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Email-based promotion of self-help for subthreshold depression: Mood Memos randomised controlled trial

  • Amy J. Morgan (a1), Anthony F. Jorm (a1) and Andrew J. Mackinnon (a1)



Subthreshold depression is common, impairs functioning and increases the risk of major depression. Improving self-help coping strategies could help subthreshold depression and prevent major depression.


To test the effectiveness of an automated email-based campaign promoting self-help behaviours.


A randomised controlled trial was conducted through the website: Participants received automated emails twice weekly for 6 weeks containing advice about self-help strategies. Emails containing general information about depression served as a control. The principal outcome was depression symptom level on the nine-item Patient Health Questionnaire (PHQ-9) (trial registration: ACTRN12609000925246).


The study recruited 1326 adults with subthreshold depression. There was a small significant difference in depression symptoms at post-intervention, favouring the active group (d = 0.17, 95% CI 0.01–0.34). There was a lower, although non-significant, risk of major depression in the active group (number needed to treat (NNT) 25, 95% CI 11 to ∞ to NNT(harm) 57).


Emails promoting self-help strategies were beneficial. Internet delivery of self-help messages affords a low-cost, easily disseminated and highly automated approach for indicated prevention of depression.


Corresponding author

Amy J. Morgan, Orygen Youth Health Research Centre, University of Melbourne, Locked Bag 10, Parkville, Victoria 3052, Australia. Email:


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Funded by a National Health and Medical Research Council Postgraduate Scholarship (567056) and a Sidney Myer Health Scholarship. Orygen Youth Health Research Centre receives funding from the Colonial Foundation.

Declaration of interest

A. J. Morgan is the author and developer of the Mood Memos website but derives no personal or financial benefit from its operation.



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1 Backenstrass, M, Frank, A, Joest, K, Hingmann, S, Mundt, C, Kronmüller, K-T. A comparative study of nonspecific depressive symptoms and minor depression regarding functional impairment and associated characteristics in primary care. Compr Psychiatry 2006; 47: 3541.
2 Cuijpers, P, Smit, F, Oostenbrink, J, de Graaf, R, ten Have, M, Beekman, A. Economic costs of minor depression: a population-based study. Acta Psychiatr Scand 2007; 115: 229–36.
3 Fournier, JC, DeRubeis, RJ, Hollon, SD, Dimidjian, S, Amsterdam, JD, Shelton, RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010; 303: 4753.
4 Cuijpers, P, Smit, F, van Straten, A. Psychological treatments of subthreshold depression: a meta-analytic review. Acta Psychiatr Scand 2007; 115: 434–41.
5 Jorm, AF, Griffiths, KM, Christensen, H, Parslow, RA, Rodgers, B. Actions taken to cope with depression at different levels of severity: a community survey. Psychol Med 2004; 34: 293–9.
6 Jorm, AF, Medway, J, Christensen, H, Korten, AE, Jacomb, PA, Rodgers, B. Public beliefs about the helpfulness of interventions for depression: effects on actions taken when experiencing anxiety and depression symptoms. Aust N Z J Psychiatry 2000; 34: 619–26.
7 Jorm, AF, Griffiths, KM. Population promotion of informal self-help strategies for early intervention against depression and anxiety. Psychol Med 2006; 36: 36.
8 Morgan, AJ, Jorm, AF, Mackinnon, AJ. Protocol for a randomised controlled trial investigating self-help email messages for sub-threshold depression: the Mood Memos study. Trials 2011; 12: 11.
9 Kroenke, K, Spitzer, RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann 2002; 32: 509–15.
10 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA, 1994.
11 Morgan, AJ, Jorm, AF. Self-help strategies that are helpful for sub-threshold depression: a Delphi consensus study. J Affect Disord 2009; 115: 196200.
12 Kroenke, K, Spitzer, RL, Williams, JBW, Löwe, B. The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry 2010; 32: 345–59.
13 Kessler, RC, Andrews, G, Colpe, LJ, Hiripi, E, Mroczek, DK, Normand, SLT, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32: 959–76.
14 Mundt, JC, Marks, IM, Shear, MK, Greist, JM. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry 2002; 180: 461–4.
15 Andrews, G, Slade, T. Interpreting scores on the Kessler Psychological Distress Scale (K10). Aust N Z J Public Health 2001; 25: 494–7.
16 Donker, T, van Straten, A, Marks, I, Cuijpers, P. Brief self-rated screening for depression on the Internet. J Affect Disord 2010; 122: 253–9.
17 Kessler, RC, Barker, PR, Colpe, LJ, Epstein, JF, Gfroerer, JC, Hiripi, E, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003; 60: 184–9.
18 Furukawa, TA, Kessler, RC, Slade, T, Andrews, G. The performance of the K6 and K10 screening scales for psychological distress in the Australian National Survey of Mental Health and Well-Being. Psychol Med 2003; 33: 357–62.
19 Horowitz, JL, Garber, J. The prevention of depressive symptoms in children and adolescents: a meta-analytic review. J Consult Clin Psychol 2006; 74: 401–15.
20 Andersson, G, Cuijpers, P. Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cogn Behav Ther 2009; 38: 196205.
21 Cuijpers, P, Donker, T, Johansson, R, Mohr, DC, van Straten, A, Andersson, G. Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS ONE 2011; 6: e21274.
22 Cohen, J. A power primer. Psychol Bull 1992; 112: 155–9.
23 Christensen, H, Griffiths, KM, Farrer, L. Adherence in internet interventions for anxiety and depression. J Med Internet Res 2009; 11: e13.
24 Bender, R. Calculating confidence intervals for the number needed to treat. Control Clin Trials 2001; 22: 102–10.
25 Altman, DG. Confidence intervals for the number needed to treat. BMJ 1998; 317: 1309–12.
26 Brugha, TS, Bebbington, P, Tennant, C, Hurry, J. The List of Threatening Experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol Med 1985; 15: 189–94.
27 Brugha, TS, Cragg, D. The List of Threatening Experiences – the reliability and validity of a brief life events questionnaire. Acta Psychiatr Scand 1990; 82: 7781.
28 Australian Bureau of Statistics. 4363.0.55.001 – National Health Survey: Users' Guide – Electronic, 2007–08. Australian Bureau of Statistics, 2009 (–08).
29 Sternfeld, B, Block, C, Quesenberry, CP Jr, Block, TJ, Husson, G, Norris, JC, et al. Improving diet and physical activity with ALIVE: a worksite randomized trial. Am J Prev Med 2009; 36: 475–83.
30 Andrews, G, Issakidis, C, Sanderson, K, Corry, J, Lapsley, H. Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. Br J Psychiatry 2004; 184: 526–33.
31 Cuijpers, P, van Straten, A, Smit, F, Mihalopoulos, C, Beekman, A. Preventing the onset of depressive disorders: a meta-analytic review of psychological interventions. Am J Psychiatry 2008; 165: 1272–80.
32 Cuijpers, P. Examining the effects of prevention programs on the incidence of new cases of mental disorders: the lack of statistical power. Am J Psychiatry 2003; 160: 1385–91.
33 McKnight, PE, Kashdan, TB. The importance of functional impairment to mental health outcomes: a case for reassessing our goals in depression treatment research. Clin Psychol Rev 2009; 29: 243–59.
34 van Beljouw, I, Verhaak, P, Prins, M, Cuijpers, P, Penninx, B, Bensing, J. Reasons and determinants for not receiving treatment for common mental disorders. Psychiatr Serv 2010; 61: 250–7.
35 Jorm, AF, Nakane, Y, Christensen, H, Yoshioka, K, Griffiths, KM, Wata, Y. Public beliefs about treatment and outcome of mental disorders: a comparison of Australia and Japan. BMC Med 2005; 3: 12.
36 Muñoz, RF, Cuijpers, P, Smit, F, Barrera, AZ, Leykin, Y. Prevention of major depression. Annu Rev Clin Psychol 2010; 6: 181212.
37 Melville, KM, Casey, LM, Kavanagh, DJ. Dropout from internet-based treatment for psychological disorders. Br J Clin Psychol 2010; 49: 455–71.
38 Eysenbach, G. The law of attrition. J Med Internet Res 2005; 7: e11.
39 Salim, A, Mackinnon, A, Christensen, H, Griffiths, K. Comparison of data analysis strategies for intent-to-treat analysis in pre-test-post-test designs with substantial dropout rates. Psychiatry Res 2008; 160: 335–45.
40 Titov, N, Andrews, G, Kemp, A, Robinson, E. Characteristics of adults with anxiety or depression treated at an internet clinic: comparison with a national survey and an outpatient clinic. PLoS One 2010; 5: e10885.
41 Carragher, N, Adamson, G, Bunting, B, McCann, S. Treatment-seeking behaviours for depression in the general population: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Affect Disord 2010; 121: 5967.
42 Atkinson, NL, Saperstein, SL, Pleis, J. Using the internet for health-related activities: findings from a national probability sample. J Med Internet Res 2009; 11: e4.
43 Donker, T, Griffiths, K, Cuijpers, P, Christensen, H. Psychoeducation for depression, anxiety and psychological distress: a meta-analysis. BMC Med 2009; 7: 79.


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Email-based promotion of self-help for subthreshold depression: Mood Memos randomised controlled trial

  • Amy J. Morgan (a1), Anthony F. Jorm (a1) and Andrew J. Mackinnon (a1)
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