Behavior change through automated e-mails: Mediation analysis of self-help strategy use for depressive symptoms

Objective: To evaluate whether automated e-mails promoting effective self-help strategies for depressive symptoms were effective in changing self-help behavior, and whether this improved depression outcomes. Method: 568 adults with sub-threshold depression participated in a randomized controlled trial and provided complete data. A series of 12 e-mails promoting the use of evidence-based self-help strategies was compared with e-mails providing non-directive depression information. Depression symptoms were assessed with the Patient Health Questionnaire depression scale (PHQ-9) and use of self-help strategies was assessed at baseline and post-intervention. We hypothesized that those receiving the self-help e-mails would increase their use of evidence-based self-help and this would be associated with improvements in depression. Mediation analyses were conducted using a non-parametric bootstrapping procedure. Results: Total use of the self-help strategies promoted in the e-mails significantly mediated the effect of the intervention on depressive symptoms (B = -0.75, SE = 0.16, 95% Cl: -1.06 to -0.48). The direct effect of the intervention on depressive symptoms was much smaller and not significant when the mediation path was included. The majority of the individual strategies also had a significant indirect effect on depressive symptoms. Conclusions: In adults with sub-threshold depression, automated e-mails based on behavior change principles can successfully increase use of self-help strategies, leading to a reduction in depressive symptoms. (C) 2012 Elsevier Ltd. All rights reserved.