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This dissertation evaluated the efficacy of three different internet-based interventions that can be regarded as indirect interventions to reduce depression since they primarily targeted risk factors for depression. For this purpose three registered randomized controlled trials were conducted. In addition to assessing the efficacy of the interventions regarding the primary outcomes, the efficacy to reduce depression and further secondary outcomes was studied. In Study I (N=200) the efficacy of an internet-based stress management intervention (iSMI), which was adapted and tailored to career starting teachers, was compared to a waitlist control group (WLG). The participants of the intervention group (IG) reported significant reductions on the primary outcome perceived stress at post-intervention (T2) and three month follow-up (3-MFU). Furthermore, it was shown that the intervention indirectly also reduced depression at T2 and 3-MFU. The effects were sustained at an extended 6-MFU. Besides efficacy, the feasibility to complement the iSMI with a newly developed internet-based classroom management training was shown. Moreover, mediation analyses corroborated the role of problem- and emotion-focused coping skills in the intervention's effect on stress and the indirect effect of the intervention on depression through stress. Study II (N=262) demonstrated the efficacy of an internet- and app-based gratitude intervention on the reduction of primary assessed repetitive negative thoughts at T2 and 3-MFU, as compared to a WLG. The participants of the IG also reported significantly reduced depressive symptoms at T2, and 3-MFU, with significant clinically meaningful effects. The effects were sustained at an extended 6-MFU. Besides efficacy, mediation analyses showed that repetitive negative thinking mediated the gratitude intervention's effect on depression. Finally, Study III N(=351) showed that an internet-based intervention, tackling worries at the beginning of the COVID-19 pandemic, was effective as compared to an active mental health advice group. At T2, two weeks after randomization, the IG reported significantly reduced levels on the primary outcome worry as compared to controls. Participants of the IG also reported significantly reduced levels of depression at T2, with significant clinically meaningful reductions. The extended follow-ups in the IG indicated that the improvements from baseline were sustained until the 2-MFU and the 6-MFU. In a mediation analysis, worry was shown to mediate the intervention's effect on depression. Across all three studies a reliable deterioration of depression was occasionally observed. In summary, the studies in this dissertation demonstrated the efficacy of various indirect interventions focusing on rather common psychological problems to indirectly reduce depressive symptoms. The extent to which depression severity could be reduced is comparable to reductions found within participants with comparable baseline depression severity, in internet-based interventions directly addressing depressive symptoms. Indirect interventions are suggested to increase the uptake of interventions that reduce depressive symptoms, since they might be perceived as less stigmatizing and might broaden the range of interventions to choose from.
Panic disorder is a common anxiety disorder, which is associated with high subjective burden as well as a high cost for the health economy. According to the National Treatment Guideline S3, cognitive behavior therapy is recommended as the most effective psychological treatment. However, many people in need do not have access to cognitive behavior therapy. Internet-based interventions have proven to be an effective way to provide access to evidence-based treatment to those affected. For anxiety disorders, such as panic disorder and agoraphobia, a good effectiveness of internet-based interventions has been proven in numerous international studies. However, the internet has changed over the last few years: mobile technologies have considerable potential to further improve the adherence and effectiveness of internet-based interventions. Against this background, the authors developed the hybrid online training "GET.ON Panic". In this training, an app has been integrated into a browser-based online training. The app consists of a mobile diary for self-monitoring as well as a mobile exposure-guide that supports participants in self-exposure exercises in their everyday lives.In an initial exploratory feasibility study, qualitative interview data and quantitative measurements were collected in a pre-post design of 10 participants. Usage, user friendliness, user satisfaction and acceptance of the app were generally considered high. The use of interoceptive exposure exercises and daily summaries of anxiety and mood were the most widely performed and rated the best, while in vivo exposure exercises and the monitoring of acute panic symptoms were found to be difficult.In the efficacy study, 92 participants with mild to moderate panic symptoms were randomized into two parallel groups. After eight weeks, the intervention group showed a significant improvement in the severity of panic symptoms compared to the waiting control group. Using the intention-to-treat approach, a covariance analysis with baseline values as a covariate yielded a mean effect of Cohen's d=0.66 in reducing the panic symptoms in favor of the intervention group. This effect increased to d=0.89 after three months and stayed at d=0.81 at the 6-month measurement point. Response and remission rates were also significantly higher in the intervention group. This positive effect was also shown for secondary outcomes such as depressive symptoms and quality of life. A correlation between app usage and clinical outcomes could not be found. This work was the first to demonstrate that a hybrid online training based on cognitive behavior therapy is effective in reducing panic symptoms as well as panic disorder. In addition, this work contributes to a deeper understanding of the potential of mobile technologies in the field of e-mental health.