive behavioural therapy (CBT), may be effective in preventing the onset or recurrence of major depressive episodes (MDEs) in patients with persistent back pain, according to results of the recent PROD-BP study.

The guided web-based self-intervention halved the risk of MDE onset (hazard ratio [HR], 0.48; 95 percent confidence interval [Cl], 0.28 to 0.81; p<0.01) and the incidence of MED (14.1 percent vs 28.1 percent) compared with standard treatment over a 12-month treatment period. The number needed to treat (NTT) to prevent one new case of MDE was 2.84 (95 percent CI, 1.79 to 9.44). [JAMA Psychiatry 2020, doi: 10.1001/jamapsychiatry.2020.1021]

It also demonstrated efficacy in improving clinician-rated depression severity (Hamilton Depression Rating Scale [HAM-D] mean score, -0.32; Quick Inventory of Depressive Symptomatology [QIDS] mean score, -0.32; Patient Health Questionnaire-9 [PHQ-9] score, -0.40), pain-related disability (Oswetry Disability Index, -0.31) and pain self-efficacy (Pain Self-Efficacy Questionnaire [PSEQ] score, 0.33), as well as quality of life (Assessment of Quality of Life [AQoL-6D] score, -0.43), at 12-month follow-up. However, the effect on work capacity (Subjective Prognostic Employment [SPE] mean score, -0.13) and pain intensity (Numerical Rating Scale mean score, -0.18) did not favour the intervention at 12 months.

Adherence to the intervention was reduced by 1.49-fold and 3.63-fold with each additional lifetime MDE and in patients who had prior psychotherapy, respectively.

No significant differences were observed in healthcare utilization (Trimbos/iMTA Questionnaire for Costs Associated with Psychiatric illness [TiC-P]) between the two groups. Patients in the intervention group were prescribed slightly less pain medication (difference, 5.58 percent) and had slightly more visits to primary care physicians (difference, 4.58 percent) vs those in the control group at 12-month follow-up. Satisfaction was high (client satisfaction with online intervention questionnaire-8 mean score, 22.87) with the guided web-based self-help intervention.  

Comparable rates of adverse events (AEs) were reported between the intervention group and control group (48.8 percent vs 51.2 percent). However, none of the AEs were associated with the intervention. No serious AEs (ie, psychiatric hospitalization, suicide attempt, or suicide) were reported.

In the PROD-BP (Prevention of Depression in Back Pain Patients) pragmatic, observer-blinded randomized trial, 295 individuals (mean age, 52.8 years; female, 62.4 percent) with a diagnosis of persistent back pain and subclinical depressive symptoms, but who were depression free, were recruited from 82 orthopaedic clinics and randomized (1:1) to receive a guided web-based self-help intervention plus treatment as usual or treatment as usual only. Most of the participants (70.2 percent) had a educational level, and less than 30 percent had prior psychotherapy.

The guided web-based self-help intervention, adapted from the principles of CBT, consisted of six compulsory modules and three optional modules (mean completion time, 43 minutes per module). Participants could opt for automated motivational text messages in addition to the online programme, which entailed brief exercises in daily life depending on treatment progress. Written feedback and answers to questions would be given by e-coaches (trained and supervised psychologists) within 24 hours after completion of each module (mean guidance time, 64.8 minutes per completed treatment).