UMMS Affiliation

Department of Quantitative Health Sciences

Publication Date


Document Type



Health Services Administration | Health Services Research | Primary Care | Psychiatry and Psychology | Telemedicine


BACKGROUND: Depressive disorders and symptoms affect more than one-third of primary care patients, many of whom do not receive or do not complete treatment. Internet-based social support from peers could sustain depression treatment engagement and adherence. We do not know whether primary care patients will accept referral to such websites nor do we know which methods of referral would be most effective.

OBJECTIVE: We conducted a randomized clinical trial to determine whether (1) a simple generic referral card (control), (2) a patient-oriented brochure that provided examples of online postings and experience (internal motivation), or (3) a physician letter of recommendation (external motivation) would generate the greatest participation in a primary care Internet depression treatment support portal focused around an Internet support group (ISG). METHODS: We used 3 offline methods to identify potential participants who had not used an ISG in the past 6 months. Eligibility was determined in part by a brief structured psychiatric interview based on the Patient Health Questionnaire-9 (PHQ-9). After consent and enrollment, participants were randomly assigned to 1 of 3 groups (control, internal motivation, or external motivation). We constructed a portal to connect primary care patients to both fact-based information and an established ISG (Psycho-Babble). The ISG allowed participants to view messages and then decide if they actually wished to register there. Participation in the portal and the ISG was assessed via automated activity tracking.

RESULTS: Fifty participants were assigned to the 3 groups: a motivation-neutral control group (n=18), an internal motivation group (n=19), and an external motivation group (n=13). Of these participants, 31 (62%) visited the portal; 27 (54%) visited the ISG itself. The internal motivation group showed significantly greater participation than the control group on several measures. The external motivation group spent significantly less time logged onto the portal than the control group. The internal motivation group showed significantly greater participation than the external motivation group on several measures.

CONCLUSIONS: Referral of primary care patients with depressive disorders and symptoms to an ISG is feasible even if they have never previously used one. This may best be accomplished by enhancing their internal motivation. TRIAL REGISTRATION: NCT00886730; (Archived by WebCite at


UMCCTS funding, depressive disorder, Internet, primary care, support groups

Rights and Permissions

© Benjamin W Van Voorhees, Robert C Hsiung, Monika Marko-Holguin, Thomas K Houston, Joshua Fogel, Royce Lee, Daniel E Ford. Originally published in the Journal of Medical Internet Research (, 12.03.2013. This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.

DOI of Published Version



J Med Internet Res. 2013 Mar 12;15(3):e42. doi: 10.2196/jmir.2197. Link to article on publisher's site

Journal/Book/Conference Title

Journal of medical Internet research

PubMed ID


Related Resources

Link to Article in PubMed