Author's response to reviews

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1 Author's response to reviews Title:Uptake and adherence of a self-directed internet-based mental health Authors: Kjersti R. Lillevoll (kjersti.lillevoll@uit.no) Hans Christian B. Vangberg (hans.christian.vangberg@uit.no) Kathleen M. Griffiths (kathy.griffiths@anu.edu.au) Knut Waterloo (knut.waterloo@uit.no) Martin R. Eisemann (martin.eisemann@uit.no) Version:2Date:2 December 2013 Author's response to reviews: see over

2 Dear Editor Re: MS: Uptake and adherence of a self-directed internet-based mental health Kjersti R. Lillevoll, Hans Christian B. Vangberg, Kathleen M. Griffiths, Knut Waterloo and Martin R. Eisemann Thank you for inviting us to submit the above revised manuscript. We would also like to thank the reviewers for their interest in our paper and constructive comments that have contributed to improving the quality of the manuscript. Below are our responses to the reviewers comments. Reviewer's report Title: Uptake and adherence of a self-directed internet-based mental health Version: 1 Date: 20 July 2013 Reviewer: Heleen Riper Reviewer's report: I would like to compliment the authors for the effort they have undertaken to conduct a rct among high school students, which is not an easy task. I do have however a number of substantial problems with this paper and these are related to both content and methodological questions: 1) the researchers conducted a rct but present here only results of the three experimental conditions due to the central questions of this paper. I guess they have not undertaken a rct with a control condition without any purpose. What happened with these data? Are they published elsewhere (I cann't find it in the ref list)? A previous version of the manuscript included data regarding effects of the intervention (although power was a serious issue), but these were discarded after review. They have now been included in the revised manuscript. 2) I don't see any underpinning why you should provide an unguided self-help intervention for depression to students who are not depressed. Depression has not been taken as an inclusion criteria (see table 1, means well below 16). Why providing a depression intervention to students who are not depressed? The intention was not only to investigate the effect of MoodGYM in reducing symptoms of depression but also to investigate if the intervention would prevent the occurrence of new cases of depression and anxiety in those without significant symptoms (universal preventive intervention). Calear et al, have demonstrated that MoodGYM prevented new cases of depression and anxiety in students without depression or anxiety. We have now also analysed the data for students with CES-D > 16 separately concerning the intervention effect and presented these results. 3) The method applied for dealing with missing values is not clear. Next, the researchers speak about power but I do not see a power calculation at all. Given the very high dropout and the very low number of students who have completed the program I think you can n't make any conclusion on the basis of the data

3 presented. We have performed completer analysis due to the substantial non-participation. The power calculations have been added to the method section. We do agree that conclusions regarding efficacy are not possible due to power limitaitons. However, we we believe the paper adds to the literature regarding school based mental health interventions and challenges using programs aimed at improving skills at an individual level. 4) the aims of the study are not clear and neither is the approach they have chosen to answer their research questions We have elaborated the aims of the study and the method correspondingly. 5) I miss clear reference to the discussion whether you should provide depression treatment at all schools, evidence so far is hinting in the direction that you should not do so (for screening it is ok) The last section of the discussion states that guided interventions may be a more suitable model for mental health interventions in schools.. 5) for sure the authors will have obtained very interesting data Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Acceptable Statistical review: Yes, and I have assessed the statistics in my report. Declaration of competing interests: I declare that I have no competing interests Reviewer's report Title: Uptake and adherence of a self-directed internet-based mental health Version: 1 Date: 31 August 2013 Reviewer: Wenceslao Penate Reviewer's report: This paper presents data about uptake and compliance / adherence to an internet-based prevention / intervention on depression: MoodGYM. This is a well articulated telehealth program, and represents one of the most efficacy internet resources dealing with mood disorder. In this sense, as telehealth care is being a prominent alternative to self-care procedures, the research represents an interesting study in new technologies applied to psychological treatment. The following commentaries must be taken as Discretionary Revisions category: 1. The manuscript is clear, well written. 2. Title and abstract are corrects. Maybe the abstract contents excessive quantitative (in general, qualitative comments of results could be sufficient). We have included results of the efficacy analysis in the abstract and all results are presented in general, verbal comments.

4 3. Introduction is directly related with the general objective, but there are absences of relevant systematic reviews and meta-analyses (there are more than 15 papers in this sense, one of these in this journal: Bee PE, Bower P, Lovell K, Gilbody S, Richards D, Gask L, Roach P: Psychotherapy mediated by remote communication technologies: a meta-analytic review. BMC Psychiatry 2008, 22: 8-60), that could improve We thank the reviewer for pointing our attention to this interesting meta-analysis. However, we do not find it relevant for the current paper, as it deals with psychotherapy delivered remotely by therapists and excludes computerized CBT. 4. The role of therapist contact (direct or s) with patients as a variable that enhances the adherence and efficacy of internet-based telepsychology program (IBTP) have been supported in previous research. In this sense, the main interest can be the MoodGYM users: adolescents and youth adults. We agree that the adolescent population is of great interest in internet intervention research. However, there has been little attention to tailored s for enhancing adherence and efficacy. 5. The two hypotheses are slightly obvious (participants indicating current need of help will have better initial uptake and better adherence with better contact ). Perhaps a clear description of objectives will be enough. Aims of the study have been revised. 6. Participants represent the greatest threat to research validity. Sample is composed by four arms. Four groups that differs among them by the frequency (no contact to regular contact), and quality of contacts (standard s or tailored s). Despite authors assessed depression level, participant assignment did not take into account that level. So, experimental a control groups was formed by participants with both high level of depression and with low level of depression. In fact, total median in depression of all participants (data per groups was unavailable) fell clearly into normality. MoodGYM is a tool especially designed to prevent mood disorders. So, this program is especially indicated to users worry about their initial mood symptoms (or worry about ). Secondary, this tool can be useful to those participants with a current diagnosis of depression. It is difficult to understand why participants without mood problems will be enrolled in a mood-preventing program. Perhaps, the outstanding level of attrition can be explained in part for this reason, even when participants manifest interest in the program. Maybe a re-analysis selecting only the participants with some degree of depression (secondary and tertiary prevention), can alter the results. We have revised the manuscript according to these recommendations. The reanalysis include the effect of the intervention regarding depressive symptoms and self-esteem among depressed (CESD>16) students, excluding non-depressed students; and effects of the intervention on self-esteem (and depression) among the sample as a whole. 7. Those levels of attrition question the validity of data. The absence of differences in adherence despite the different contact modality can be due to the internal validity of the study. Secondary, how adherence is measure (0 modules compliance, 1 module compliance, and 2 or more modules compliance),

5 it is also questionable, since MoodGYM contents fives modules, and a discrete variable of adherence (0 to 5) could be established. The interest to increase statistical power analysis could hide real results. A direct data about drop-outs by groups and modules could be clearer. We do agree that the adherence measure is not ideal. However, analyzing the data with actual module compliance as the dependent variable would result in a number of zero frequency cells that compromise the analysis. 8. Besides the level of depression, participants were also measured in self-efficacy and self-esteem. The appropriateness of those variables can be understood, but maybe an explanation in this sense (why these variables) is needed. This is included in the introduction in the revised manuscript. 9. There is no data about the efficacy of MoodGYM. Obviously, the main interest of the study was the initial uptake, and the adherence. But there are measures about depression and self-esteem that would allow a pre-post analysis. Also, there were variables as self-efficacy, level of adherence and need of help, which can covariate with the outcome measures. If that, this study could increment its interest. This is included in the revised manuscript. 10. According to last commentary, maybe it is a secondary study of a initial primary study (about efficacy), but I could not test it. Level of interest: An article of limited interest Quality of written English: Acceptable Statistical review: Yes, and I have assessed the statistics in my report. Declaration of competing interests: I don not have any conflict of interest with this review Kind regards, Kjersti Lillevoll