Skip to main content

Web-based intervention for depressive symptoms in adults with types 1 and 2 diabetes mellitus: a health economic evaluation

  • Stephanie Nobis (a1), David Daniel Ebert (a2), Dirk Lehr (a3), Filip Smit (a4), Claudia Buntrock (a5), Matthias Berking (a6), Harald Baumeister (a7), Frank Snoek (a8), Burkhardt Funk (a9) and Heleen Riper (a10)...

Web-based interventions are effective in reducing depression. However, the evidence for the cost-effectiveness of these interventions is scarce.


The aim is to assess the cost-effectiveness of a web-based intervention (GET.ON M.E.D.) for individuals with diabetes and comorbid depression compared with an active control group receiving web-based psychoeducation.


We conducted a cost-effectiveness analysis with treatment response as the outcome and a cost-utility analysis with quality-adjusted life-years (QALYs) alongside a randomised controlled trial with 260 participants.


At a willingness-to-pay ceiling of €5000 for a treatment response, the intervention has a 97% probability of being regarded as cost-effective compared with the active control group. If society is willing to pay €14 000 for an additional QALY, the intervention has a 51% probability of being cost-effective.


This web-based intervention for individuals with diabetes and comorbid depression demonstrated a high probability of being cost-effective compared with an active control group.

Declaration of interest

S.N., D.D.E., D.L., M.B. and B.F. are stakeholders of the Institute for Online Health Trainings, which aims to transfer scientific knowledge related to this research into routine healthcare.

Corresponding author
Correspondence: Stephanie Nobis, PhD, Wangerooger Straße 2, 49393 Lohne, Germany. Email:
Hide All
1Lin, EH, von Korff, M. Mental disorders among persons with diabetes – results from the World Mental Health Surveys. J Psychosom Res 2008; 65: 571–80.
2Schram, MT, Baan, CA, Pouwer, F. Depression and quality of life in patients with diabetes: a systematic review from the European Depression in Diabetes (EDID) research consortium. Curr Diabetes Rev 2009; 5: 112–9.
3Snoek, FJ, Bremmer, MA, Hermanns, N. Depression and diabetes 1: constructs of depression and distress in diabetes: time for an appraisal. Lancet Diabetes Endocrinol 2015; 3: 450–60.
4Smit, F, Cuijpers, P, Oostenbrink, J, Batelaan, N, de Graaf, R, Beekman, A. Costs of nine common mental disorders: implications for curative and preventive psychiatry. J Ment Health Policy Econ 2006; 9: 193200.
5Simon, GE, Katon, WJ, Lin, EHB, Ludman, E, von Korff, M, Ciechanowski, P, et al. Diabetes complications and depression as predictors of health service costs. Gen Hosp Psychiatry 2005; 27: 344–51.
6Lehnert, T, Konnopka, A, Riedel-Heller, S, König, HH. Diabetes mellitus and comorbid depression: economic findings from a systematic literature review. Psychiatr Prax 2011; 38: 369–75.
7Von Korff, M, Katon, W, Lin, EHB, Simon, G, Ciechanowski, P, Ludman, E, et al. Work disability among individuals with diabetes. Diabetes Care 2005; 28: 1326–32.
8Baumeister, H, Hutter, N, Bengel, J. Psychological and pharmacological interventions for depression in patients with diabetes mellitus and depression. Cochrane Database Syst Rev 2012; 12: CD008381.
9Kok, JL, Williams, A, Zhao, L. Psychosocial interventions for people with diabetes and co-morbid depression. A systematic review. Int J Nurs Stud 2015; 52: 1625–39.
10Jeeva, F, Dickens, C, Coventry, P, Bundy, C, Davies, L. Is treatment of depression cost-effective in people with diabetes? A systematic review of the economic evidence. Int J Technol Assess Health Care 2013; 29: 384–91.
11Richards, D, Richardson, T. Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clin Psychol Rev 2012; 32: 329–42.
12Nobis, S, Lehr, D, Ebert, DD, Baumeister, H, Snoek, F, Riper, H, et al. Efficacy of a web-based intervention with mobile phone support in treating depressive symptoms in adults with type 1 and type 2 diabetes: a randomized controlled trial. Diabetes Care 2015; 38: 776–83.
13Ebert, D, Nobis, S, Lehr, D, Baumeister, H, Riper, H, Auerbach, RP, Snoek, F, Berking, M. The 6-month effectiveness of Internet-based guided self-help for depression in adults with type 1 and 2 diabetes mellitus. Diabetic Med 2016; 34: 90107.
14van Bastelaar, KMP, Pouwer, F, Cuijpers, P, Riper, H, Snoek, FJ. Web-based depression treatment for type 1 and type 2 diabetic patients: a randomized, controlled trial. Diabetes Care 2011; 34: 320–5.
15Andersson, G, Titov, N. Advantages and limitations of Internet-based interventions for common mental disorders. World Psychiatry 2014; 13: 411.
16Hollinghurst, S, Peters, TJ, Kaur, S, Wiles, N, Lewis, G, Kessler, D. Cost-effectiveness of therapist-delivered online cognitive-behavioural therapy for depression: randomised controlled trial. Br J Psychiatry 2010; 197: 297304.
17Warmerdam, L, Smit, F, van Straten, A, Riper, H, Cuijpers, P. Cost-utility and cost-effectiveness of internet-based treatment for adults with depressive symptoms: randomized trial. J Med Internet Res 2010; 12: e53.
18Gerhards, SAH, de Graaf, LE, Jacobs, LE, Severens, JL, Huibers, MJH, Arntz, A, et al. Economic evaluation of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial. Br J Psychiatry 2010; 196: 310–8.
19McCrone, P, Knapp, M, Proudfoot, J, Ryden, C, Cavanagh, K, Shapiro, DA, et al. Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry 2004; 185: 5562.
20Geraedts, AS, van Dongen, JM, Kleiboer, AM, Wiezer, NM, van Mechelen, W, Cuijpers, P, et al. Economic evaluation of a web-based guided self-help intervention for employees with depressive symptoms: results of a randomized controlled trial. J Occup Environ Med 2015; 57: 666–75.
21Nobis, S, Lehr, D, Ebert, DD, Berking, M, Heber, E, Baumeister, H, et al. Efficacy and cost-effectiveness of a web-based intervention with mobile phone support to treat depressive symptoms in adults with diabetes mellitus type 1 and type 2: design of a randomised controlled trial. BMC Psychiatry 2013; 13: 306.
22Hautzinger, M, Bailer, M, Hofmeister, D, Keller, F. Allgemeine Depressionsskala. [General Depression Scale.] 2nd edn. Hogrefe Publishing, 2012.
23Radloff, LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1: 385401.
24Cuijpers, P, van Straten, A, Warmerdam, L. Behavioral activation treatments of depression: a meta-analysis. Clin Psychol Rev 2007; 27: 318–26.
25Cuijpers, P, van Straten, A, Warmerdam, L. Problem solving therapies for depression: a meta-analysis. Eur Psychiatry 2007; 22: 915.
26BÄK, KBV, AWMF, AkdÄ, BPtK, BApK, DAGSHG, DEGAM, DGPM, DGPs, DGRW. S3 Guideline unipolar depression, 2015 (
27Jacobson, NS, Truax, P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991; 59: 12–9.
28Drummond, MF, Sculpher, MJ, Torrance, GW, O'Brien, BJ, Stoddart, GL. Methods for the Economic Evaluation of Health Care Programmes, 3rd edn. Oxford University Press, 2005.
29EuroQol Group. EuroQol - a new facility for the measurement of health-related quality of life. Health Policy 1990; 16: 199208.
30Dolan, P. Modeling valuations for EuroQol health states. Med Care 1997; 35: 1095–108.
31Hakkaart-van Roijen, L. Manual Trimbos/iMTA Questionnaire for Costs Associated with Psychiatric Illness (in Dutch). Institute for Medical Technology Assessment, 2002.
32Krauth, C, Hessel, F, Hansmeier, T, Wasem, J, Seitz, R, Schweikert, B. Empirische Bewertungssätze in der gesundheitsökonomischen Evaluation - ein Vorschlag der AG Methoden der gesundheitsökonomischen Evaluation (AG MEG). [Empirical Standard Costs for Health Economic Evaluation in Germany - a Proposal by the Working Group Methods in Health Economic Evaluation.] Gesundheitswesen 2005; 67: 736–46.
33Bock, JO, Brettschneider, C, Seidl, H, Bowles, D, Holle, R, Greiner, W, et al. Ermittlung standardisierter Bewertungssätze aus gesellschaftlicher Perspektive für die gesundheitsökonomische Evaluation. [Calculation of Standardised Unit Costs from a Societal Perspective for Health Economic Evaluation.] Gesundheitswesen 2014; 77: 5361.
34Husereau, D, Drummond, M, Petrou, S, Stavros, P, Carswell, C, Moher, D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS)—explanation and elaboration: a report of the ISPOR health economic evaluation publication guidelines good reporting practices task force. Value Health 2013; 16: 231–50.
35van Hout, BA, Al, MJ, Gordon, GS, Rutten, FFH. Costs, effects and C/E-ratios alongside a clinical trial. Health Econ 1994; 3: 309–19.
36Schafer, JL, Graham, JW. Missing data: our view of the state of the art. Psychol Methods 2002; 7: 147–77.
37Matthews, JN, Altman, DG, Campbell, MJ, Royston, P. Analysis of serial measurements in medical research. BMJ 1990; 300: 230–5.
38Barrett, B, Byford, S. Acceptable mental health care? A new decision-making tool for cost-effectiveness analysis. Ment Health Res Rev 2001; 9: 3941.
39Hirth, RA, Chernew, ME, Miller, E, Fendrick, AM, Weissert, WG. Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making 2000; 20: 332–42.
40American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Dsm-IV (4th ed). American Psychiatric Press, 1994.
41First, MB, Spitzer, RL, Gibbon, M, Williams, JBW. User Guide for the Structured Clinical Interview for DSM-IV Axis 1 Disorders. American Psychiatric Association, 1996.
42Mihalopoulos, C, Chen, G, Iezzi, A, Khan, MA, Richardson, J. Assessing outcomes for cost-utility analysis in depression: comparison of five multi-attribute utility instruments with two depression-specific outcome measures. Br J Psychiatry 2014; 205: 390–7.
43Turner, N, Campbell, J, Peters, TJ, Wiles, N, Hollinghurst, S. A comparison of four different approaches to measuring health utility in depressed patients. Health Qual Life Outcomes 2013; 11: 81.
44Faria, R, Gomes, M, Epstein, D, White, IR. A guide to handling missing data in cost-effectiveness analysis conducted within randomised controlled trials. PharmacoEconomics 2014; 32: 1157–70.
45Egede, LE, Ellis, C. Diabetes and depression: global perspectives. Diabetes Res Clin Pract 2010; 87: 302–12.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Web-based intervention for depressive symptoms in adults with types 1 and 2 diabetes mellitus: a health economic evaluation

  • Stephanie Nobis (a1), David Daniel Ebert (a2), Dirk Lehr (a3), Filip Smit (a4), Claudia Buntrock (a5), Matthias Berking (a6), Harald Baumeister (a7), Frank Snoek (a8), Burkhardt Funk (a9) and Heleen Riper (a10)...
Submit a response


No eLetters have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *