Internet-based interventions for the prevention and treatment of depression in people living in developing countries: A systematic review

Highlights

• Most were feasibility studies of Internet-based interventions for depression (IBIDs).

• These IBIDs were acceptable and useful to potential users.

• The interventions were highly structured and provided limited human support.

• No effectiveness studies were identified.

• Least developed countries were not represented, nor individuals of a lower social standing.

Abstract

Background

Internet-based interventions for depression may be a valuable resource to reduce the treatment gap for those living in developing countries. However, evidence comes mainly from developed countries. This systematic review summarized the evidence on preventive or therapeutic Internet-based interventions for depression for people who reside in developing countries.

Methods

CINAHL, EMBASE, PubMed, SciELO Citation Indexes, the Journal of Medical Internet Research, and the Telemedicine and e-Health journal, were searched up to June 2017, to identify feasibility or effectiveness studies of preventive or therapeutic Internet-based interventions for depression, with or without human support. Studies included subjects residing in developing countries, and were published in English or Spanish. Study protocols were included. Risk of bias and/or quality of the reporting of the studies included was assessed.

Results

Five feasibility studies, aimed at the prevention of depression, and a study protocol were included in this systematic review. Reports came mostly from the Americas (n = 4). Internet-based interventions aimed at the prevention of depression presented low levels of human support, were useful and acceptable to their users, and require further design refinements to improve their use and retention.

Limitations

No gray literature was searched or included in this systematic review. Searches were limited to English and Spanish languages.

Discussions

Internet-based interventions aimed at the prevention of depression in people who reside in developing countries are in an early phase of development, limiting the generalizability of the results. Future studies must employ persuasive designs to improve user retention, incorporating larger samples and a control group to conclusively determine feasibility.

Introduction

Depressive disorders are characterized by marked symptoms of low mood and anhedonia, and can have a recurrent course, impairing functional abilities of the individuals affected (American Psychiatric Association (APA), 2013). According to the recent Global Health Estimates published by the World Health Organization, depressive disorders have been ranked as the single largest cause of global disability, with a worldwide pooled prevalence of 4.4% and an upward trend in low- and middle-income countries (World Health Organization (WHO), 2017).

Although effective and low-cost strategies for the prevention and treatment of depression exist (Patel, 2017), the current treatment gap for this disorder has been estimated to be between 72% and 93% of all depressed people, with those from the poorest countries receiving less coverage (Chisholm et al., 2016). When it is not timely and properly treated, depression may increase the risk of worse health outcomes (Ghio et al., 2014, Rotella and Mannucci, 2013).

Internet-based interventions are defined as “treatments that have been operationalized and transformed for delivery via the Internet… highly structured, self or semi-self-guided; based on effective face-to-face interventions; personalized to the user; interactive; enhanced by graphics, animations, audio, and possibly video; and tailored to provide follow-up and feedback” (Ritterband and Thorndike, 2006). There is evidence that has proven their feasibility and effectiveness in the prevention and treatment of depression (Andersson and Cuijpers, 2010, Richardson and Richardson, 2012).

These programs are usually based on cognitive-behavioral principles, with guided programs providing more positive results than unguided ones thus becoming a promising alternative or complement to face-to-face interventions by helping to reduce the treatment gap (Anderson and Cuijpers, 2010; Anderson et al., 2013; Richardson and Richardson, 2012; Schröder et al., 2016). More recently, meta-analyses have showed that unguided Internet-based interventions are more effective (Karyotaki et al., 2017) and are associated with a reduced risk of symptom deterioration (Ebert et al., 2016), compared with controls. However, methodological problems, such as a lack of blinding, selection bias, and low adherence, may hinder their internal and external validity (Ye et al., 2014).

Moreover, evidence comes mainly from people living in developed countries (Schröder et al., 2016), whereas it may be a valuable resource to reduce the treatment gap for those living in less developed countries, thus ameliorating social health inequalities between regions (Latulippe et al., 2017), there is little knowledge about purposely developed internet based interventions for depression in such countries. The objective of this systematic review was to summarize the evidence regarding internet-based interventions for the prevention or treatment of depression in people living in developing countries.