A four-year experience with a Web-based self-help intervention for depressive symptoms in Mexico

Transcription

1 Investigción originl / Originl reserch Pn Americn Journl of Public Helth A four-yer experience with Web-bsed self-help intervention for depressive symptoms in Mexico Mrí Asunción Lr, 1 Mrcel Tiburcio, 1 Arceli Aguilr Abrego, 1 nd Alejndro Sánchez-Solís 1 Suggested cittion Lr MA, Tiburcio M, Aguilr AA, Sánchez-Solís A. A four-yer experience with Web-bsed self-help intervention for depressive symptoms in Mexico. Rev Pnm Slud Public. 2014;35(5/6): bstrct Key words Objective. To describe four-yer descriptive, nturlistic study monitoring the use of HDep (Help for Depression or Ayud pr depression (ADep) in Spnish), n openccess/free Web-bsed, psycho-eduction, cognitive-behviorl intervention progrm produced in Mexico consisting of seven self-help modules tht include feedbck-generting ssessments of depressive symptoms, vignettes, recorded messges, relxtion exercise, personl workbook, blogs, nd user discussion forums. Methods. Dt were collected on ll individuls who entered the HDep site since the progrm s lunching in Those who entered the site two or more times nd lso registered s users or prticipnts. The user dt consisted of 1) user profiles; 2) scores for the CES-D (Center for Epidemiologicl Studies Depression Scle), for users who completed the feedbck-generting ssessments of depressive symptoms; 3) user evlutions of the usefulness of HDep; nd 4) trnscripts of HDep discussion forum posts. The rw user dt were obtined through Moodle (Modulr Object-Oriented Dynmic Lerning Environment, free softwre e-lerning pltform) nd nlyzed quntittively (using SPSS) nd qulittively (using ATLAS.ti). Results. A totl of individuls ccessed HDep nd of those (61.6%) qulified s users. Of ll users, 84.4% were women, 64.6% used the workbook, nd 60.9% entered the discussion forums (of whom 16.3% dded post). Depressive symptoms (CES-D score 16) were observed in 97.1% of the users who completed the feedbck-generting ssessment (n = ). User retention dropped cross the seven modules (from users for 1 to 626 for 7). However, ll seven modules were rted very high for helpfulness/ usefulness, with men scores ll bove 4 on 1 5 scle. The HDep discussion forums showed rich socil interction. Predictors of entering t lest one module (bsed on stepwise logistic regression nlysis) included being womn, being 30 yers old, reporting disbility, nd hving ttempted suicide. Of the 72 prticipnts who completed the finl user evlution of HDep, 97.5% sid it hd n enormous influence on helping them to identify nd trnsform negtive thoughts. Conclusions. Despite the high ttrition mong users, nd the need for further structure dpttion, HDep cn be considered potentilly useful mentl helth tool in Mexico for 1) detecting depression (vi the CES-D ssessments) nd 2) providing mens of socil support to those with depression. The high levels of depressive symptoms detected mong users suggest tht the role of free-ccess, self-help, Web-bsed interventions in public mentl helth progrms should be further investigted. The effectiveness of HDep in reducing depressive symptoms nd providing support system hs yet to be ssessed nd should be exmined in future reserch. Depression; Internet; socil support; cognitive therpy; Mexico. 1 Instituto Ncionl de Psiquitrí Rmón de l Fuente Muñiz, Mexico City, Mexico. Send correspondence to: Mrí Asunción Lr, lrcn@imp.edu.mx Rev Pnm Slud Public 35(5/6),

2 Originl reserch Lr et l. Web-bsed self-help intervention for depressive symptoms in Mexico As the Internet is incresingly incorported into everydy routines, it cn lso become vluble resource for public mentl helth. Even in developing countries such s Mexico, there is widespred use, with 37.6 million Internet users (40.6% of the popultion), 6.9 million households with Internet ccess (23.3%), nd n unknown number of users connecting t Internet cfés (1). Web-bsed interventions hve the potentil to ply n importnt role in nrrowing the tretment gp for mentl helth problems. Due to their ccessibility nd lower cost, nd users bility to remin nonymous if desired (due to the stigm ssocited with mentl helth problems), Webbsed interventions re n ttrctive lterntive to trditionl tretments (2). In ddition, their potentil for providing ccess to tretment for common mentl helth disorders such s depression is encourging (2, 3). Depression is one of the most common mentl helth disorders worldwide nd is ssocited with enormous personl suffering nd costs. Of the globl popultion, between 3.3% nd 21.4% suffer from mood disorder (4). Lifetime prevlence of depression in Mexico is 5.4% in mles nd 10.4% in femles (5). It is expected tht by the yer 2020 mjor depressive disorder will be the second-leding cuse of morbidity worldwide (6, 7). At present, depression is the principl cuse of disbility-djusted life yers lost (DALYs) mong Mexicn women nd the ninth-rnked cuse for Mexicn men (8). Although depression is tretble, only smll minority of those ffected by the most severe form of this nd other mentl helth conditions receive tretment. Across ll countries worldwide the proportion of those ffected by depression rnges from 6.0% to 52.1% (9), nd in Mexico, only 19.6% of those with mentl helth disorder, including depression, seek tretment (10). Most Web-bsed interventions for depression re bsed on cognitive behviorl therpy (CBT) (11, 12). A met-nlysis of 13 Web-bsed CBT interventions for depression nd nxiety symptoms reports moderte overll men effect size nd significnt heterogeneity, wheres tretment with some kind of dditionl support showed lrger men effect size nd no heterogeneity (2). Although online interventions in Spnish developed in the United Sttes for mentl helth problems hve been well received mong Spnish-speking Ltinos in the United Sttes nd in other popultions (13, 14), in Ltin Americ, there is s yet no published reserch on Web-bsed interventions designed in the region tht consider popultions with wide rnge in eductionl nd economic levels. HDep (Help for Depression or Ayud pr depresión (ADep) in Spnish) is n open-ccess/free Web-bsed, psycho-eduction, cognitive-behviorl intervention progrm produced in Mexico consisting of seven self-help modules tht include feedbck-generting ssessments of depressive symptoms, vignettes, recorded messges, relxtion exercise, personl workbook, blogs, nd user discussion forums. It is the first online intervention for depression in Mexico nd, to best of the uthors knowledge, the first in Spnish. The im of this descriptive, nturlistic study is to summrize four-yer experience monitoring the use of HDep through quntittive nd qulittive nlyses. The study explores the type of users reched by HDep, their use of the website s intervention for depression, whether they perceive it s useful, chnges in ny depressive symptoms they my hve during their use of the progrm, nd vribles ffecting user retention. The results of the study were used in the ongoing process of designing nd dpting HDep to better meet user needs nd were the bsis for the second edition of HDep, which is lredy online ( These findings my be useful to other reserchers in designing Web-bsed interventions in Ltin Americ. MATERIALS AND METHODS Intervention 2 Modulr Object-Oriented Dynmic Lerning Environment ( free softwre e-lerning pltform). This progrm ws selected to tke dvntge of its openccess nd efficient resources for designing questionnires, editing text, nd incorporting imges; creting dtbses trnsportble to other sttisticl progrms for nlysis (e.g., SPSS); nd producing multiple products from the dt collected, including blogs nd forums, nd thus voiding the cost of hving to build those elements from scrtch. 3 The initil study protocol, which ssessed the effectiveness of the fce-to-fce intervention from HDep ws developed using the Moodle 2 pltform, bsed on the results of previous fce-to-fce intervention imed t preventing depression in women (15, 16). 3 For the current study, dt were collected on ll individuls who visited the HDep site since the progrm s lunching in Those who registered nd entered the site two or more times qulified s users or prticipnts. The user dt consisted of 1) user profiles; 2) scores for the CES-D (Center for Epidemiologicl Studies Depression Scle), for users who completed the feedbckgenerting ssessments of depressive symptoms; 3) user evlutions of the usefulness of HDep; nd 4) trnscripts of HDep discussion forum posts. The rw user dt for the study were obtined through Moodle nd nlyzed quntittively (using SPSS) nd qulittively (using ATLAS.ti). HDep website content includes seven modules tht include ssessments of depressive symptoms tht provide feedbck to users, vignettes, recorded messges, relxtion exercise, personl workbook, blogs, nd discussion forums (Tble 1). In the discussion forums, ccessible t the end of ech module, users cn shre their thoughts bout wht they hve lerned. Users re free to move through the modules t their own pce but re dvised to 1) red the mteril in the initil modules, 2) tke time to prctice the wys of thinking nd behviors recommended within them, nd 3) tke t lest eight weeks to complete the seven-module series. Users re not instructed to complete ll of the modules. The HDep homepge contins the terms nd conditions of use of the website. Users re dvised to utilize pseudonyms to protect their nonymity nd re informed tht user dt will be used for reserch purposes but tht confidentility will be ensured by not disclosing nmes. By registering with the site, users ccept these conditions nd t the sme time gree not to trnsfer ny informtion obtined from HDep outside the site. The site is checked for proper functioning prticulrly the discussion forums t lest twice per week. Prticipnts The nlysis of site usge ws bsed on utomticlly recorded dt on ll visitors to HDep between Mrch 2009 nd April 2013 (n = ). which HDep ws derived, ws pproved by the institutionl review bord of the Rmón de l Fuente Muñiz Ntionl Institute of Psychitry in Mexico City. 400 Rev Pnm Slud Public 35(5/6), 2014

3 Lr et l. Web-bsed self-help intervention for depressive symptoms in Mexico Originl reserch TABLE 1. HDep website content, Mrch 2009 April 2013 Content component/module Eduction segments nd vignettes Discussion forums nd blogs Frequency per content component/module CES-D b ssessment Recorded relxtion exercise Recorded messges c Personl workbook entries Welcome to HDep (progrm introduction) 1 Bseline ssessment d 1 1. Depressive symptoms nd risk fctors for depression Negtive thoughts ffecting mood Negtive thought ptterns lerned from childhood CES-D Everydy stressors nd life events The femle role/stereotype nd depression Socil support nd plesnt ctivities Violence, ddictions, nd depression e Finl summry (HDep progrm) 1 1 Finl user evlution f nd CES-D ssessment 1 HDep (Help for Depression or Ayud pr depresión), n open-ccess/free Web-bsed, self-help, psycho-eduction, cognitive-behviorl intervention progrm produced in Mexico using the open-ccess/free e-lerning pltform known s Moodle (Modulr Object-Oriented Dynmic Lerning Environment). b Center for Epidemiologicl Studies Depression Scle. Three CES-D ssessments were vilble for completion by users: 1) t bseline (user registrtion), 2) fter completion of 3 (intermedite ssessment), nd 3) fter completion of 7 (finl ssessment). c Welcome to HDep (introduction to HDep progrm), module introduction, module summry, nd finl summry of HDep progrm. d User questionnire collecting demogrphic dt (t user registrtion) nd bseline CES-D ssessment. e Added by request from HDep sponsor, Fundción Gonzálo Río Arronte (Mexico City). f User perceptions of the usefulness of HDep. Quiz Mesurements The bseline HDep user questionnire required for user registrtion collected demogrphic dt, including sex, ge, plce of residence, mritl sttus, eductionl ttinment, nd occuption. User depressive symptoms were mesured t bseline nd fter users completion of 3 (intermedite ssessment) nd 7 (finl ssessment), using the Center for Epidemiologicl Studies Depression Scle (CES-D) (17). The CES-D is 20-item scle yielding continuous score (0 60). The norml cutoff score for indiction of depressive symptoms is 16. Other indictions of mentl helth problems explored through purposively designed questionnires were the presence or bsence of: 1) disbility; 2) suicide ttempt; 3) excess drinking; 4) drug use; 5) previous psychologicl or psychitric tretment for depression; nd 6) drug tretment (Figure 1). Site use ws mesured s 1) the number of self-reported ctivities completed in ech module ( ll, hlf or more, or less thn one/none ) nd 2) the number of prticipnts using the vrious tools (workbook, forums, nd blogs), bsed on the Moodle dt. User retention ws mesured s the proportion of people entering ll modules of those who entered 1. s nd ctivities were evluted using brief scles mesuring users perception of their helpfulness/ usefulness vi their responses to three sttements nswered on five-point Likert scle (1 = not helpful/useful to 5 = very helpful/useful ) % CES-D ( 16) 54.90% Disbility 1 9% Suicide ttempt % After completing ll the modules, prticipnts were sked to complete finl evlution of HDep, bsed on their perceptions of its usefulness, which included two closed questions ( Did this FIGURE 1. Proportion of HDep users (n = ) who completed the bseline CES-D b ssessment (n = ) nd ttined score indicting depressive symptoms (97.10%) nd their mentl helth chrcteristics, Mrch 2009 April Those who nswered Yes to the question: In the lst month, hve you hd to stop working, ttending school, or performing your dily ctivities becuse of problems such s feeling lonely, sd or listless? 2 Those who nswered Yes to the question: In the lst six months, hve you tried to end your life? 3 Those who nswered Yes to the question: Do you consume lcohol excessively? 4 Those who nswered Yes to the question: Do you use some kind of illicit drug such s mrijun, cocine, inhlnts, or nonprescription drugs? 5 Those who nswered Yes to the question: Are you or hve you received psychologicl or psychitric tretment for depression? 6 Those who nswered Yes to the question: Hve you tken mediction for feeling nervous, nxious or excessively energetic? 37.80% 5.10% 30% Excess Drug use 4 Psychologicl drinking 3 or psychitric tretment 5 Drug tretment 6 Registered, repet visitors to HDep (Help for Depression or Ayud pr depresión), n open-ccess/free Web-bsed, selfhelp, psycho-eduction, cognitive-behviorl intervention progrm produced in Mexico. b Center for Epidemiologicl Studies Depression Scle (CES-D), mentl helth ssessment tool vilble on the HDep website. Rev Pnm Slud Public 35(5/6),

4 Originl reserch Lr et l. Web-bsed self-help intervention for depressive symptoms in Mexico intervention help you lift your mood? (Yes/No), nd Did prticipting in this intervention hve n influence on your current problems or the wy you look t life? (0 = negtive influence to 5 = enormous influence ), followed by seven open-ended questions: 1) Wht influence did the intervention hve on you? 2) Wht spect of the intervention ws most helpful? 3) Wht spect of the intervention ws lest helpful? 4) Wht improvements would you mke? 5) Will you continue using these techniques in your everydy life? 6) Which ones? nd 7) Under wht circumstnces? As prticiption in the discussion forums yielded rich source of informtion on the use of HDep, content nlysis of the trnscripts of the forums ws lso crried out. Dt were obtined from two periods: the first six months fter the HDep lunch (Mrch August 2009), nd the lst three months fter the lunch (Februry April 2013). These two study periods yielded bout the sme number of user discussion forum posts. In preprtion for the qulittive nlyses, ll discussion forum posts for the two selected study periods were compiled in text file nd nlyzed ccording to the ctegories used by Slem et l. (18) to explore the type of interctions tht tke plce in Web-bsed mutul-help groups for persons suffering from depression (e.g., emotionl support, dvice or informtion, disclosure, reflections, etc.). The ctegoriztion ws crried out by two of the couthors (AAA nd AS) supervised by two other couthors (MAL nd MT). For the finl smple, reserch ssistnt confirmed the prevlence of the ctegories nd sought new ones supervised by one of the couthors (AAA), finding similr ctegories in this second smple. Prior to coding the entire text, 90% interrter relibility ws ttined by coding 15% of the posts. Becuse the contents of single post sometimes included severl topics, it ws possible tht some posts were clssified in more thn one ctegory. Procedure Immeditely fter the lunch of HDep in 2009, dissemintion ctivities only included few rdio nd television interviews. However, s of 2011, HDep ws promoted on the Web, thnks to grnt from Google AdWords (www. google.com.mx/intl/es/grnts/). Dt on the number of visits to the site were retrieved from Google Anlytics (www. google.com/nlytics), nd the ctivity of ech prticipnt within the site s well s his/her nswers to the questionnires were utomticlly recorded by Moodle, nd then converted into dtbse. Dt nlyses The rw dt generted by Moodle were orgnized in Excel dtbses for further nlyses. Descriptive nlyses were performed to obtin mens nd stndrd devitions. Two stepwise logistic regression nlyses were conducted to ssess predictors of user retention for s 1 3 only becuse retention ws very low in the remining modules. The independent vribles included sex, ge, mritl sttus, occuption, suicide behvior (Yes/No), nd psychologicl tretment (Yes/No). These nlyses yielded mximum likelihood estimtes for combined reltive odds with 95% confidence intervls (CIs). Anlyses were conducted using SPSS version 19 (IBM SPSS Sttistics for Windows, IBM Corp., Armonk, NY, USA) nd qulittive nlysis of forum content ws crried out using ATLAS.ti version (ATLAS.ti Scientific Softwre Development GmbH, Berlin, Germny). RESULTS Chrcteristics of HDep users During the four-yer study period, individuls ccessed the HDep online intervention but only (61.6%) registered nd entered the site two or more times, qulifying s users or prticipnts. The mjority of ll visitors to the site (83.2%) lerned bout HDep through serches on the Internet. Surprisingly s HDep is designed for women 15.6% of registered users were mle. In ddition, 80% were yers old, most lived in Mexico City (95%), nd the mjority hd medium or high eductionl ttinment (64%) (Tble 2). Depressive symptoms (indicted by CES-D score 16) were observed in 97.1% of users nswering the scle (n = ), mong which 54.9% reported disbility ssocited with depressive symptoms, 9% suicide ttempt, 12.3% excess drinking, nd 5.1% consumption of illegl drugs. Almost one-third (30%) sid they hd received psychologicl or psychitric tretment for depression, nd 37.8% sid they hd tken mediction for nerves or nxiety (Figure 1). The percentges of HDep users who reported suicidl behvior nd disbility from depression nd hd lso received tretment were further investigted. The nlyses found tht 34.2% nd 42.4% respectively of those reporting disbility hd been given psychologicl/ psychitric tretment or tken mediction becuse of n emotionl condition, while 40.2% nd 50.3% respectively of those reporting suicide ttempt in the previous six months hd received psychologicl/ psychitric tretment or mediction. Very few prticipnts completed the intermedite CES-D ssessment (fter s 1 3) or the finl CES-D ssessment (fter s 4 7), precluding comprisons with the bseline CES-D ssessments. Among those tht did complete the follow-up CES-Ds, 79.2% (n = 592) (intermedite ssessment) nd 63% (n = 191) (finl ssessment) reported depressive symptoms. TABLE 2. Chrcteristics of HDep users (n = ), Mrch 2009 April 2013 Chrcteristic No. % Sex Femle Mle Age (yers) < > Country Mexico Other Mritl sttus Single Hs prtner Eduction Primry school High school University Occuption Student Homemker Employed Registered, repet visitors to HDep (Help for Depression or Ayud pr depresión), n open-ccess/free Webbsed, self-help, psycho-eduction, cognitive-behviorl intervention progrm produced in Mexico. 402 Rev Pnm Slud Public 35(5/6), 2014

5 Lr et l. Web-bsed self-help intervention for depressive symptoms in Mexico Originl reserch HDep use Overll, of ll users nswered the initil CES-D ssessment nd prticipted twice or more in HDep. Tble 3 (top row) shows the number of individuls who ccessed ech module, with numbers rnging from for 1 (which ddresses depressive symptoms nd risk fctors) to 626 for 7. Of those ccessing 1, smll percentge (5.06%) completed ll seven modules. Even fewer individuls completed the user evlutions of the modules (Tble 3, second row). Completion rtes for the module ctivities, reported in the user evlutions of ech module, were between 29.5% nd 65%. s 5 nd 7 hd lower completion rtes (Tble 3, rows 3 5). These lower rtes re most likely due to the fct tht s 5 nd 7 ddress femle roles/stereotypes nd depression nd violence, ddictions, nd depression, nd re therefore not likely to be ccessed by men. Rtes of use for other components of HDep include the following: 64.6% used the workbook; 60.9% entered the discussion forums, nd 16.3% dded post; nd 66.8% contributed to the blogs. All modules were rted very high for helpfulness/usefulness, with men scores higher thn 4 on 1 5 scle (Tble 3, rows 6 8). The lowest men scores for tht criterion were for 1, which is more eductionl; users described 1 content s not being much help in lifting their mood, nd sid the ctivities were less useful. User retention predictors The stepwise logistic regression nlysis ssessing the predictors for users ccessing t lest one module ws significnt (c 2 = 48.93, degrees of freedom (df) = 4; P = 0.000) (Tble 4). The predictors were 1) being womn, 2) being over 30, 3) reporting disbility, nd 4) hving ttempted suicide. The stepwise logistic regression nlysis for ccessing t lest two modules ws lso significnt (c 2 = 42.42, df = 4; P = 0.000). Predictive fctors for tht criterion included 1) being womn, 2) being homemker, 3) being employed, nd 4) reporting disbility from mentl illness. The sme nlysis for entering t lest three modules ws lso significnt (c 2 = 14.31, df = 4; P= 0.006), nd the predictors were 1) being womn, 2) being homemker, nd 3) being employed. Discussion forums Qulittive nlysis showed tht copious, open exchnge of experiences (using empthetic nd positive sttements rther thn neutrl/flt lnguge) occurred in the discussion forums. No potentilly hrmful exchnges were detected. Of the posts nlyzed, the most frequent ctegories were: 1) reflections (60% of posts), defined s thoughts nd delibertions bsed on personl experiences, the content of the intervention, or posts by others; 2) disclosure (45%), defined s descriptions of feelings, desires, nd behviors not often reveled to others; 3) dvice or informtion provided by users (30%), defined s suggestions or guidnce bout possible courses of ction, or informtion intended to be useful to others; nd 4) emotionl support (29%), defined s comments tht nurtured, encourged, supported, or pproved of other members comments. Finl user evlution of HDep The finl user evlution of HDep usefulness ws completed by 72 women nd 7 men, 94.9% of which thought tht the intervention helped lift their mood. With regrd to the influence of the intervention on their current problems or the wy they looked t life, 97.5% sid it hd n enormous influence nd 2.5% sid it hd some influence; no users sid it hd negtive influence. Wys in which the intervention provided the gretest benefit, ccording to users, included helping them to: 1) identify negtive thoughts nd trnsform them into thinking pttern tht ws more relistic nd fvorble to decision-mking nd positive thinking; 2) understnd the connection between childhood/dolescent experiences nd their dult behvior nd depression; 3) understnd nd nlyze their feelings, prticulrly those relted to depression; 4) lern how to sk for help; 5) find n environment in which they could freely express their feelings nd chieve better understnding of their problems; nd 6) relize their need for professionl help. Mle users lso cited the intervention s vlue in providing n opportunity to better understnd women s perspectives. According to users, lest useful res nd those in need of improvement included the user-friendliness of HDep (e.g., some users sid they did not know how to determine where they hd left HDep during the previous session) nd the lck of both personlized feedbck nd ccess to n online system dministrtor to nswer questions. While onethird of the respondents sid tht s 5 nd 7 were of little use to them, TABLE 3. Number of HDep users who ccessed nd evluted vrious modules nd completed some or ll module ctivities, nd men scores (on 1 5 scle) for progrm helpfulness/usefulness, Mrch 2009 April Accessed module Evluted module Completed module ctivities (%) All (65.1) 565 (50.9) 138 (50.4) 90 (44.1) 18 (29.5) 31 (43.1) 19 (33.3) More thn hlf (27.5) 452 (40.6) 111 (40.5) 96 (47.1) 33 (54.1) 33 (45.8) 20 (35.1) Less thn hlf/none 510 (7.4) 94 (8.5) 25 (9.1) 18 (8.8) 10 (16.4) 8 (11.1) 18 (31.6) Men score for helpfulness/usefulness (SD b ) It helped me know wht to do to lift my 3.73 (0.8) 4.3 (0.7) 4.4 (0.7) 4.4 (0.6) 4.5 (0.6) 4.6 (0.5) 4.5 (0.8) mood The informtion ws useful 4.14 (0.9) 4.5 (0.7) 4.6 (0.6) 4.5 (0.6) 4.5 (0.6) 4.5(0.6) 4.4 (0.9) The ctivities were useful 3.94 (0.9) 4.3 (0.8) 4.4 (0.7) 4.4 (0.7) 4.4 (0.6) 4.5 (0.5) 4.4 (0.7) Registered, repet visitors to HDep (Help for Depression or Ayud pr depresión), n open-ccess/free Web-bsed, self-help, psycho-eduction, cognitive-behviorl intervention progrm produced in Mexico. b SD: stndrd devition Rev Pnm Slud Public 35(5/6),

6 Originl reserch Lr et l. Web-bsed self-help intervention for depressive symptoms in Mexico TABLE 4. Stepwise logistic regression nlyses: predictors of retention mong HDep users who completed the bseline CES-D ssessment (n = ), Mrch 2009 April 2013 mny respondents sid tht the current version of HDep ws fine. The mjority sid tht they would use the techniques lerned from HDep in their everydy life, whether they felt depressed or not, nd qurter of them sid they would use HDep techniques in combintion with those lerned from other resources. DISCUSSION Accessed t lest one module The four-yer study of HDep, n innovtive, online free-ccess intervention designed for women, nd to the best of the uthors knowledge the first one in Spnish, provided useful informtion on HDep s strengths nd weknesses. The reltively high number of visits to HDep (28 078) shows tht Mexicns with depression do seek help/informtion for this problem on the Internet. However, more thn one-third of the people ccessing the site filed to register. Some hypotheses bout why these visitors were not motivted to register nd revisit the site include 1) the possibility tht for some reson mles were discourged from continuing, nd 2) technicl difficulties upon user sign-in (which ws frequently reported). These results highlight the need for 1) dditionl content for mles nd 2) redesign of the homepge. HDep s rech ws minly locl, with most users living in Mexico. As expected, the mjority were women, predominntly within the ge rnge nd with high eductionl ttinment (middle nd higher). This outcome is consistent with previous evidence showing tht people using Web-bsed interventions for depression re mostly Accessed t lest two modules Accessed t lest three modules Chrcteristic OR b CI c OR CI OR CI > 30 yers old 1.08 d e Femle 1.19 d d d Homemker 1.80 d f Employed 1.14 d d Disbility due to depression 1.15 d d Suicide ttempt 1.10 d Registered, repet visitors to HDep Help for Depression or Ayud pr depresión), n open-ccess/free Web-bsed, selfhelp, psycho-eduction, cognitive-behviorl intervention progrm produced in Mexico. b OR: odds rtio. c CI: confidence intervl. d p e ORs nd CIs only provided for vribles included in the regression eqution. f p highly educted women from their mid- 20s to mid-40s (11, 19 21). Compred to these studies, HDep users were younger nd more often single (22). Mle prticiption in HDep (15.6%) highlights men s need for help for depression. The reserch tem speculted tht the nonymity of Web-bsed interventions might be ttrctive to mle users becuse the mle role often prevents fce-to-fce expression of feelings of sdness nd helplessness (23). HDep users reported high levels of psychopthology. Depressive symptoms (CES-D score 16) were reported by 97% of them, with hlf of those reporting ssocited disbility, nd 9% suicide ttempt in the previous six months. Mny users with depressive symptoms lso ppered to hve substnce buse problems. A high level of depressive symptoms reltive to popultion smples hs lso been observed in studies of other Web-bsed interventions for depression. For exmple, Christensen et l. (22) found tht 90% of the prticipnts in their intervention reported being highly depressed. About one-third of HDep users sid they hd sought some kind of mentl helth tretment (psychologicl/psychitric). Likewise, Christensen et l. (22) found tht 64% of their users hd sought professionl help t some time prior to prticipting in the online intervention. These findings rise the question of the extent to which n open- ccess/ free Web-bsed intervention such s HDep, ccessed by popultion with high levels of depressive symptoms nd other probble pthologies, cn reduce these symptoms in cliniclly significnt wy. Conversely, consistent with popultion studies (10), high percentge of HDep users with this symptomtology were not receiving ny type of professionl help. Some uthors hve expressed concern bout individuls eschewing fce-to-fce tretment in fvor of the online environment (20), suggesting tht further studies re required to determine the role plyed by Webbsed interventions in the choices people mke when seeking help. For those tht did seek professionl tretment, the question remins whether HDep cn be useful complement to professionl tretment, prticulrly in primry cre, where there is shortge of mentl helth professionls (24). User retention decresed with every consecutive module (from in 1 to 626 in 7). Possible fctors ssocited with this low retention rte (5.6%) my be relted to user gender, users not being instructed to complete ll of the modules, nd technicl difficulties ttributble to the HDep softwre pltform. Attrition in Web-bsed interventions for depression hs been considered function of the length rther thn the content of specific sections (19), mening tht this spect of HDep must be revised. User ttrition hs been documented in severl openccess, non-trcked, fully utomted Web-bsed interventions (25). Certin fetures in these utomted interventions unfiltered users, nonymity, ese of enrollment, prticiption free of cost mke it esy to drop out (25). In contrst with the low user retention rtes, ctive prticiption ws observed in users who styed, reflected in the lrge proportion tht used the workbook (64%) nd wrote in the blogs (66.8%). In ddition, user rtings of the helpfulness/usefulness of HDep were very high. Nevertheless, the smll number of respondents nd the likelihood tht only those most stisfied with the intervention nswered the questionnire constitute significnt bis. Predictors for ccessing one, two, or three modules included being 1) womn, 2) > 30 yers old, 3) homemker, nd 4) employed. Future reserch is needed to help determine why HDep is less ppeling to younger people nd wht fetures encourge homemkers nd employees to persevere. Reporting suicidl behvior predicted ccessing one module while reporting disbility 404 Rev Pnm Slud Public 35(5/6), 2014

7 Lr et l. Web-bsed self-help intervention for depressive symptoms in Mexico Originl reserch due to depression predicted ccessing one or two modules. Femle gender nd higher pretest depression scores hve been found to be predictors of dherence in CBT website for depression for dolescents (26). These results were interpreted in terms of motivtion: those with higher symptoms regrded HDep s being more relevnt or beneficil to them. The trnscripts of the HDep discussion forums showed very rich socil interction. These forums were visited by high proportion of users (60.9%), lthough only few posted comments (16.3%). The question remins s to wht fosters or inhibits prticiption in forums. The socil interctions observed in the forums included shring thoughts nd personl experiences, disclosing feelings, giving dvice nd informtion, nd offering mutul emotionl support. In this respect, HDep forum interctions closely resemble those tht tke plce in Internet support groups (20, 27). The potentil benefit of this type of socil communiction is reduction in feelings of loneliness nd socil isoltion. Of the smll proportion of users tht completed the finl evlution of HDep, most (94.5%) sid tht HDep helped lift their mood nd hd n enormous (97%) influence on their current problems nd the wy they looked t life. Specific benefits mentioned by users were HDep s interctive fetures nd the identifiction of their negtive thoughts nd wys to try to chnge them. This type of user feedbck encourges the reserch tem to continue their efforts to dpt HDep to improve user retention. Conclusions Overll, the study findings 1) show tht HDep is useful mentl helth tool for Mexicns nd 2) indicte tht chnges should be mde to the progrm s design, some of its content, nd its length, which my be prtly responsible for user ttrition. While Moodle ws not the most suitble pltform for development of this intervention in terms of user friendliness, finncil constrints prevented the use of other options. The second edition of HDep (ADep in Spnish) ws built using open Web technology with greter cpcity. 4 While user retention ws very low, the more frequent users to HDep sid tht they liked the content, found the ctivities helpful, nd used the forums s source of socil support. The high level of symptoms of depression nd other mentl disorders mong users (of whom bout one-third were using other types of therpy) suggests tht the role of Web-bsed interventions in providing guidnce to those seeking help should be further investigted. Web-bsed interventions hve n enormous potentil to rech people with unmet needs. The current study results suggest tht HDep is promising mentl helth tool tht, if the bove-mentioned weknesses re ddressed, hs the potentil to 1) serve s useful tool for educting people bout depression, nd how to chnge negtive thinking ptterns, nd 2) be source of socil 4 The minimum Internet requirements for HDep re 2 megbytes on the server side nd 1 megbit for the user Internet connection. support. HDep feedbck to users lso stresses the importnce of seeking professionl help when depressive symptoms re detected, which could increse the dignosis of untreted depression. Collecting nd systemtizing dt from ll users for n extended study period (four yers) proved extremely effective in providing the informtion required to modify HDep. The next step will involve running rndomized controlled tril studying the efficcy nd cost-effectiveness of HDep in reducing depressive symptoms to help provide evidence on whether or not the progrm cn be used s tool to help bridge the mentl helth tretment gp. A mjor contribution of the current study results is tht, to the best of the uthors knowledge, this is the first nlysis of the fesibility of using Web-bsed intervention s self-help tool for depression in Ltin Americ. Acknowledgments. The uthors thnk Ptrici Fuentes, for coordinting the development of the softwre; Lilin Delgdo, for conducting the nlyses of subsequent forums; Lourdes Nieto, for helping orgnize the mteril for the mnuscript; nd Lur Nvrrete, for crrying out the sttisticl nlyses. Funding. The development nd production of HDep ( ws mde possible by the generous support of the Fundción Gonzálo Río Arronte in Mexico City. The funder hs no dditionl role in the use of HDep. Conflicts of interest. None. 1. Instituto Ncionl de Estdístic y Geogrfí. Encuests en hogres: disponibilidd y uso de ls tecnologís de l informción en los hogres. Mexico City: INEGI; Avilble from: tos/encuests/hogres/modulos/endutih/ defult.spx Accessed on 1 June Spek V, Cuijpers P, Nyklícek I, Riper H, Keyzer J, Pop V. Internet-bsed cognitive behviour therpy for symptoms of depression nd nxiety: met-nlysis. Psychol Med. 2007;37(3): Andrews G, Cuijpers P, Crske MG, McEvoy P, Titov N. Computer therpy for the nxiety nd depressive disorders is effective, cceptble nd prcticl helth cre: metnlysis. PLOS One. 2010;5(10):e doi: /journl.pone Kessler RC, Angermeyer M, Anthony JC, De Grf R, Demyttenere K, Gsquet I, et l. REFERENCES Lifetime prevlence nd ge-of-onset distributions of mentl disorders in the World Helth Orgniztion s World Mentl Helth Survey Inititive. World Psychitry. 2007;6(3): Rfful C, Medin-Mor ME, Borges G, Benjet C, Orozco R. Depression, gender, nd the tretment gp in Mexico. J Affect Disord. 2012;138(1 2): Murry CJ, López AD, editors. The globl burden of disese. Globl burden of disese nd injury series. 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8 Originl reserch Lr et l. Web-bsed self-help intervention for depressive symptoms in Mexico site usge nd chnges in depression nd nxiety scores. J Med Internet Res. 2002;4(1):e Clrke G, Reid E, Eubnks D, O Connor E, DeBr LL, Kelleher C, et l. Overcoming depression on the Internet (ODIN): rndomized controlled tril of n Internet depression skills intervention progrm. J Med Internet Res. 2002;4(3):E Muñoz RF, Brrer AZ, Delucchi K, Penill C, Torres LD, Pérez-Stble EJ. Interntionl Spnish/English Internet smoking cesstion tril yields 20% bstinence rtes t 1 yer. Nicotine Tob Res. 2009;11(9): Brrer AZ, Pérez-Stble EJ, Delucchi KL, Muñoz RF. Globl rech of n Internet smoking cesstion intervention mong Spnishnd English-speking smokers from 157 countries. Int J Environ Res Public Helth. 2009;6(3): Lr MA, Nvrro C, Rubí NA, Mondrgón, L. Two levels of intervention in low-income women with depressive symptoms: complince nd progrmme ssessment. 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Am J Psychitry. 2002;159(12): Mnuscript received on 15 July Revised version ccepted for publiction on 16 My resumen Experienci de cutro ños en un intervención de utoyud pr síntoms depresivos bsd en l internet y llevd cbo en México Plbrs clve Objetivo. Presentr un estudio descriptivo y nturlist de cutro ños de durción que relizó un seguimiento del uso del progrm de Ayud pr l Depresión (ADep), un progrm grtuito de cceso bierto, bsdo en l internet, con finliddes de psicoeducción e intervención cognitivo-conductul, elbordo en México, y que se compone de siete módulos de utoyud que incluyen evluciones de síntoms depresivos que brindn retrolimentción, viñets, mensjes grbdos, un ejercicio de reljción, un cuderno de ejercicios personl, bitácors y foros de discusión pr los usurios. Métodos. Se recopilron dtos de tods ls persons que se inscribieron y entrron en l págin web de ADep dos o más veces desde l puest en mrch del progrm en el 2009, y se ls clificó como usurios o prticipntes. Los dtos de los usurios consistieron en: 1) los perfiles de usurio; 2) ls puntuciones obtenids en l Escl de Depresión del Centro de Estudios Epidemiológicos (CES-D) en el cso de los usurios que cumplimentron ls evluciones de síntoms depresivos que brindn retrolimentción; 3) ls evluciones de los usurios sobre l utilidd del ADep; y 4) ls trnscripciones de ls portciones l foro de discusión del ADep. Se obtuvieron los dtos brutos de los usurios medinte l pltform grtuit de ciberpreindzje Moodle y se nlizron cuntittivmente (medinte SPSS) y culittivmente (medinte Atls.ti). Resultdos. En totl, persons entrron en l págin de ADep y de ells (61,6%) fueron clificds como usurios l inscribirse y entrr en el sitio dos o más veces. Del totl de usurios, 84,4% fueron mujeres, 64,6% utilizron el cuderno de ejercicios, y 60,9% entrron en los foros de discusión (de estos 16,3% hicieron lgún comentrio). Se observron síntoms depresivos (puntución de l CES-D 16) en 97,1% de los usurios que cumplimentron l evlución que brind retrolimentción (n = ). L permnenci de los usurios descendió lo lrgo de los siete módulos (desde usurios del módulo del módulo 7). Sin embrgo, los siete módulos recibieron un puntución lt en cunto beneficio o utilidd, con puntuciones medis en todos los csos superiores 4 en un escl de 1 5. Los foros de discusión del ADep mostrron un ric intercción socil. Los fctores predictivos de que se entrr l menos en un módulo (con bse en un nálisis de regresión logístic grdul) incluyeron el sexo femenino, l edd igul o superior 30 ños, l notificción de discpcidd y los ntecedentes de intento de suicidio. De los 72 prticipntes que completron l evlución finl de los usurios del ADep, 97,5% indicron que el progrm hbí sido de grn yud pr detectr y trnsformr los pensmientos negtivos. Conclusiones. A pesr del lto índice de bndono por prte de los usurios, y l necesidd de nuevs dptciones estructurles, el ADep se puede considerr como un herrmient de slud mentl potencilmente útil en México pr detectr l depresión (medinte ls evluciones de l CES-D) y proporcionr un medio de poyo socil ls persons con depresión. Los niveles ltos de síntoms depresivos detectdos en los usurios indicn que debe investigrse más l función de ls intervenciones de cceso libre y utoyud con bse en l internet en los progrms públicos de slud mentl. L eficci del ADep en l reducción de los síntoms depresivos y como sistem de poyo ún no h sido evlud, por lo que se l deberí nlizr en futurs investigciones. Depresión; internet; poyo socil; terpi cognitiv; México. 406 Rev Pnm Slud Public 35(5/6), 2014