Centre for Mental Health Research, The Australian National University, Canberra, ACT 0200, Australia
Correspondence: Dr Kathy Griffiths, Director, Depression and Anxiety Consumer Research Unit, Centre for Mental Health Research, The Australian National University, Canberra, ACT 0200, Australia. Fax: +62 2 6125 0733; e-mail: Kathy.griffiths{at}anu.edu.au
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ABSTRACT |
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Aims To investigate the effects on stigma of two internet depression sites.
Method A sample of 525 individuals with elevated scores on a depression assessment scale were randomly allocated to a depression information website (BluePages), a cognitivebehavioural skills training website (MoodGYM) or an attention control condition. Personal stigma (personal stigmatising attitudes to depression) and perceived stigma (perception of what most other people believe) were assessed before and after the intervention.
Results Relative to the control, the internet sites significantly reduced personal stigma, although the effects were small. BluePages had no effect on perceived stigma and MoodGYM was associated with an increase in perceived stigma relative to the control. Changes in stigma were not mediated by changes in depression, depression literacy or cognitivebehavioural therapy literacy.
Conclusions The internet warrants further investigation as a means of delivering stigma reduction programmes for depression.
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INTRODUCTION |
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METHOD |
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Participants
Participants were 525 adults with elevated scores on a depressive symptom
assessment scale. They were recruited by means of a postal screening
questionnaire sent to 27000 individuals aged 1852 years who had been
randomly selected from the Canberra electoral roll using the Statistical
Package for the Social Sciences (SPSS) SELECT CASES random selection option. A
total of 6130 people (22.7% response rate; 24.6% excluding those whose
questionnaire was returned to sender) completed the screening questionnaire;
their mean age was 37.3 years (s.d.=9.9) and 35.8% were male. Respondents were
not eligible for inclusion in the trial if they
Of the 822 respondents who were potentially eligible based on the screening survey, 24 (2.9%) were found not to have suitable internet access during the recruitment call. In addition, 41 (5%) reported that they were receiving psychiatric or psychological care and were excluded from the trial to ensure that it did not interfere with their treatment. Of the remaining respondents, 657 indicated a willingness to participate in the study and were sent consent and pre-intervention forms. Of these, 525 participants returned completed forms and were randomised to the interventions. The sample comprised 150 men and 375 women. The mean respondent age was 36.4 years (s.d.=9.4) and the mean K10 score was 17.8 (s.d.=5.2).
Design
Eligible individuals who completed consent forms were randomly assigned to
access a depression literacy website (BluePages, n=165), a
cognitivebehavioural therapy skills training site (MoodGYM,
n=182) or an attention control condition (control, n=178).
Participants were randomised to interventions by a statistician using the SPSS
SELECT CASES random selection option and enrolled in the trial by the project
manager. Those enrolled completed pre-intervention surveys by post and began
the intervention an average of 1.7 weeks (s.d.=1) later. Screening and
interventions were staggered between August 2002 and May 2003. The project
protocol was approved by the human ethics committee of the Australian National
University.
Interventions
The BluePages website
(http://www.bluepages.anu.edu.au)
provided information about depression, including symptoms, general and
specific sources of help, evidence-based information about medical,
psychological and alternative/lifestyle treatments for depression, and
information about depression prevention. The site indicated that depression is
an illness, provided information that moderate depression is as disabling as
multiple sclerosis, emphasised that depression can and should be treated and
stressed the importance and wisdom of seeking help. It also included short
biographies of famous people who have experienced depression. Descriptions of
the rationale for many of the treatments incorporated biomedical explanations
of depression (e.g. neurotransmitter depletion), but some emphasised
non-biomedical factors or approaches to depression (e.g. conflict reduction in
interpersonal therapy, changing negative thoughts and improving social skills
in cognitivebehavioural therapy). The intervention consisted of
directing participants to read a different specified section of the BluePages
site each week for 5 weeks.
The MoodGYM intervention (http://www.moodgym.anu.edu.au) comprised five interactive modules that covered cognitive therapy, behavioural methods for over-coming dysfunctional thinking, relaxation, problem solving, assertiveness and self-esteem training, and strategies for coping with relationship break-up. The intervention did not emphasise biomedical factors but rather focused on training the participant to develop strategies for coping with events and circumstances that might activate depression. As with the BluePages site, participants were directed to read a different specified module of the MoodGYM site each week for 5 weeks.
The control intervention involved weekly contact with an interviewer, who asked open-ended questions about factors that might influence depression, including physical and artistic activities, hobbies and educational activities, relationships, social support and financial management, work stress and relationships, health and nutrition and alcohol intake. The contacts were made at weekly intervals over 5 weeks and were designed to last for approximately 10 min.
Procedures
Individuals who indicated in their screening questionnaire that they might
be willing to participate in an intervention trial were contacted by telephone
by a trained interviewer, who described each of the three interventions and
asked if the respondent would be willing to be randomised to one of them.
Participants who agreed were advised that they would soon receive a consent
form and pre-intervention questionnaire through the post.
Participants randomised to the two website conditions were provided with a log-in identification number and a manual containing information about the relevant website. This booklet also outlined the sections or modules of the websites that were to be completed for each of the 5 weeks. At the end of the intervention period, participants were sent a post-intervention questionnaire. Lay interviewers were not given access to questionnaire results.
Interviewers maintained weekly telephone contact with participants over the period of the intervention (a total of six contacts of approximately 10 min each: one at the outset of the intervention and one at the end of each of the 5 weeks of the intervention). During these contacts, participants using the websites were asked standard questions about their use of the website over the past week and reminded of their task for the following week. Interviewers were provided with separate instruction booklets for each participant, containing verbatim instructions for each of the weekly contacts. These booklets also included a form for recording telephone calls to participants.
Prior to the study, all interviewers attended a 1-day training session on the trial. Of the six interviewers, none had formal qualifications in mental health or a related field, although four had many years of experience in conducting survey interviews for the Centre for Mental Health Research; the other two were undergraduates without prior interviewing experience.
Measures
Demographic and clinical history, psychological distress, stigma, level of
depressive symptoms and mental health knowledge were assessed by postal
questionnaire.
Demographic and clinical history
Age, gender, education and previous history of depression were
recorded.
Kessler Psychological Distress Scale
This 10-item test of psychological distress, which has been validated on an
Australian population (Andrews & Slade,
2001), was used to screen for depressive disorder. The scale is
scored from 0 to 40, with higher scores indicating greater psychological
stress.
Depression stigma scale
Changes in stigma were assessed using an 18-item test that we constructed
for the purpose (Table 1;
further details available from the authors upon request). Items were derived
from major recurring broad themes extracted from websites on depression and
stigma. In particular, themes were based on the first 100 results returned
using the Google search engine and the keywords STIGMA DEPRESSION and on the
Google depression directory using the keyword STIGMA. (Google was selected for
the search because of its extensive coverage of the web and its demonstrated
superiority in returning relevant content:
Hawking et al, 2001).
Themes reflected in the items included status of depression as an illness
(depression is not a real medical illness), extent to which
depression is under personal control/fault (people could snap out of
depression if they wanted), character flaw (sign of
weakness), dangerousness, unpredictability, shame/concealment
(would not tell anyone), avoidance (avoid people with
depression) and discrimination (not vote for politician with
depression, not employ someone with depression). Half of
the items required the participant to rate how strongly they personally agreed
with a statement about depression (e.g. people with depression are
unpredictable). The other half of the items asked the participant to
indicate what they thought most other people believed about the same issue
(e.g. most people believe that people with depression are
unpredictable). Ratings were made on a five-point Likert scale. A
principal components analysis on the data of the trial participants showed
that the scale had two factors:
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Scores on the total scale can range from 0 to 36 for the full scale and 0
to 18 for each of the two nine-item sub-scales, with higher scores indicating
greater stigma. Cronbachs values for the total, personal and
perceived depression stigma scales were 0.78, 0.76 and 0.82 respectively and
the correlation between the scores on the personal and perceived stigma scales
was 0.10 (n=525; P=0.02). Individual item total correlations
are shown in Table 1.
Center for Epidemiologic Studies Depression scale
Severity of depression was assessed using the 20-item Center for
Epidemiologic Studies Depression scale (CESD;
Radloff, 1977). Scores on the
CESD range from 0 to 60; higher scores represent greater psychological
distress, and a score in excess of 15 was treated as reflecting a clinical
level of depression.
Depression Literacy and Cognitive Behaviour Therapy Literacy
Depression literacy was assessed using a 22-item true/false test of
knowledge about depression (DLit), and cognitivebehavioural
therapy literacy was assessed using a 16-item true/false test of knowledge
about the principles of this therapy (CBTLit). For each of these tests,
which were developed for the study, a higher score indicated greater
literacy.
Automatic Thoughts Questionnaire
Dysfunctional thoughts were evaluated using the 30-item Automatic Thoughts
Questionnaire (ATQ; Hollon & Kendall,
1980). Scores on the ATQ range from 30 to 150, with higher scores
indicating more severely dysfunctional thoughts.
Analysis
Baseline characteristics of the three groups were compared using one-way
analyses of variance (ANOVAs) for continuous measures and chi-squared analyses
for categorical variables. The effects of the interventions were assessed
using both intent-to-treat and completer analyses. In the intent-to-treat
analyses, participants who did not respond to the post-intervention
questionnaire were allocated their baseline score for the post-test score.
Personal and perceived stigma were analysed separately using repeated-measures
ANOVAs. Where a significant intervention x time interaction effect was
obtained, the effect of the intervention on stigma was compared between the
conditions using one-way ANOVAs of the change in stigma score
(post-intervention score minus pre-intervention score) followed by
Bonferroni-adjusted multiple comparisons. All effects were tested at the
P < 0.05 level. Effect sizes were calculated using Cohens
d (standardised mean difference;
Cohen, 1988).
Potential mediators of the intervention programmes were tested using techniques and criteria described by Baron & Kenny (1986) and MacKinnon (1994). This approach involves the following steps:
Analyses were conducted separately for the BluePages and MoodGYM interventions for those who completed the intervention. In addition, analyses were made using both single mediator models (in which the effect of a potential mediator might have been confounded by the contribution of other potential mediators) and multiple mediator models (where the effect of each potential mediator was computed independently of the effect of other potential mediators).
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RESULTS |
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Participation
Of the 525 participants, 435 (83%) completed the post-intervention survey
and 414 (79%) completed both the allocated intervention and the
post-intervention survey (Table
2). Participants who returned their questionnaires did not differ
in age (F(1,522)=2.68, P=0.10), gender
(2(1)=1.84, P=0.18) or years of education
(F(1,508)=1.81, P=0.18) from those who failed to
return their questionnaire. Nor did they differ in baseline personal or
perceived stigma scores (personal, F(1,523)= 0.59,
P=0.44; perceived, F(1,523)=3.35,
P=0.07), although there was a trend towards higher perceived stigma
among those who did not complete the questionnaire. The latter group also had
higher psychological distress and depression scores at baseline (K10,
F(1,523)=7.64, P=0.006; CESD,
F(1,523)=5.15, P=0.024). Questionnaire return
rates differed across the intervention groups (
2(2)=14.18,
P < 0.001); in particular, a significantly greater proportion of
participants enrolled in the MoodGYM intervention failed to complete the
post-intervention survey compared with the BluePages (
2=5.5,
P=0.02) or control (
2=12.97, P < 0.001)
conditions.
Test-retest reliability of depression stigma sub-scales
The testretest reliabilities based on pre- and post-test data for
the combined, control, BluePages and MoodGYM conditions were 0.71
(n=435), 0.66 (n=159), 0.79 (n=136) and 0.70
(n=140) respectively for the personal stigma scale, and 0.67
(n=0.434), 0.67 (n=159), 0.63 (n=135) and 0.73
(n=140) respectively for the perceived stigma scale (P <
0.001 in each case).
Effects for personal stigma
Table 2 shows the mean
personal stigma scores for participants who were randomised to an intervention
condition (intent-to-treat). The main effect for time was not significant
(F(1,522)=2.95, P > 0.05), but there was a
significant interaction between time and intervention group
(F(2,522)=4.36, P=0.016), indicating that the
interventions had different effects on stigma. An analysis of the change in
stigma over time demonstrated a significant main effect for intervention
(F(2,522)=4.36, P=0.013). In particular, stigma
reduction was significantly greater in both the BluePages and MoodGYM groups
than in the control condition after Bonferroni correction: BluePages
v. control groups, mean difference 0.94, 95% CI 0.071.82,
P=0.031; MoodGYM v. control groups, mean difference 0.90,
95% CI 0.0431.75, P=0.036. There was no significant difference
between the two websites in stigma reduction (mean difference 0.04, 95% CI
-0.83 to 0.92, P=1.0). Re-analysis of the results using education as
a covariate yielded the same pattern of findings as above, except the greater
stigma reduction in the MoodGYM condition relative to the control only
approached significance (P=0.054) after Bonferroni correction. The
pattern of results for those who completed both the intervention and the
post-intervention questionnaire was similar to that for the intent-to-treat
groups, but the effect for MoodGYM (which was significant using an unadjusted
t-test) was not significant following Bonferroni adjustment (mean
difference 0.96, 95% CI -0.12 to 2.04, P=0.10).
Effects for perceived stigma
The mean perceived stigma scores for each intervention before and after the
intervention are shown in Table
2. The main effect for time was not significant
(F(1,522)=0.3, P > 0.05), but there was a
significant interaction between time and intervention group
(F(2,522)=4.16, P=0.016), indicating that the
interventions had different effects on perceived stigma. There was a
significant effect for intervention on change in stigma
(F(2,522)=4.16, P=0.016). In particular, stigma
increased in the MoodGYM group relative to the control group (MoodGYM
v. control, mean difference -1.07, 95% CI -1.96 to -0.177,
P=0.012), but there was no other significant difference in stigma
reduction for the interventions (BluePages v. control, mean
difference 0.60, 95% CI -1.5 to 0.32, P=0.35; BluePages v.
MoodGYM, mean difference -0.47, 95% CI -1.38 to 0.44, P=0.64).
Re-analysis of the results using education as a covariate yielded the same
pattern of results as above, notably a significant interaction between
intervention and time and a significantly greater increase in stigma in the
MoodGYM group.
Size of the effects
The pre- minus post-effect sizes for personal stigma were 0.12 (BluePages),
0.11 (MoodGYM) and -0.07 (control) for the intent-to-treat group, and 0.13,
0.10 and -0.09 respectively for those who completed the trial. The
corresponding prepost effect sizes for perceived stigma were 0.01,
-0.09 and 0.14 for the intent-to-treat group and 0.02, -0.14 and 0.15 for
those who completed the trial.
Analyses of mediation effects
The following analyses included change in depressive symptoms, and change
in depression and cognitivebehavioural therapy literacy as potential
mediators in the model. However, dysfunctional thoughts were excluded from the
model since there was a high correlation between the ATQ and CESD
change scores (BluePages r=0.70, MoodGYM r=0.59, control
r=0.71).
Personal stigma
Consistent with the results reported above, the mediation analysis
demonstrated that the websites each decreased personal stigma relative to the
control condition (Conclusion 1 met). In addition, each of the websites
significantly influenced the three potential mediators, being associated with
depression reduction, increased depression literacy and increased
cognitivebehavioural therapy literacy. For the BluePages group
(n=136), CESD (prepost) 3.62, P=0.001;
DLit=-4.28, P < 0.001;
CBTLit=-1.47,
P < 0.001. For the MoodGYM group (n=121),
CESD=4.52, P < 0.001;
DLit=-0.70,
P=0.02;
CBTLit=-2.84, P < 0.001 (Conclusion
2 met). However, controlling for intervention, the potential mediators did not
affect personal stigma levels for either the BluePages or the MoodGYM
interventions. This was the case when the effect of a potential mediator was
considered controlling for the effects of the other mediators (multiple
mediator model) and also when the mediators were considered singly (single
mediator model). For the BluePages group (n=136): multiple model,
CESD, ß=0.03 (s.e.=0.02), P=0.20;
DLit=-0.06 (s.e.=0.09), P=0.51;
CBTLit=-0.04 (s.e.=0.12), P=0.76; single model,
CESD, ß=0.03 (s.e.=0.02), P=0.18;
DLit=-0.07 (s.e.=0.09), P=0.42;
CBTLit=-0.06 (s.e.=0.12), P=0.64. For the MoodGYM group
(n=121): multiple model,
CESD, ß=0.02
(s.e.=0.024), P=0.53;
DLit=-0.08 (s.e.=0.09),
P=0.38;
CBTLit=-0.16 (s.e=0.11), P=0.14;
single model,
CESD, ß=0.02 (s.e.=0.024), P=0.44;
DLit=-0.11 (s.e.=0.09), P=0.24;
CBTLit=-0.19 (s.e.=0.11), P=0.09 (Conclusion 3 not
met). Accordingly, it was concluded that the personal stigma reduction effects
of the website interventions were not mediated by change in depression or
change in depression literacy.
Perceived stigma
Since, as noted above, the BluePages intervention did not lead to a change
in perceived stigma (Conclusion 1), no mediation analysis was conducted for
this intervention. The MoodGYM intervention, however, was associated with an
increase in perceived stigma relative to the control group: ß=-1.41
(s.e.=0.49), t=2.87, P=0.004 (Conclusion 1 met). In
addition, the relationship between the mediators and change in stigma was
significant, as documented above (Conclusion 2 met). Controlling for
intervention, greater depression literacy improvement was associated with less
perceived stigma reduction for both the single and multiple mediator models:
for MoodGYM, multiple model, CESD, ß=0.04 (s.e.=0.03),
P=0.14;
DLit=-0.21 (s.e.=0.10), P=0.04;
CBTLit=0.04 (s.e.=0.12), P=0.77; single model,
CESD, ß=0.04 (s.e.=0.03), P=0.10;
DLit=-0.22 (s.e.=0.10), P=0.03;
CBTlIT=-0.02 (s.e.=0.12), P=0.89 (Conclusion 3 met for
depression literacy change). However, the mediated effect was not significant
(ratio of the indirect to the direct effect -0.10, Sobel test 1.65,
P=0.10). The other mediators (change in symptoms, depression
literacy) did not lead to perceived stigma change (Conclusion 3 not met). In
conclusion, there was no evidence that the perceived stigma increase for
MoodGYM relative to the control group was associated with change in depression
or change in depression or cognitivebehavioural therapy literacy.
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DISCUSSION |
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Although the magnitude of the effect sizes for the web-based interventions are small, particularly when compared with that usually required for a clinical intervention, even small effect sizes can translate into worthwhile gains in a public health context involving large numbers of people and where an intervention can be delivered conveniently and at low cost (Jorm et al, 2003). The MoodGYM website, for example, currently attracts 17000 unique visitors per month.
The finding that an educational intervention can reduce stigmatising attitudes has been reported previously for the conditions of schizophrenia and mental illness (e.g. Morrison, 1977; Morrison & Teta, 1979; Holmes et al, 1999; Penn et al, 1999; Corrigan et al, 2001b; Pinfold et al, 2003a,b), primarily in quasi-experimental or observational studies. However, to our knowledge there has been no previous study of the effect of a psychoeducational intervention on personal stigma among people with elevated depressive symptoms or a history of depression. There has been one study (a randomised controlled trial) of the effects of a psychoeducational programme in reducing the stigma associated with depression among adults enrolled in a community college (Corrigan et al, 2001b). This brief face-to-face programme rebutted a series of myths about mental illness. The researchers found no effect of the programme on negative attributions for controllability in depression (belief that depressed people are to blame for their problems; prepost effect size 0.04), but the programme did reduce negative stability attributions about depression (belief that depression is treatable; prepost effect size 0.48) Corrigan et als programme has the advantage that it requires significantly less time commitment from the participant than does the BluePages website. However, its demonstrated effects for depression were limited to stability attributions. Moreover, the BluePages website has the advantage that its positive effects are not confined to stigma; it is also associated with significant improvement in depressive symptoms and depression literacy among participants (Christensen et al, 2004).
There was some evidence from our study that recipients of cognitivebehavioural therapy showed a reduction in personal stigma. Significantly, this effect was not mediated by decreased depressive symptoms. To our knowledge, this is the first study to report the impact of cognitivebehavioural therapy on stigma. It has previously been proposed that cognitivebehavioural therapy might be useful in reducing self-stigma (Hayward & Bright, 1997; Gray, 2002). In particular, Hayward & Bright (1997) proposed addressing self-stigma by assessing specific self-denigrating beliefs and combating them using a cognitivebehavioural approach. Interestingly, the MoodGYM intervention did not specifically target stigmatising attitudes; thus, any stigma-reducing effect of the intervention might have been due to generalisation of the cognitive techniques to the domain of stigma. Conceivably, a more targeted approach such as that suggested by Hayward & Bright (1997) would have been more effective. An alternative explanation for the results is that MoodGYM reinforced the message that psychological problems are amenable to intervention, which in turn was associated with a reduction in personal stigma. Although the results for personal stigma are encouraging, the finding that cognitivebehavioural therapy was associated with an increase in perceived stigma requires some attention. It might have been expected that as the dysfunctional thoughts associated with depression decreased, perceived stigma would also decrease. This was not the case. It is possible that the emphasis in MoodGYM on changing emotions by changing thoughts and behaviours led participants to perceive that others believe that depression is under the control (and hence is the fault) of the depressed person. It has been proposed that such attributions of controllability are associated with stigmatising reactions (Hayward & Bright, 1997). It is of interest that whatever mechanism led to increased perceived stigma in the MoodGYM group did not influence the personal views of the group. Nevertheless, it might be advisable for clinicians delivering cognitivebehavioural therapy to consider strategies for reducing perceived stigma, particularly if it is associated with the therapy itself.
The finding that the control group showed a decrease in perceived stigma was unexpected but of potential interest. It is possible that part of this effect was due to some active component of the weekly telephone interviews. Whereas interviews with the internet participants focused on programme activities and feedback (e.g. Did you visit any links to other websites this week?), questions asked of control participants related to their own personal experiences (e.g. to what extent they thought particular activities protected or put them at risk of depression). Perhaps the experience of speaking about these matters to another, non-judgemental person (in this case the trial interviewer) affected participants perceptions about the attitudes of others.
Limitations of the study
The major limitation of this study is that the effect sizes were small.
There are a number of possible reasons for this. First, pre-intervention
personal stigma was not marked, the approximate mean score being 10 (out of a
maximum score of 36). This might have placed a floor on the potential for
participant improvement. Second, the intervention might have been suboptimal
for the current purposes. In particular, neither the exercises nor the other
content of MoodGYM specifically addressed issues of self-stigma. Similarly,
BluePages was not specifically designed as an anti-stigma package but rather
as a site about depression in general, with an emphasis on evidence-based
treatments. BluePages did incorporate an illness/biomedical model of
depression and the strong message that depression is treatable, with the aim
(in part) of reducing controllability and stability attributions, since social
attribution theory predicts that reducing these attributions should reduce
stigma (Corrigan et al,
2000). However, it has been argued that the biomedical model of
mental illness might increase stigma (e.g.
Walker & Read, 2002;
Dietrich et al,
2004). Inclusion of the model in BluePages might therefore have
reduced the effect size of the intervention. However, any effects on stigma of
a biomedical explanation could operate differently for people with and without
depression, and more targeted research on the role of the biomedical model is
needed (Griffiths & Christensen,
2004).
Another limitation of our study is that stigma measured by means of self-completed questionnaires may lack ecological validity, possibly measuring participant cognitions or hypotheses rather than their attitudes in a real-life context (Haghighat, 2001). In addition, apparent changes in self-reported stigma may reflect social desirability bias (Haghighat, 2001).
Because our study was conducted in the broader context of a depression intervention trial (Christensen et al, 2004), the control condition was designed to be credible as an intervention for depression. It did not therefore incorporate a neutral website, a limitation for the purposes of this study because the nature of the interviewer contacts for the control group differed from those for the website groups. Another potential weakness of our findings is that the response rate for the screening survey was low. However, as we have noted in a previous paper, the more relevant factor in a design such as this is the response rate among people with a high level of depressive symptoms (Jorm et al, 2003). Using data from the Australian National Survey of Mental Health and Well-Being (Andrews & Slade, 2001), it is estimated that 1831 people in the original sample of 27 000 would have obtained a K10 score in the required range. In fact, 1586 (86.6%) people in this range returned completed surveys. Thus, the response rate to the screening survey was high among the target group of interest. Only 33.1% (525) of respondents with a high level of depressive symptoms met other necessary criteria for inclusion in the trial, including having internet access, not currently receiving treatment from a psychologist or psychiatrist and being willing to participate. It seems likely, however, that the attributes of the intervention sample reflect the subset of the community who would be willing to undertake an internet intervention to decrease psychological distress.
Another limitation of our study is that testing occurred soon after completion of the interventions. Clearly, a meaningful intervention must have longer-term sustainable effects. In addition, since the current personal stigma scale clustered into one factor, it is not possible to determine if the intervention differentially affected different aspects of personal stigma. Moreover, it is not possible to judge from the study which aspects of the websites content were effective in reducing personal stigma. Finally, it remains to be seen if BluePages can reduce personal stigma among people without depressive symptoms.
Future research
The internet is used by a range of organisations and individuals to deliver
public health messages designed to combat stigmatising attitudes to mental
health disorders. However, the effect of these sites on stigma has not
previously been evaluated. The results of this study suggest that the internet
warrants further investigation as a potentially effective means of delivering
stigma reduction programmes for depression. The challenge is to develop
programmes that exert larger effects on stigma. This would involve
systematically testing and identifying the content and contexts which are most
effective in reducing stigma. There would also be value in comparing the
efficacy of different delivery methods, including face-to-face interviews,
internet websites and printed material. Finally, there is a need to explore
the effectiveness of educational programmes in reducing stigma among family
members of people with depression, among people without depressive symptoms
and among people with high levels of stigma about depression.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication October 28, 2003. Revision received May 24, 2004. Accepted for publication May 31, 2004.
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