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Internet-based interventions can be effective in the treatment of depression. However, internet-based interventions for older adults with depression are scarce, and little is known about their feasibility and effectiveness.
To present the design of 2 studies aiming to assess the feasibility of internet-based cognitive behavioral treatment for older adults with depression. We will assess the feasibility of an online, guided version of the Moodbuster platform among depressed older adults from the general population as well as the feasibility of a blended format (combining integrated face-to-face sessions and internet-based modules) in a specialized mental health care outpatient clinic.
A single-group, pretest-posttest design will be applied in both settings. The primary outcome of the studies will be feasibility in terms of (1) acceptance and satisfaction (measured with the Client Satisfaction Questionnaire-8), (2) usability (measured with the System Usability Scale), and (3) engagement (measured with the Twente Engagement with eHealth Technologies Scale). Secondary outcomes include (1) the severity of depressive symptoms (measured with the 8-item Patient Health Questionnaire depression scale), (2) participant and therapist experience with the digital technology (measured with qualitative interviews), (3) the working alliance between patients and practitioners (from both perspectives; measured with the Working Alliance Inventory–Short Revised questionnaire), (4) the technical alliance between patients and the platform (measured with the Working Alliance Inventory for Online Interventions–Short Form questionnaire), and (5) uptake, in terms of attempted and completed modules. A total of 30 older adults with mild to moderate depressive symptoms (Geriatric Depression Scale 15 score between 5 and 11) will be recruited from the general population. A total of 15 older adults with moderate to severe depressive symptoms (Geriatric Depression Scale 15 score between 8 and 15) will be recruited from a specialized mental health care outpatient clinic. A mixed methods approach combining quantitative and qualitative analyses will be adopted. Both the primary and secondary outcomes will be further explored with individual semistructured interviews and synthesized descriptively. Descriptive statistics (reported as means and SDs) will be used to examine the primary and secondary outcome measures. Within-group depression severity will be analyzed using a 2-tailed, paired-sample
The studies were funded in October 2019. Recruitment started in September 2022.
The results of these pilot studies will show whether this platform is feasible for use by the older adult population in a blended, guided format in the 2 settings and will represent the first exploration of the size of the effect of Moodbuster in terms of decreased depressive symptoms.
PRR1-10.2196/41445
Depression is a common mental disorder that is associated with the substantial loss of a person’s well-being and quality of life [
Late-life depression is often not recognized or treated [
In recent years, internet-based interventions for the treatment of various common mental disorders, including depression, have been developed and evaluated [
Research into internet-based interventions for older depressed adults is scarce, underlining the need for more research to be able to assess the feasibility and effectiveness of these interventions for this specific group. A study by Spek et al [
The 2 current studies aim to evaluate the feasibility of an online treatment platform (Moodbuster) that targets depressive symptoms in older adults (aged at least 55 years) in 2 settings. The first study will test the feasibility of Moodbuster with an online guided treatment format for older adults with mild to moderate depressive symptoms recruited from the general population. The second study will test the intervention in a blended treatment format by integrating face-to-face and online sessions into one treatment protocol. It will target older adults with moderate to severe depression recruited from a specialized mental health care outpatient clinic. The primary aim of both studies is to evaluate the feasibility of the online platform in terms of (1) acceptance and satisfaction, (2) usability, and (3) engagement. Secondary outcomes include depressive symptom severity, participant experience with digital technologies, technical alliance, working alliance, and uptake.
A single-group, pretest-posttest design will be used in both studies. Assessments will be taken at screening (T–1), at baseline (T0), and postintervention (T1). The intervention will last 8 weeks for the group with mild to moderate depressive symptoms from the general population and 16 to 20 weeks for the group with moderate to severe depressive symptoms from the specialized mental health care outpatient clinic. Written informed consent will be obtained from all participants.
Flowchart of the study design for the group of older adult with mild to moderate depressive symptoms. GDS: Geriatric Depression Scale.
Flowchart of the study design for the group of older adult with moderate to severe depressive symptoms. GDS: Geriatric Depression Scale.
Participants with mild to moderate depressive symptoms will be recruited from the general population in the Netherlands. They will be eligible to participate if they (1) are aged at least 55 years, (2) have a Geriatric Depression Scale-15 (GDS-15) score between 5 and 10, (3) are able to work with a computer, and (4) have access to a computer with internet. Candidates will be excluded from the study if they (1) do not have adequate proficiency in the Dutch language or (2) have suicidal thoughts, assessed as having a score of 1 or higher on the 9th item of the Patient Health Questionnaire 9 (PHQ-9) [
Participants with moderate to severe depressive symptoms will be recruited via a specialized mental health care outpatient clinic (Geestelijk gezondheidszorg [GGZ] inGeest, Amsterdam, the Netherlands). Patients who are in treatment at the clinic will be eligible to participate if they (1) are aged at least 55 years, (2) have a GDS-15 score between 8 and 15, (3) are able to work with a computer, and (4) have access to a computer with internet. Candidates will be excluded from the study if they (1) do not have adequate proficiency in the Dutch language or (2) have suicidal thoughts, assessed as having a score of 1 or higher on the 9th item of the PHQ-9 [
Moodbuster 2.0 has been developed and tested in a number of European projects. It is an innovative online and mobile solution for the treatment of adult depression and can be applied for research purposes. The platform has a patient and therapist portal (
Screenshot of the patient portal of Moodbuster 2.0.
Moodbuster 2.0 for older adults consists of 7 web-based CBT modules. These modules are aimed at psychoeducation, behavioral activation, cognitive therapy, problem-solving, exercise, sleep, and relapse prevention. The sleep module is a new addition we have made to the platform; it is aimed at older adults, as insomnia and other sleep-related problems are strongly associated with the persistence of depressive symptoms in older adults [
The online guided treatment for older adults from the general population includes the support of an online coach [
The blended CBT treatment that will be offered to participants with moderate to severe depressive symptoms is based on evidence-based CBT protocols implemented in routine practice [
The participants will be recruited from the 2 target groups and settings simultaneously. Participants with mild to moderate depressive symptoms (as assessed with the GDS-15) [
Patients with moderate to severe depressive symptoms will be recruited from the patient population of the specialized mental health care outpatient clinic. For this group, the following steps will be taken: patients who express interest during intake with their therapist will receive an information letter and an informed consent form at the end of the session. Patients who sign the consent form will be assessed by their therapist to confirm they have moderate to severe depressive symptoms (as assessed with the GDS-15 [
Questionnaires will be completed online for both groups. Data will be collected and managed using Castor EDC.
Measures at each assessment interval.
Questionnaires | Aim | Screening (T-1) | Baseline (T0) | Posttreatment (T1) | |||||
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Geriatric Depression Scale-15 | Depressive symptoms | ✓ |
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Item 9 of Patient Health Questionnaire-9 | Suicidal ideation | ✓ |
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Client Satisfaction Questionnaire-8 | Acceptability/ satisfaction |
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✓ | ||||
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System Usability Scalea | Usability |
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✓ | ||||
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Twente Engagement with eHealth Platforms Scale | Engagement |
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✓ | ✓ | ||||
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Patient Health Questionnaire-8 | Depressive symptoms |
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✓ | ✓ | ||||
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Working Alliance Inventory—Short Forma | Working alliance |
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✓ | ||||
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Working Alliance Inventory Technical—Short Form | Technical alliance |
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✓ | ||||
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Uptake | Continued use |
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✓ | ||||
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Digital experiences | General experiences |
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✓ |
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Digital Health Literacy Instrument | Digital literacy |
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✓ |
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aMeasure taken from from participants and practitioners.
The GDS-15 [
Participants will be screened for suicidal ideation using item 9 from the PHQ-9 [
Acceptance and user satisfaction will be measured with the Client Satisfaction Questionnaire-8 (CSQ-8) for internet-based interventions [
Usability will be measured with the System Usability Scale (SUS), which was developed by Brooke [
Engagement with the platform will be measured with the Twente Engagement with eHealth Technologies Scale (TWEETS), developed by Kelder and Kip [
Depression severity will be assessed with the Patient Health Questionnaire-8 (PHQ-8) [
Working alliance will be measured using the short version of the Working Alliance Inventory–Short Form (WAI-SF) [
Technical alliance will be measured with the Dutch Working Alliance Inventory for Online Interventions-Short Form (WAI-TECH-SF) [
Uptake refers to the degree to which a participant engages with the content of the intervention by using or not using [
Participants’ experiences with the platform will also be explored by means of semistructured interviews. This is to gain a better understanding of participants’ satisfaction with the use of Moodbuster. Qualitative interviews allow the participants more freedom in how to respond [
Demographic information will include age, sex (as assigned at birth), living situation, educational level, relationship status, daytime activities, and whether a participant has children.
Digital literacy is operationalized as the degree of a person’s knowledge, comfort, and perceived skills on a digital instrument such as a computer. Digital literacy will be measured using 2 subscales of the Digital Health Literacy Instrument (DHLI), developed by van der Vaart and Drossaert [
Calculating the sample size for a pilot study is not standardized. Sample size can range from 15 to 100 participants and depends on the aim of the study [
When the data collection is completed, the data will be cleaned and assessed for accuracy. The data from participants from the general population will be analyzed separately from the data from the participants that are recruited from the specialized mental health care outpatient clinic.
Quantitative analysis will be conducted using SPSS (version 25; IBM Corp). The primary outcomes will only be assessed after the completion of the interventions (T1). Descriptive statistics (reported as means and SDs) will be calculated to examine and summarize the acceptance and satisfaction of the participants, system usability, and participant engagement with the platform.
Descriptive statistics will be also used to assess the working alliance, technical alliance, and the participants’ use of the intervention (ie, uptake). To investigate baseline differences between participants who complete the studies and those who drop out, a 2-tailed, independent-sample
The interviews and questionnaires will be analyzed using thematic analysis [
All raw data will be collected and managed using Castor EDC. Paper-based documents (such as signed informed consent forms) will be stored in a keycard-secured archive at the Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam. All participants will receive a random study participant code. In the studies, participants will be referred to exclusively by that participant code, and the document linking the numbers will be destroyed once the studies are completed and the results have been disseminated. FAIR (Findability, Accessibility, Interoperability and Reusability) principles of data management will be applied. After data collection is completed, data will be kept in a repository (DarkStor) that serves as an offline archive for storing sensitive information and data.
Ethics approval was granted by the University Medical Centre, Amsterdam (2021.0435).
Study enrollment started in September 2022. The studies were funded in October 2019 by ZorgOnderzoek Nederland–Medische Wetenschappen (ZonMw). Few studies have studied the acceptability, satisfaction, usability, and engagement of iCBT in a guided and blended format for older adults. In our pilot studies, we expect that iCBT in a guided and blended format will prove acceptable and usable by older adults with depressive symptoms. Furthermore, we expect that symptoms of depression will decrease after following the online (guided or blended) treatment. According to the CONSORT (Consolidated Standards of Reporting Trials) guidelines [
The results of these pilot studies will show whether Moodbuster, an online depression treatment platform, is feasible for use by older adults in 2 study settings. We will measure (1) acceptance and satisfaction with the platform, (2) usability of the platform, and (3) engagement with the platform. The treatment will be evaluated in 2 target groups with 2 formats: (1) participants with mild to moderate depressive symptoms in the general population, who will use a guided format, and (2) participants with moderate to severe depressive symptoms at a specialized mental health care outpatient clinic, who will use a blended format. In these pilot studies, a possible main finding could be that older adults will find that online treatment and the use of technology are acceptable. Furthermore, we expect that the platform will be usable by the participants, as well as by the therapists and guides. Lastly, we expect that the participants will be engaged with the platform. iCBT interventions have been widely studied and have been proven effective for a variety of common mental health disorders, including depression [
This pilot study is a first step in the development and evaluation of a digital intervention for older adults. This approach avoids wasting resources and placing unnecessary burdens on participants, because feasibility issues will be identified and addressed prior to the main RCT. Furthermore, this study will be the first empirical study of older adults in 2 settings and in 2 different groups. We have assessed the power of our sample size according to the recommendations and guidelines for conducting pilot studies found in the existing literature. However, it might prove to be the case that our sample size is too limited, which might influence the results we obtain.
Given the limited number of studies on this topic, more research is needed to demonstrate the possibilities of online mental health care for older adults with depression in unguided, guided, and blended settings. The results of this study may provide valuable information on next steps, such as an RCT for testing the clinical effectiveness and cost-effectiveness of iCBT for depressed older adults, and may potentially lead the way to its future implementation in routine care.
cognitive behavioral therapy
Client Satisfaction Questionnaire-8
Digital Health Literacy Inventory
electronic data capture
Geriatric Depression Scale
Geestelijk Gezondheidszorg inGeest
internet cognitive behavioral therapy
Patient Health Questionnaire-8
Patient Health Questionnaire-9
randomized controlled trial
System Usability Scale
Twente Engagement with eHealth Technologies Scale
Working Alliance Inventory–Short Form
Working Alliance Inventory for Online Interventions–Short Form
ZorgOnderzoek Nederland–Medische Wetenschappen
This study was funded by ZorgOnderzoek Nederland–Medische Wetenschappen (ZonMw) (73500095005). The funder had and has no role in the intervention development; study design; collection, management, analysis, or interpretation of the data; writing of the report; or the decision to submit the report for publication. The authors would like to express their sincere thanks to Mr. Tjerk Zweers for his help with designing the recruitment material and website.
The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
KA is the principal investigator and pilot coordinator. KA adjusted the intervention. KA, MHJS, AK, and HR designed the study.
None declared.