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"v1_Abstract": "Objective:The main hypothesis, and the objective of the study, was to test if the participants allocated to the treatment group would show a larger reduction in depressive symptoms than those in the control group Methods:This study was a randomized nine week trial of an Internet-administered treatment based on guided physical exercise for Major Depressive Disorder (MDD). A total of 48 participants with mild to moderate depression, diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders , were randomized either to a treatment intervention or to a waiting-list control group. The main outcome measure for depression was the Beck Depression Inventory-II (BDI-II), and physical activity level was measured using the International Physical Activity Questionnaire (IPAQ). The treatment program consisted of nine text modules, and included therapist guidance on a weekly basis. Results:The results showed significant reductions of depressive symptoms in the treatment group compared to the control group, with a moderate between-group effect size (Cohen\u2019s d = 0.67; 95 % confidence interval: 0.09-1.25). No difference was found between the groups with regards to increase of physical activity level. For the treatment group, the reduction in depressive symptoms persisted at six months follow-up. Conclusions:Physical activity as a treatment for depression can be delivered in the form of guided Internet-based self-help. Trial Registration:The trial was registered at ClinicalTrials.gov (NCT01573130).",
"v1_col_introduction": "introduction : The\u00a0World\u00a0Health\u00a0Organization\u00a0(WHO,\u00a02001)\u00a0predicts\u00a0that\u00a0depression\u00a0will\u00a0be\u00a0one\u00a0of\u00a0the\u00a0three\u00a0 most\u00a0burdensome\u00a0diseases\u00a0in\u00a0the\u00a0world\u00a0in\u00a02020.\u00a0With\u00a0the\u00a0advancement\u00a0of\u00a0communication\u00a0 technologies,\u00a0new\u00a0ways\u00a0of\u00a0providing\u00a0and\u00a0delivering\u00a0psychological\u00a0treatments\u00a0have\u00a0emerged\u00a0(P\u00a0 Carlbring\u00a0&\u00a0Andersson,\u00a02006).\u00a0The\u00a0Internet\u00a0has\u00a0made\u00a0it\u00a0possible\u00a0to\u00a0reach\u00a0people\u00a0over\u00a0great\u00a0 distances\u00a0and\u00a0provide\u00a0psychological\u00a0interventions\u00a0to\u00a0a\u00a0vast\u00a0number\u00a0of\u00a0patients\u00a0at\u00a0a\u00a0low\u00a0cost\u00a0due\u00a0to shorter\u00a0treatment\u00a0time\u00a0per\u00a0person\u00a0(Andersson,\u00a02009).\u00a0Internetdelivered\u00a0treatments\u00a0also\u00a0have\u00a0the\u00a0 opportunity\u00a0to\u00a0increase\u00a0accessibility\u00a0for\u00a0patients\u00a0in\u00a0remote\u00a0geographical\u00a0locations\u00a0and\u00a0to\u00a0make\u00a0 support\u00a0available\u00a0for\u00a0people\u00a0who\u00a0would\u00a0not\u00a0otherwise\u00a0seek\u00a0care\u00a0(Newman,\u00a0Szkodny,\u00a0Llera,\u00a0&\u00a0 Przeworski,\u00a02011).\u00a0Furthermore,\u00a0Internetdelivered\u00a0treatments\u00a0have\u00a0the\u00a0possibility\u00a0of\u00a0giving\u00a0 patients\u00a0quick\u00a0feedback\u00a0and\u00a0presentation\u00a0of\u00a0material\u00a0in\u00a0a\u00a0stepbystep\u00a0basis\u00a0(Titov,\u00a02011).\u00a0\nCurrently,\u00a0several\u00a0studies\u00a0have\u00a0investigated\u00a0the\u00a0effects\u00a0of\u00a0Internetdelivered\u00a0treatments\u00a0for\u00a0 depression\u00a0(Johansson\u00a0&\u00a0Andersson,\u00a02012).\u00a0A\u00a0large\u00a0part\u00a0of\u00a0these\u00a0studies\u00a0have\u00a0been\u00a0based\u00a0on\u00a0 cognitive\u00a0behavior\u00a0therapy\u00a0(CBT)\u00a0as\u00a0the\u00a0main\u00a0theoretical\u00a0framework,\u00a0but\u00a0there\u00a0are\u00a0exceptions\u00a0 (Johansson\u00a0et\u00a0al.,\u00a02012).\u00a0Andersson\u00a0and\u00a0Cuijpers\u00a0(2009)\u00a0did\u00a0a\u00a0metaanalysis\u00a0and\u00a0found\u00a0a\u00a0 significant\u00a0difference\u00a0between\u00a0supported\u00a0(d\u00a0=\u00a00.61)\u00a0and\u00a0unsupported\u00a0(d\u00a0=\u00a00.25)\u00a0depression\u00a0 treatments.\u00a0In\u00a0a\u00a0more\u00a0recent\u00a0metaanalysis,\u00a0a\u00a0similar\u00a0result\u00a0was\u00a0found\u00a0by\u00a0Richards\u00a0and\u00a0Richardson (2012).\u00a0In\u00a0addition,\u00a0Johansson\u00a0and\u00a0Andersson\u00a0(2012)\u00a0found\u00a0a\u00a0strong\u00a0and\u00a0significant\u00a0association\u00a0 between\u00a0support\u00a0and\u00a0effect\u00a0size\u00a0with\u00a0a\u00a0Spearman\u00a0correlation\u00a0of\u00a0 \u00a0=\u00a00.64,\u00a0indicating\u00a0that\u00a0more\u00a0\u03c1 support\u00a0yields\u00a0larger\u00a0effects.\nSince\u00a0the\u00a0beginning\u00a0of\u00a0the\u00a020th\u00a0century,\u00a0a\u00a0large\u00a0amount\u00a0of\u00a0research\u00a0has\u00a0been\u00a0conducted\u00a0 concerning\u00a0the\u00a0effects\u00a0of\u00a0physical\u00a0activity\u00a0on\u00a0clinical\u00a0depression.\u00a0Several\u00a0studies\u00a0have\u00a0found\u00a0 treatment\u00a0effects\u00a0ranging\u00a0in\u00a0size\u00a0from\u00a0moderate\u00a0to\u00a0large\u00a0(Barbour,\u00a0Edenfield,\u00a0&\u00a0Blumenthal,\u00a0 2007;\u00a0Silveira\u00a0et\u00a0al.,\u00a02013).\u00a0However,\u00a0there\u00a0is\u00a0still\u00a0no\u00a0consensus\u00a0about\u00a0the\u00a0mechanisms\u00a0of\u00a0change\u00a0 that\u00a0mediate\u00a0reductions\u00a0in\u00a0depressive\u00a0symptoms\u00a0following\u00a0psychotherapy\u00a0(Lundh,\u00a02009),\u00a0and\u00a0 there\u00a0is\u00a0also\u00a0limited\u00a0knowledge\u00a0regarding\u00a0mediators\u00a0of\u00a0change\u00a0following\u00a0physical\u00a0activity\u00a0for\u00a0 depression,\u00a0apart\u00a0from\u00a0the\u00a0physiological\u00a0effects\u00a0of\u00a0increased\u00a0activity.\u00a0\nA\u00a0metaanalysis\u00a0by\u00a0Davies\u00a0et\u00a0al.\u00a0(2012)\u00a0investigated\u00a0the\u00a0effects\u00a0of\u00a0Internetdelivered\u00a0interventions\u00a0 to\u00a0increase\u00a0physical\u00a0activity\u00a0levels.\u00a0The\u00a0result\u00a0showed\u00a0generally\u00a0small\u00a0but\u00a0statistically\u00a0significant\u00a0 increases\u00a0in\u00a0physical\u00a0activity\u00a0levels\u00a0in\u00a0the\u00a034\u00a0studies\u00a0reviewed.\u00a0To\u00a0our\u00a0knowledge,\u00a0there\u00a0are\u00a0few\u00a0 studies,\u00a0if\u00a0any,\u00a0on\u00a0guided\u00a0Internetdelivered\u00a0physical\u00a0activity\u00a0for\u00a0major\u00a0depression.\u00a0\nThe\u00a0purpose\u00a0of\u00a0the\u00a0present\u00a0study\u00a0was\u00a0to\u00a0evaluate\u00a0a\u00a0treatment\u00a0for\u00a0major\u00a0depression\u00a0based\u00a0on\u00a0 physical\u00a0exercise\u00a0administered\u00a0via\u00a0the\u00a0Internet.\u00a0The\u00a0treatment\u00a0program\u00a0was\u00a0intended\u00a0to\u00a0decrease\u00a0 depressive\u00a0symptoms\u00a0and\u00a0to\u00a0motivate\u00a0participants\u00a0to\u00a0increase\u00a0their\u00a0level\u00a0of\u00a0physical\u00a0activity.\u00a0The\u00a0 treatment\u00a0group\u00a0was\u00a0compared\u00a0to\u00a0a\u00a0waitinglist\u00a0control\u00a0group.\u00a0\nThe\u00a0main\u00a0hypothesis,\u00a0and\u00a0the\u00a0objective\u00a0of\u00a0the\u00a0study,\u00a0was\u00a0to\u00a0test\u00a0if\u00a0the\u00a0participants\u00a0allocated\u00a0to\u00a0the\u00a0 treatment\u00a0group\u00a0would\u00a0show\u00a0a\u00a0larger\u00a0reduction\u00a0in\u00a0depressive\u00a0symptoms\u00a0than\u00a0those\u00a0in\u00a0the\u00a0control\u00a0 group,\u00a0as\u00a0measured\u00a0by\u00a0the\u00a0Beck\u00a0Depression\u00a0Inventory:\u00a0Second\u00a0Version\u00a0(BDIII;\u00a0Beck,\u00a0Epstein,\u00a0 Brown,\u00a0&\u00a0Steer,\u00a01988)\u00a0and\u00a0the\u00a0Montgomery\u00c5sberg\u00a0Depression\u00a0Rating\u00a0Scale:\u00a0Short\u00a0Version\u00a0 (MADRSS;\u00a0Svanborg\u00a0&\u00a0\u00c5sberg,\u00a02001).\u00a0Since\u00a0depression\u00a0also\u00a0has\u00a0impact\u00a0on\u00a0other\u00a0aspects\u00a0of\u00a0a\u00a0\n17\n18 19 20 21 22 23 24 25 26 27\n28 29 30 31 32 33 34 35 36\n37 38 39 40 41 42 43\n44 45 46 47\n48 49 50 51\n52 53 54 55 56\nPeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013)\nR ev ie w in g M an\nus cr ip t\nperson\u2019s\u00a0life\u00a0we\u00a0wanted\u00a0to\u00a0explore\u00a0this\u00a0further\u00a0(Kennedy,\u00a0Eisfeld,\u00a0&\u00a0Cooke,\u00a02001).\u00a0Hence,\u00a0it\u00a0was\u00a0 hypothesized\u00a0that\u00a0participants\u00a0in\u00a0the\u00a0treatment\u00a0group\u00a0would\u00a0show\u00a0larger\u00a0reductions\u00a0of\u00a0anxiety\u00a0 symptoms\u00a0as\u00a0measured\u00a0with\u00a0the\u00a0Beck\u00a0Anxiety\u00a0Inventory\u00a0(BAI;\u00a0Beck\u00a0et\u00a0al.,\u00a01988),\u00a0and\u00a0greater\u00a0 increases\u00a0in\u00a0levels\u00a0of\u00a0physical\u00a0activity\u00a0as\u00a0measured\u00a0with\u00a0the\u00a0International\u00a0Physical\u00a0Activity\u00a0 Questionnaire\u00a0(IPAQ;\u00a0Craig\u00a0et\u00a0al.,\u00a02003)\u00a0compared\u00a0to\u00a0participants\u00a0in\u00a0the\u00a0control\u00a0group.\u00a0Moreover, the\u00a0authors\u00a0expected\u00a0that\u00a0participants\u00a0in\u00a0the\u00a0treatment\u00a0group\u00a0would\u00a0show\u00a0a\u00a0larger\u00a0increase\u00a0in\u00a0 quality\u00a0of\u00a0life\u00a0compared\u00a0to\u00a0the\u00a0control,\u00a0measured\u00a0with\u00a0the\u00a0Quality\u00a0of\u00a0Life\u00a0Inventory\u00a0(QOLI;\u00a0 Frisch,\u00a0Cornell,\u00a0Villanueva,\u00a0&\u00a0Retzlaff,\u00a01992).",
"v2_Abstract": "Methods: This study was a randomized nine week trial of an Internet-administered treatment based on guided physical exercise for Major Depressive Disorder (MDD). A total of 48 participants with mild to moderate depression, diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders , were randomized either to a treatment intervention or to a waiting-list control group. The main outcome measure for depression was the Beck Depression Inventory -II (BDI-II), and physical activity level was measured using the International Physical Activity Questionnaire (IPAQ). The treatment program consisted of nine text modules, and included therapist guidance on a weekly basis.",
"v2_col_introduction": "introduction : The\u00a0World\u00a0Health\u00a0Organization\u00a0(WHO,\u00a02001)\u00a0predicts\u00a0that\u00a0depression\u00a0will\u00a0be\u00a0one\u00a0of\u00a0 the\u00a0three\u00a0most\u00a0burdensome\u00a0diseases\u00a0in\u00a0the\u00a0world\u00a0in\u00a02020.\u00a0With\u00a0the\u00a0advancement\u00a0of\u00a0 communication\u00a0technologies,\u00a0new\u00a0ways\u00a0of\u00a0providing\u00a0and\u00a0delivering\u00a0psychological\u00a0 treatments\u00a0have\u00a0emerged\u00a0(P\u00a0Carlbring\u00a0&\u00a0Andersson,\u00a02006).\u00a0The\u00a0Internet\u00a0has\u00a0made\u00a0it\u00a0 possible\u00a0to\u00a0reach\u00a0people\u00a0over\u00a0great\u00a0distances\u00a0and\u00a0provide\u00a0psychological\u00a0interventions\u00a0 to\u00a0a\u00a0vast\u00a0number\u00a0of\u00a0patients\u00a0at\u00a0a\u00a0low\u00a0cost\u00a0due\u00a0to\u00a0shorter\u00a0treatment\u00a0time\u00a0per\u00a0person\u00a0 (Andersson,\u00a02009).\u00a0Internetdelivered\u00a0treatments\u00a0also\u00a0have\u00a0the\u00a0opportunity\u00a0to\u00a0increase\u00a0 accessibility\u00a0for\u00a0patients\u00a0in\u00a0remote\u00a0geographical\u00a0locations\u00a0and\u00a0to\u00a0make\u00a0support\u00a0 available\u00a0for\u00a0people\u00a0who\u00a0would\u00a0not\u00a0otherwise\u00a0seek\u00a0care\u00a0(Newman,\u00a0Szkodny,\u00a0Llera,\u00a0&\u00a0 Przeworski,\u00a02011).\u00a0Furthermore,\u00a0Internetdelivered\u00a0treatments\u00a0have\u00a0the\u00a0possibility\u00a0of\u00a0 giving\u00a0patients\u00a0quick\u00a0feedback\u00a0and\u00a0presentation\u00a0of\u00a0material\u00a0in\u00a0a\u00a0stepbystep\u00a0basis\u00a0 (Titov,\u00a02011).\u00a0\nCurrently,\u00a0several\u00a0studies\u00a0have\u00a0investigated\u00a0the\u00a0effects\u00a0of\u00a0Internetdelivered\u00a0 treatments\u00a0for\u00a0depression\u00a0(Johansson\u00a0&\u00a0Andersson,\u00a02012).\u00a0A\u00a0large\u00a0part\u00a0of\u00a0these\u00a0 studies\u00a0have\u00a0been\u00a0based\u00a0on\u00a0cognitive\u00a0behavior\u00a0therapy\u00a0(CBT)\u00a0as\u00a0the\u00a0main\u00a0theoretical\u00a0 framework,\u00a0but\u00a0there\u00a0are\u00a0exceptions\u00a0(Johansson\u00a0et\u00a0al.,\u00a02012).\u00a0Andersson\u00a0and\u00a0Cuijpers\u00a0 (2009)\u00a0did\u00a0a\u00a0metaanalysis\u00a0and\u00a0found\u00a0a\u00a0significant\u00a0difference\u00a0between\u00a0supported\u00a0(d\u00a0=\u00a0 0.61)\u00a0and\u00a0unsupported\u00a0(d\u00a0=\u00a00.25)\u00a0depression\u00a0treatments.\u00a0In\u00a0a\u00a0more\u00a0recent\u00a0 metaanalysis,\u00a0a\u00a0similar\u00a0result\u00a0was\u00a0found\u00a0by\u00a0Richards\u00a0and\u00a0Richardson\u00a0(2012).\u00a0In\u00a0 addition,\u00a0Johansson\u00a0and\u00a0Andersson\u00a0(2012)\u00a0found\u00a0a\u00a0strong\u00a0and\u00a0significant\u00a0association\u00a0 between\u00a0support\u00a0and\u00a0effect\u00a0size\u00a0with\u00a0a\u00a0Spearman\u00a0correlation\u00a0of\u00a0 \u00a0=\u00a00.64,\u00a0indicating\u00a0\u03c1 that\u00a0more\u00a0support\u00a0yields\u00a0larger\u00a0effects.\nSince\u00a0the\u00a0beginning\u00a0of\u00a0the\u00a020th\u00a0century,\u00a0a\u00a0large\u00a0amount\u00a0of\u00a0research\u00a0has\u00a0been\u00a0 conducted\u00a0concerning\u00a0the\u00a0effects\u00a0of\u00a0physical\u00a0activity\u00a0on\u00a0clinical\u00a0depression.\u00a0Several\u00a0 studies\u00a0have\u00a0found\u00a0treatment\u00a0effects\u00a0ranging\u00a0in\u00a0size\u00a0from\u00a0moderate\u00a0to\u00a0large\u00a0(Barbour,\u00a0 Edenfield,\u00a0&\u00a0Blumenthal,\u00a02007;\u00a0Silveira\u00a0et\u00a0al.,\u00a02013).\u00a0However,\u00a0there\u00a0is\u00a0still\u00a0no\u00a0 consensus\u00a0about\u00a0the\u00a0mechanisms\u00a0of\u00a0change\u00a0that\u00a0mediate\u00a0reductions\u00a0in\u00a0depressive\u00a0 symptoms\u00a0following\u00a0psychotherapy\u00a0(Lundh,\u00a02009),\u00a0and\u00a0there\u00a0is\u00a0also\u00a0limited\u00a0 knowledge\u00a0regarding\u00a0mediators\u00a0of\u00a0change\u00a0following\u00a0physical\u00a0activity\u00a0for\u00a0depression,\u00a0 apart\u00a0from\u00a0the\u00a0physiological\u00a0effects\u00a0of\u00a0increase\u00a0activity.\u00a0\nA\u00a0metaanalysis\u00a0by\u00a0Davies\u00a0et\u00a0al.\u00a0(2012)\u00a0investigated\u00a0the\u00a0effects\u00a0of\u00a0Internetdelivered\u00a0 interventions\u00a0to\u00a0increase\u00a0physical\u00a0activity\u00a0levels.\u00a0The\u00a0result\u00a0showed\u00a0generally\u00a0small\u00a0 but\u00a0statistically\u00a0significant\u00a0increases\u00a0in\u00a0physical\u00a0activity\u00a0levels\u00a0in\u00a0the\u00a034\u00a0studies\u00a0 reviewed.\u00a0To\u00a0our\u00a0knowledge,\u00a0there\u00a0are\u00a0few\u00a0studies,\u00a0if\u00a0any,\u00a0on\u00a0guided\u00a0 Internetdelivered\u00a0physical\u00a0activity\u00a0for\u00a0major\u00a0depression.\u00a0\nThe\u00a0purpose\u00a0of\u00a0the\u00a0present\u00a0study\u00a0was\u00a0to\u00a0evaluate\u00a0a\u00a0treatment\u00a0for\u00a0major\u00a0depression\u00a0 based\u00a0on\u00a0physical\u00a0exercise\u00a0administered\u00a0via\u00a0the\u00a0Internet.\u00a0The\u00a0treatment\u00a0program\u00a0was\u00a0 intended\u00a0to\u00a0decrease\u00a0depressive\u00a0symptoms\u00a0and\u00a0to\u00a0motivate\u00a0participants\u00a0to\u00a0increase\u00a0\n2PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013)\nR ev ie w in g M an\nus cr ip t\ntheir\u00a0level\u00a0of\u00a0physical\u00a0activity.\u00a0The\u00a0treatment\u00a0group\u00a0was\u00a0compared\u00a0to\u00a0a\u00a0waitinglist\u00a0 control\u00a0group.\u00a0\nThe\u00a0main\u00a0hypothesis\u00a0was\u00a0that\u00a0the\u00a0results\u00a0would\u00a0show\u00a0a\u00a0larger\u00a0reduction\u00a0in\u00a0depressive\u00a0 symptoms\u00a0for\u00a0the\u00a0treatment\u00a0condition\u00a0compared\u00a0to\u00a0the\u00a0control,\u00a0as\u00a0measured\u00a0by\u00a0the\u00a0 Beck\u00a0Depression\u00a0Inventory:\u00a0Second\u00a0Version\u00a0(BDIII;\u00a0Beck,\u00a0Epstein,\u00a0Brown,\u00a0&\u00a0Steer,\u00a0 1988)\u00a0and\u00a0the\u00a0Montgomery\u00c5sberg\u00a0Depression\u00a0Rating\u00a0Scale:\u00a0Short\u00a0Version\u00a0 (MADRSS;\u00a0Svanborg\u00a0&\u00a0\u00c5sberg,\u00a02001).\u00a0In\u00a0addition,\u00a0it\u00a0was\u00a0hypothesized\u00a0that\u00a0the\u00a0 treatment\u00a0condition\u00a0would\u00a0show\u00a0reductions\u00a0of\u00a0anxiety\u00a0symptoms\u00a0as\u00a0measured\u00a0with\u00a0 the\u00a0Beck\u00a0Anxiety\u00a0Inventory\u00a0(BAI;\u00a0Beck\u00a0et\u00a0al.,\u00a01988),\u00a0and\u00a0increase\u00a0the\u00a0level\u00a0of\u00a0 physical\u00a0activity\u00a0compared\u00a0to\u00a0the\u00a0control\u00a0as\u00a0measured\u00a0with\u00a0the\u00a0International\u00a0Physical\u00a0 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"v1_text": "results : As evident from Table 1, participants were predominantly female (83 %), currently married or cohabiting (46 %), had attained college or higherlevel education (71 %), and had previous experience of psychotherapy (62%). As evident from Table 1, the treatment and the control group should be considered equal on all demographic characteristics with all p\u00b4s > .25 (For sex \u03c721= 0.0, p = 1.0; age t40.66 = 0.25, p = . 80; marital status \u03c723 = 2.92, p = .40; highest educational level \u03c724 = 4.12, p = .40; medication, \u03c722 = 5.34, p = .07; and psychotherapy \u03c722 = 0.0, p = 1.0). During the treatment period of 9 weeks, 14/24 (58 %) of the participants in the treatment group completed all treatment modules (see Figure 1). The remaining participants did not complete the program within the given time frame, or dropped out. However, in compliance with the ITT principle, no participants were excluded from the statistical analyses due to low adherence or dropout. Reasons given for not completing the program were that participants believed they did not have sufficient time for physical activity (n = 4), the program was perceived as noneffective (n = 2), or that changes in life events or sickness made it impossible for participants to complete the program (n = 1). Some participants ended the program without giving any reason for termination (n = 3). Table 2 includes means, effect sizes and tests of significance for group, time, and interaction effects on all outcome measures. No significant difference was found at pretreatment between groups on all measures. Posttesting indicated that the treatment condition was superior to the control on both measures of depression (MADRSS & BDIII), with significant interaction effects and medium effect sizes. No significant differences were found between groups on measures of anxiety (BAI), quality of life (QOLI), and physical activity level (IPAQ). Both groups achieved significant decreases in depressive symptoms and anxiety, and increases in quality of life and physical activity level during the study. Followup after 6 months 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t As seen in both Table 2 and Figure 2, the treatment effects were maintained at the 6month followup. Actually, on the general measure of anxiety (BAI), there was a continued improvement between post and followup (t23 = 2.51, p < .05). The mean post to followup withingroup effect size was d=0.17 with a low of 0.04 (IPAQ) and a high of d=0.35 (BAI). Clinical significance At posttreatment, 17/24 (70.8 %) of the participants in the treatment group were considered reliably improved on the main outcome measure, and 9/24 (37.5 %) as both reliably improved and recovered. In the control group, 8/24 (33.3 %) were considered improved, and 1/24 (4.2 %) reliably improved and recovered (Figure 3). Results at pre- and post-treatment for measures of depression, anxiety, physical activity, and quality of life. In addition, the 6-month follow-up for the Treatment group is reported PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Time Treatment (n=24) Control (n=24) ANOVA Between groups effect size Within groups effect size M SD M SD F Cohen\u00b4s d Cohen\u00b4s d Montgomery\u00c5sberg Depression Rating Scale: SelfRated Version (MADRSS) Pre Post 6mo 23.54 15.71 14.46 (4.39) (7.54) (7.63) 23.92 20.38 N/a (3.87) (7.87) N/a G: 3.02 T: 29.82*** I: 4.25* 0.62 Tx: 1.30 C: 0.58 Beck Depression Inventory: Second Version (BDIII) Pre Post 6mo 26.92 17.88 15.63 (9.30) (11.30) (11.44) 28.25 24.04 N/a (7.08) (6.86) N/a G: 2.52 T: 48.77*** I: 6.49* 0.67 Tx: 0.89 C: 0.62 Beck Anxiety Inventory (BAI) Pre Post 6mo 15.50 12.92 10.71 (7.96) (6.36) (6.41) 15.71 13.71 N/a (6.53) (5.27) N/a G: 0.08 T: 9.29** I: 0.15 0.14 Tx: 0.37 C: 0.34 International Physical Activity Questionnaire (IPAQ) Pre Post 6mo 778 1331 1282 (695) (990) (1255) 953a 1143 N/a (670)a (918)a N/a G: 0.00 T: 6.41* I: 1.47 0.20 Tx: 0.66 C: 0.24 Quality of Life Inventory (QOLI) Pre Post 6mo -0.50 0.16 0.33 (1.72) (1.99) (2.00) -0.25 0.23 N/a (1.54) (1.47) N/a G: 0.12 T: 11.49** I: 0.28 0.04 Tx: 0.36 C: 0.33 Note: G = Group effect; T = Time effect; I = Interaction effect; Tx = Treatment group; C = Control group; N/a = not available; *** p < .001; ** p < .01; * p < .05; a n=22 due to incomprehensible data 2 3 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t discussion : The aim of this study was to develop and evaluate a treatment program for mild to moderate major depressive disorder based on physical activity administered via the Internet. The hypotheses were that participants in the treatment condition would have reduced their depressive and anxiety symptoms and at the same time increased levels of physical activity and quality of life more than participants in the control group. Results showed a statistically significant interaction effect at posttesting favoring the treatment condition compared to the control condition, with a moderate betweengroups effect size of Cohen\u2019s d = 0.67 (95 % confidence interval: 0.091.25) on the main outcome measure of depression, BDIII. The withingroup effect size was large for the treatment group with Cohen\u2019s d = 0.89 (95 % confidence interval: 0.671.92) and moderate for the control group with d = 0.62 (95 % confidence interval: 0.031.19). The effects found in the current study are in line with efficacy outcomes from other well established evidencebased psychological treatments. For example, Silveira et al. (Silveira et al., 2013) reviewed the effects of physical activity for depression and found an effect size of d = 0.61 for depressive symptoms compared to the control in all the studies included in the analysis. In addition to this, Andersson and Cuijpers (Andersson & Cuijpers, 2009) found a betweengroup effect size of d = 0.61 for supported computerized CBT treatments for depression, with a majority being studies on Internetdelivered CBT. However, results in this study showed no significant difference between the groups on secondary measures of anxiety, physical activity, and quality of life (BAI, IPAQ, and QOLI). A possible explanation for this could be the low statistical power of the study due to a small sample size of N = 48. Calculations made prior to the study indicated that a sample size of N = 80 would be required to find significant interaction effects if they existed in the population. The main reason for the small sample size was in part the limited number of participants registering their interest in the study (N = 159), and in part the large percentage of excluded participants (69.8 %). The main reason for this exclusion rate was high selfrated levels of physical activity at baseline for participants registered for the study. Also, these findings are in line with the results in a similar trial where no relation between reduced depressive symptoms and secondary measures such as changes in quality of life were found (Dozois, Dobson, & Ahnberg, 1998). 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t The most surprising findings were the nonsignificant interaction effect on IPAQ. Two explanations for these results should be considered. Firstly, a large number of the participants in the study showed moderate or high levels of physical activity at pretreatment (60.5 %). This ceiling effect in the sample provided small opportunities for increased levels of physical activity. Ideally, only participants with a low level of physical activity should have been included in the study since those individuals were expected to gain most from the treatment. However, such a rigorous exclusion would have left few participants to the study. Secondly, the IPAQ has several issues in need of consideration. Ekelund et al. (Ekelund et al., 2006) found that people significantly overestimate their physical activity using the IPAQ compared to using an objective measure. This brings some uncertainty to the results found in this study. It is possible that people in the treatment condition overestimated their physical activity less at posttreatment, than people in the control condition, since the treatment included detailed monitoring of physical activity. Thirdly, data cleaning was needed due to unreasonable answers. This was done to answers from eight participants according to principles from the International Physical Activity Questionnaire Group (2005). This process may have led to misinterpretations of the intended answers of the respondents. Lastly, four participants gave incomprehensible answers to questions on the IPAQ, indicating misunderstandings of the instructions. In summary, the findings in this study indicate that internetadministered therapistguided physical activity can be an effective treatment for depressive symptoms for people with mild to moderate major depression, but there is no evidence of effectiveness in raising levels of physical activity or quality of life, nor reducing symptoms of anxiety. Since the effects found for depressive symptoms cannot be explained by changes in physical activity, questions are raised concerning the active ingredients in the treatment. While Internetdelivered therapy has potential benefits there are also issues of potential concerns e.g., the risk of missing physical signs of depression such as agitation or retardation; difficulty identifying clients adequately for followup of increasingly suicidal patients, including involuntary treatment if required. Some researchers state that there is no doseresponse relationship between levels of physical activity and depressive symptoms (Kesaniemi et al., 2001). This implies that other aspects than the frequency, duration, and intensity of physical activity mediates changes in depressive symptoms. Considering this, it seems unlikely that improved fitness and related physiological changes account for reduced depressive symptoms in this study. Rather, it seems that other aspects of the treatment account for the obtained effects. Firstly, earlier research has shown that selfhelp programs in which support is provided are more effective than programs without support (Spek et al., 2007; Palmqvist, Carlbring, & Andersson, 2007). In this program, feedback based on motivational interviewing principles (cf. Miller & Rollnick, 2002) was given each week. This could possibly explain the positive outcome to some extent. Secondly, the program included features of behavioral activation strategies such as exercise planning and monitoring. This was introduced early in the program and continued until the end. 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Research shows that behavioral activation is an effective treatment for depression (Dimidjian, Barrera, Martell, Munoz, & Lewinsohn, 2011) which can be administered over the Internet (P. Carlbring, Hagglund, et al., 2013). The planning and monitoring of exercise could account for some of the positive outcome effect on depressive symptoms. Thirdly, a reoccurring feature of the treatment was that participants set their goals independently. Participants were encouraged to set efficient goals every week and to achieve them. Studies have shown increased levels of selfefficacy in people striving for and achieving their goals (Biddle & Fox, 1998). To obtain goals and to enhance selfefficacy for physical activity can be seen as positively reinforced behavior. According to the spiral model, based on the same principles as behavioral activation, this can be a way to break depressive patterns and inactivity (Waller & Gilbody, 2009). A pedometer was also sent to each participant in the treatment condition. The purpose was to increase adherence to the program and to maximize the likelihood of participants engaging in physical activity. However, it could be argued that the pedometer that was sent free of charge was simply a way of enhancing a possible placebo effect (Sliwinski & Elkins, 2013). A little more than half (58 %) of the participants in the treatment condition completed all nine text modules on time. This low adherence rate is a cause for concern, but is in line with earlier reviews of Internetbased treatment studies which found that just over half of the participants complete all sessions during the treatment period (Eysenbach, 2005). All participants included in the study completed posttesting, which is uncommon for studies of this kind (Christensen & Mackinnon, 2006). Usually, the last observation carried forward principle is used for missing data. Having a complete dataset for both pre and posttesting for both conditions increases reliability and validity of the results. Since it is feasible that other active treatments influence outcome measures in this study, a conservative way of handling data was preferred. There were significantly more females than males in the study. This is common for studies on depression, but should be considered as a limitation for the generalizability of the results. In addition, the mean age in the sample was high (Table 1), with only 10 participants under 40 years of age. Future research could dismantle the different parts of the treatment, such as physical activity, therapist support, and selfefficacy to estimate to which extent they influence the outcome (cf. P. Carlbring, Lindner, et al., 2013). Studies should include objective measures of physical activity as well as measures of mediating factors to distinguish between active ingredients of the treatment. This study has introduced a new, potentially effective Internetbased treatment for depression based on a physical activity intervention. The treatment program may be a valid alternative to traditional treatments for depression for people unwilling to use antidepressant medication or psychotherapy. Because of the Internetdelivered nature of the program, it may be considered costeffective and not limited by large geographical distances (Hedman, Ljotsson, & Lindefors, 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t 2012). Acknowledgement: Thank you to Lina Aittamaa, Linda Ek, Linda Westling, Mikael Granlund, Jessica Henriksson, and Linda Ternedal for serving as therapists, and to Alexander Alasj\u00f6 for web programming. 287 288 289 290 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t References Andersson, G. (2009). Using the Internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47(3), 175180. Andersson, G., & Cuijpers, P. (2009). 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Criterion validity, severity cut scores, and testretest reliability of the Beck Depression InventoryII in a university counseling center sample. Journal of Counseling Psychology, 49(3), 381385. doi: Doi 10.1037//00220167.49.3.381 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Svanborg, P., & \u00c5sberg, M. (2001). A comparison between the Beck Depression Inventory (BDI) and the selfrating version of the Montgomery Asberg Depression Rating Scale (MADRS). Journal of Affective Disorders, 64(23), 203216. Titov, N. (2011). Internetdelivered psychotherapy for depression in adults. Curr Opin Psychiatry, 24(1), 1823. doi: 10.1097/YCO.0b013e32833ed18f Waller, R., & Gilbody, S. (2009). Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence. Psychol Med, 39(5), 705712. doi: 10.1017/S0033291708004224 World Health Organization. (2001). The World Health Report 2001\u2013Mental Health: New Understanding, New Hope Retrieved from http://www.who.int/whr/2001/en/whr01_en.pdf 422 423 424 425 426 427 428 429 430 431 432 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Figure 1 demographic description : Demographic description of the participants at pre-treatment PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Treatment (n=24) Control (n=24) Total (n=48) Sex Female Male 20 4 (83.3%) (16.7%) 20 4 (83.3%) (16.7%) 40 8 (83.3%) (16.7%) Age Mean (SD) MinMax 48.8 2467 (12.7) 49.6 3565 (8.7) 49.2 2467 (10.7) Marital status Married/Living together Living apart Single Other 13 2 8 1 (54.2%) (8.3%) (33.3%) (4.2%) 9 2 13 0 (37.5%) (8.3%) (54.2%) 22 4 21 1 (45.8%) (8.3%) (43.8%) (2.1%) Highest educational level Compulsory school Secondary school Vocational school College/university (ongoing) College/university (compl.) 1 3 0 2 18 (4.2%) (12.5%) (8.3%) (75%) 0 3 3 2 16 (12.5%) (12.5%) (8.3 %) (66.7%) 1 6 3 4 34 (2.1%) (12.5%) (6.3%) (8.3%) (70.8%) Medication None Earlier Present 10 11 3 (41.7%) (45,8%) (12.5%) 14 6 4 (58.3%) (25.0%) (16.7%) 24 17 7 (50.0%) (35.4%) (14.6%) Psychotherapy None Earlier Present 9 15 0 (37.5%) (62.5%) 9 15 0 (37.5%) (62.5%) 18 30 0 (37.5%) (62.5%) PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Table 2(on next page) intervention : The treatment used in this study was a guided selfhelp program administered through an Internetbased system. The program consisted of nine text modules developed by the authors, consisting of 72 pages in total. Participants were given one text module every Monday over nine weeks. At the end of each week, the therapists gave written feedback on home assignments included in the modules. Message exchange and the delivery of the treatment modules used were transmitted via an encrypted webbased system. Some material, such as the pedometer given participants in the treatment condition, and the written form of consent, were sent using the postal service. The purpose of the pedometer was for the participants to monitor their own physical activity in the form of walking, which was a part of the treatment program. The pedometers were used for motivational purposes alone and since participants had different ways of using them no data was collected in the study The modules consisted of selfhelp texts about how to become more physically active (see Table 2). Each module ended with 35 essay questions where the participant was asked to report on the progress and the weekly planning of the exercise. The core principles of the program were inspired by Haase and coworkers (2010) and were intended to: 1) maximize the likelihood for participants to increase and maintain physical activity; 2) maximize the likelihood of participants remaining engaged in the program; 3) focus on the participants\u2019 preferences and needs, taking particular notice of the challenges faced by people with major depression; 4) promote physical activity in a broad sense in accordance with the WHO\u00b4s guidelines for physical activity (Mendes, Sousa, & Barata, 2011), including all types of activity in everyday life; 5) increase selfefficacy for physical activity; and 6) help participants to master challenges faced with when trying to get more active. The study was examined and approved by the regional ethical committee at Ume\u00e5, Sweden (201114531 \u00d6), and is registered in Clinical Trials (NCT01573130). Statistical analysis The data were analyzed using the statistical programming language R, version 3.0.0. Reproducible code can be found in the supplemental file (Progredi.R). Significance testing of group differences regarding demographic data in Table 1 and pretreatment measurements was conducted using Welch\u2019s two sample ttest for continuous data and chi2tests for nominal data. Differences between the groups in pre and postmeasurements were analyzed using a twoway mixed analysis of variance model (ANOVA), with treatment condition and time used as independent variables. Effect sizes were calculated using Cohen\u2019s d. Data were analyzed using an intentiontotreat (ITT) approach. The response rate for all outcome measures was 100 % (48 of 48) for pre and posttreatment measurements, and 87.5 % (21 of 24) for the 6month followup. Due to the small number of missing data, we did not impute the missing data at 6month followup, but used baseline carried forward as an estimate for the three 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t missing data points. For ethical reasons the wait list received treatment immediately following the post assessment. Hence, there is no control group data at 6month followup. Participants who changed their medication or began psychological treatment during the study were considered unchanged in the analysis to control for effects from other treatments (treatment n = 1, control n = 3, NS). Two participants gave inadequate answers on the IPAQ pretreatment, and were therefore excluded from the analysis on that measure. Clinically significant change on the main outcome measure, BDIII, was calculated according to Jacobson and Truax (1991), with testretest data from Sprinkle et al. (2002), and clinical cutoff scores in accordance with the BDIII manual (Beck & Steer, 1996). Reliable change (RC) was calculated with 95 % confidence intervals. method : Information about the study was advertised in a major Swedish newspaper, online with Google AdWords, and at an online service site containing information about ongoing research projects on Internet therapy. The participants were recruited between January and February 2012. The basic inclusion criteria in the study was mild to moderate major depression diagnosis and a sedentary lifestyle. Exclusion was based on the following criteria: subclinical depressive symptoms, severe depressive symptoms, dysthymia as a primary diagnosis, elevated suicide risk, high levels of physical activity prior to treatment, recent changes in medication and/or somatic illness making physical exercise inappropriate. The eligibility screening process consisted of selfreport questionnaires regarding depressive symptoms, anxiety, and level of physical activity, and a clinical interview via telephone to investigate the primary diagnoses of the participants. The screening questionnaires used were the MADRSS, BAI, and IPAQ. The telephone interview was based on the Structured Clinical Interview for DSMIV: Clinical version (SCIDICV; First, Gibbon, Spitzer, & Williams, 1997). A full description of participant recruitment is included in Figure 1, and a demographic description of the participants at pretreatment is presented in Table 1. The study included 48 participants meeting the criteria for major depression. The participants were randomly allocated to the two groups, treatment or waiting list control, by a person independent of the research group using a true random number service on the Internet (www.random.org). Participants\u2019 levels of depression as well as anxiety, physical activity, and quality of life were measured at pre and posttreatment, as well as at a 6months followup. The study was conducted between February and April 2012, and the followup measurements were collected in October 2012. The main outcome measure for the assessments of depression and depressive symptoms was the BDIII with reported reliability estimates (coefficient \u03b1) for Swedish samples between \u03b1 = .88 and \u03b1 = .92 (Per Carlbring et al., 2007). As a secondary measure of depression, we used the MADRSS, which has a reported reliability estimate of \u03b1 = .84 (Fantino & Moore, 2009). The psychometric properties of the Internet versions of these instruments have proved to be equivalent to the paperandpencil versions (Hollandare, Andersson, & Engstrom, 2010). For evaluating changes in anxiety, physical activity, and quality of life, the BAI, IPAQ, and QOLI were administered; all of which showing satisfactory psychometric properties (Lindner, Andersson, \u00d6st, & Carlbring, in press; Ekelund et al., 2006). 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t flowchart of study participants : Flowchart of study participants, point of random assignment, and drop-outs at each stage PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Figure 2 Mean scores and confidence intervals The Beck Depression Inventory II (BDI-II) scores at pre, post and follow-up for the Treatment and the Control group including 95% confidence intervals. PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Figure 3 Clinically significant change on BDI-II post- treatment PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Table 1(on next page) content : Overview of content and home assignments of the Progredi intervention PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Module Content Home assignments 1. 2. 3. 4. 5. 6. 7. Brief introduction to depression; signs and symptoms. Explanation of depression using the spiral modela. Overview of different types of PAb, and how PA can be helpful to treat depression. Presentation of treatment structure and how to use the EWBSc. Presentation of how to set up and use the pedometer. Introduction on how a sedentary lifestyle influences overall health. Description of how PA affects the human body in physical, mental, and neurological ways, and level of PA needed to acquire positive health effects. Presentation of stages of changed Most common barriers for PA and how to overcome them. Examination of pros and cons of increasing PA or maintaining the status quo, using a motivational balance exercise. Introduction to goal setting using SMART goal setting principlese. How to work with activity scheduling to incorporate regular PA into everyday life. Examples of different forms of PA. Important aspects of change management and how to increase selfefficacy for PA. Introduction on how to follow up and review the goal and schedule from last week. Possible links between PA and mood. Introduction to handling setbacks and relapses during behaviour change. Presentation of the most common thinking errors when afflicted by setbacks and how to deal with them. How to reward progress in PA and to facilitate long lasting behaviour change. How to get sufficient rest and recovery after PA General nutrition advice before and after PA. Participants are introduced to aspects of acceptance and commitment theoryf, and are initiated to think about how PA can be part of heightened quality of life. Subjects learns about living in accordance with what they value in terms of health and PA, and are introduced to the concept of having a permissive attitude towards all experiences when moving in their valued direction, even the difficult ones. 1. Participants are asked to give a brief narrative of their depressive symptoms and prior experience of PA. 2. What are the participants thoughts about their chance of increasing PA level? 3. Which are the participants main barriers for PA? 4. The participants are asked to use the pedometer in three walks during the coming week and to register the total number of steps taken. 1. What is the participants view of the treatment program so far? 2. Which stage of change do the participants find themselves in right now? 3. What do the participants believe is their main obstacle for PA? 4. Motivational balance exercise. 5. Participants are encouraged to keep taking three walks the coming week and if they want, to increase the length of the walks. 1. SMART goalsetting for the next week. 2. Making a schedule of PA activities to meet the goals for next week. 3. Patients are encouraged to register all PA conducted during the week (using the pedometer). 1. From this week on, SMART goalsetting, activity scheduling and registration of PA for the coming week are incorporated as a weekly routine. 2. Participants are asked to review the goal and the schedule from the past week. 3. Which were the biggest obstacles for PA this week? 4. How did the participants deal with them? 1. Do the participants recognize any of the common thinking errors when afflicted by setbacks? 2. What progress have the participants experienced so far? 3. How can these accomplishments be rewarded? 1. What do the participants find particularly important as a \u201ctake home message\u201d regarding rest and nutrition? 1. Valued direction exercise focusing on health and PA. PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t 8. 9. Mindfulness walking and how to incorporate acceptance in the struggle to increase and maintain PA How to maintain PA after the end of the treatment program. Summary of the previous modules. 1. Participants are encouraged to do a mindfulness walking exercise. What were their experiences? 1. Participants are encouraged to answer the posttreatment questionnaires administered over the Internet. Note: a Haase and coworkers, 2010 b physical activity c encrypted webbased system d Prochaska & DiClemente, 1983 e Hassm\u00e9n & Hassm\u00e9n, 2005 f Hayes, Luoma, Bond, Masuda & Lillis, 2006 PeerJ reviewing PDF | (v2013:07:662:1:1:CHECK 13 Sep 2013) R ev ie w in g M an us cr ip t Table 3(on next page)",
"v2_text": "results : As evident from Table 1, participants were predominantly female (83%), currently married or cohabiting (46 %), had attained college or higherlevel education (71%), and had previous experience of psychotherapy (62%). As evident from Table 1, the treatment and the control group should be considered equal on all demographic characteristics with all p\u00b4s > .25 (For sex \u03c721= 0.0, p = 1.0; age t46 = -0.25, p = .80; marital status \u03c732 = 2.92, p = .40; highest educational level 5PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t \u03c752 = 4.12, p = .39; medication, \u03c722 = 2.28, p = .32; and psychotherapy \u03c722 = 0.0, p = 1.0.). During the treatment period of 9 weeks, 14/24 (58 %) of the participants in the treatment group completed all treatment modules. The remaining participants did not complete the program within the given time frame, or dropped out. Reasons given for not completing the program were that participants believed they did not have sufficient time for physical activity (n=4), the program was perceived as noneffective (n=2), or that changes in life events or sickness made it impossible for participants to complete the program (n=1). Some participants ended the program without giving any reason for termination (n=3). Table 2 includes means, effect sizes and tests of significance for group, time, and interaction effects on all outcome measures. No significant difference was found at pretreatment between groups on all measures. Posttesting indicated that the treatment condition was superior to the control on both measures of depression (MADRSS & BDIII), with significant interaction effects and medium effect sizes. No significant differences were found between groups on measures of anxiety (BAI), quality of life (QOLI), and physical activity level (IPAQ). Both groups achieved significant decreases in depressive symptoms and anxiety, and increases in quality of life and physical activity level during the study. INSERT TABLE 2 ABOUT HERE Followup after 6 months As seen in both Table 2 and Figure 2, the treatment effects were maintained at the 6month followup. Actually, on the general measure of anxiety (BAI), there was a continued improvement between post and followup (t23=2.51,p<.05). The mean post to followup withingroup effect size was d=0.17 with a low of 0.04 (IPAQ) and a high of d=0.35 (BAI). 6PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t INSERT FIGURE 2 ABOUT HERE Clinical significance At posttreatment, 17/24 (70.8 %) of the participants in the treatment group were considered reliably improved on the main outcome measure, and 9/24 (37.5 %) as both reliably improved and recovered. In the control group, 8/24 (33.3 %) were considered improved, and 1/24 (4.2 %) reliably improved and recovered (Figure 3). INSERT FIGURE 3 ABOUT HERE discussion : The aim of this study was to develop and evaluate a treatment program for mild to moderate major depressive disorder based on physical activity administered via the Internet. The hypotheses were that participants in the treatment condition would have reduced their depressive and anxiety symptoms and at the same time increased levels of physical activity and quality of life compared to the control participants. In addition, a correlation was expected between reductions in depressive symptoms and increased levels of physical activity for all participants. Results showed a statistically significant interaction effect at posttesting favoring the treatment condition compared to the control condition, with a moderate betweengroups effect size of Cohen\u2019s d = 0.62 (95 % confidence interval: 0.041.20) and d = 0.67 (95 % confidence interval: 0.091.25) on selfreported measures of depression, MADRSS and BDIII. Withingroup effect sizes for the treatment group were large, with Cohen\u2019s d = 1.30 (95 % confidence interval: 0.671.92) and d = 0.89 (95 % confidence interval: 0.671.92) respectively. The effects found in the current study are in line with efficacy outcomes from other wellestablished evidencebased psychological treatments. For example, Silveira et al. (Silveira et al., 2013) reviewed the effects of physical activity for depression and found an effect size of d=0.61 for depressive symptoms compared to the control in all the studies included in the analysis. In addition to this, Andersson and Cuijpers (Andersson & Cuijpers, 2009) found a betweengroup effect size of d = 0.61 for supported computerized CBT treatments for depression, with a majority being studies on Internetdelivered CBT. However, results in this study showed no significant difference between the groups on 7PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t secondary measures of anxiety, physical activity, and quality of life (BAI, IPAQ, and QOLI). One possible reason for the lack of significant results on the secondary measures is the general regression to the mean effect, and possible spontaneous remission in the control group. Withingroups effect sizes on all secondary measures in the control group were between Cohen\u2019s d = 0.24 and d = 0.79, and significant time effects were found on all measures. This might be due to factors such as positive climatic changes during springtime, Hawthorne effects from being a part of the study, or placebo effects. Another explanation for the nonsignificant result on the secondary measures could be the low statistical power of the study due to a small sample size of N = 48. Calculations made prior to the study indicated that a sample size of N = 80 would be required to find significant interaction effects if they exist. The main reason for the small sample size was in part the limited amount of participants registering their interest in the study (N = 159), and in part the large percentage of excluded participants (69.8%). The main reason for this exclusion rate was high selfrated levels of physical activity at baseline for participants registered for the study. Finally, in line with the results in this study, a similar trial found no relation between reduced depressive symptoms and secondary measures such as changes in quality of life (Dozois, Dobson, & Ahnberg, 1998). The most surprising findings were the nonsignificant interaction effects on IPAQ. Two explanations for these results should be considered. Firstly, a large amount of the participants in the study showed moderate or high levels of physical activity at pretreatment (60.5%). This ceiling effect in the sample provided small opportunities for increased levels of physical activity. Ideally, only participants with a low level of physical activity should have been included in the study since those individuals were expected to gain most from the treatment. However, such a rigorous exclusion would have left few participants for the study. Secondly, the IPAQ has several issues in need of consideration. Ekelund et al. (Ekelund et al., 2006) found that people significantly overestimate their physical activity using the IPAQ compared to using an objective measure. This brings some uncertainty to the results found in this study. It is possible that people in the treatment condition overestimated their physical activity less at posttreatment, than people in the control condition, since the treatment included detailed monitoring of physical activity. Also, data cleaning was needed due to unreasonable answers. This was done to answers from eight participants according to principles from the International Physical Activity Questionnaire Group (2005). This process may have led to misinterpretations of the intended answers of the respondents. Lastly, four participants gave incomprehensible answers to questions on the IPAQ, indicating misunderstandings of the instructions. In summary, the findings in this study indicate that physical activity is effective for depressive symptoms for people with major depression, but there is no evidence of effectiveness in raising levels of physical activity. Since the effects found for 8PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t depressive symptoms cannot be explained by changes in physical activity, questions are raised concerning the active ingredients in the treatment. Some researchers state that there is no doseresponse relationship between levels of physical activity and depressive symptoms (Kesaniemi et al., 2001). This implies that other aspects than the frequency, duration, and intensity of physical activity mediates changes in depressive symptoms. Considering this, it seems unlikely that improved fitness and related physiological changes account for reduced depressive symptoms in this study. Rather, it seems that other aspects of the treatment account for the obtained effects. Firstly, earlier research has shown that selfhelp programs in which support is provided are more effective than programs without support (Spek et al., 2007; Palmqvist, Carlbring, & Andersson, 2007). In this program, feedback based on motivational interviewing principles (cf. Miller & Rollnick, 2002) was given each week. This could possibly explain the positive outcome to some extent. Secondly, the program included features of behavioral activation strategies such as exercise planning and monitoring. This was introduced early in the program and continued until the end. Research shows that behavioral activation is an effective treatment for depression (Dimidjian, Barrera, Martell, Munoz, & Lewinsohn, 2011) which can be administered over the Internet (P. Carlbring, Hagglund, et al., 2013). The planning and monitoring of exercise could account for some of the positive outcome effect on depressive symptoms. Thirdly, a reoccurring feature of the treatment was that participants set their goals independently. Participants were encouraged to set efficient goals every week and to achieve them. Studies have shown increased levels of selfefficacy in people striving for and achieving their goals (Biddle & Fox, 1998). To obtain goals and to enhance selfefficacy for physical activity can be seen as positively reinforced behavior. According to the spiral model, based on the same principles as behavioral activation, this can be a way to break depressive patterns and inactivity (Waller & Gilbody, 2009). A pedometer was also sent to each participant in the treatment condition. The purpose was to increase adherence to the program and to maximize the likelihood of participants engaging in physical activity. However, it could be argued that the pedometer that was sent free of change was simply a way of enhancing a possible placebo effect (Sliwinski & Elkins, 2013). A majority 58 % of the participants in the treatment condition completed all nine text modules on time. This adherence rate is a cause for concern, but is in line with earlier reviews of Internetbased treatment studies which found that just over half of the 9PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t participants complete all sessions during the treatment period (Eysenbach, 2005). All participants included in the study completed posttesting, which is uncommon for studies of this kind (Christensen & Mackinnon, 2006). Usually, the last observation carried forward principle is used for missing data. Having a complete dataset for both pre and posttesting for both conditions increases reliability and validity of the results. Since it is feasible that other active treatments influence outcome measures in this study, a conservative way of handling data was preferred. There were significantly more females than males in the study. This is common for studies on depression, but should be considered as a limitation for the generalizability of the results. In addition, the mean age in the sample was high (Table 1), with only 10 participants under 40 years of age. Future research could dismantle the different parts of the treatment, such as physical activity, therapist support, and selfefficacy, for example, to estimate to what extent they influence the outcome (cf. P. Carlbring, Lindner, et al., 2013). Studies should include objective measures of physical activity as well as measures of mediating factors to distinguish between active ingredients of the treatment. This study has introduced a new, potentially effective Internetbased treatment for depression based on a physical activity intervention. The treatment program may be a valid alternative to traditional treatments for depression for people unwilling to use antidepressant medication or psychotherapy. Because of the Internetdelivered nature of the program, it may be considered costeffective and not limited by large geographical distances (Hedman, Ljotsson, & Lindefors, 2012). Acknowledgement: Thank you to Lina Aittamaa, Linda Ek, Linda Westling, Mikael Granlund, Jessica Henriksson, and Linda Ternedal for serving as therapists, and to Alexander Alasj\u00f6 for web programming. This study was made possible by a generous grant from the Swedish Council for Working Life and Social Research, Swedish Research Council, and a professor\u00b4s contract awarded to Gerhard Andersson. 10PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t References Andersson, G. (2009). Using the Internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47(3), 175180. 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S., & Ahnberg, J. L. (1998). A psychometric evaluation of the Beck Depression Inventory II. Psychological Assessment, 10(2), 8389. doi: Doi 10.1037/10403590.10.2.83 Ekelund, U., Sepp, H., Brage, S., Becker, W., Jakes, R., Hennings, M., & Wareham, N. J. (2006). Criterionrelated validity of the last 7day, short form of the International Physical Activity Questionnaire in Swedish adults. Public Health Nutrition, 9(2), 258265. doi: Doi 10.1079/Phn2005840 Eysenbach, G. (2005). The law of attrition. J Med Internet Res, 7(1), e11. doi: v7e11 [pii] 10.2196/jmir.7.1.e11 Fantino, B., & Moore, N. (2009). The selfreported MontgomeryAsberg Depression Rating Scale is a useful evaluative tool in Major Depressive Disorder. BMC Psychiatry, 9, 26. doi: 10.1186/1471244X926 First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1997). Structured clinical interview for DSMIV Axis I Disorders (SCIDI). Washington, D.C.: American Psychiatric Press. Frisch, M. B., Cornell, J., Villanueva, M., & Retzlaff, P. J. (1992). Clinical validation of the Quality of Life Inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment, 4(1), 92101. Haase, A. M., Taylor, A. H., Fox, K. R., Thorp, H., & Lewis, G. (2010). Rationale and development of the physical activity counselling intervention for a pragmatic TRial of Exercise and Depression in the UK (TREADUK). Mental Health and Physical Activity, 3(2), 8591. doi: http://dx.doi.org/10.1016/j.mhpa.2010.09.004 Hedman, E., Ljotsson, B., & Lindefors, N. (2012). Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and costeffectiveness. Expert Rev Pharmacoecon Outcomes Res, 12(6), 745764. doi: 10.1586/erp.12.67 Hollandare, F., Andersson, G., & Engstrom, I. (2010). A comparison of psychometric properties between internet and paper versions of two depression instruments (BDIII and MADRSS) administered to clinic patients. J Med Internet Res, 12(5), e49. doi: 10.2196/jmir.1392 International Physical Activity Questionnaire Group. (2005). Guidelines for the data processing and analysis of the \"International Physical Activity Questionnaire. http://www.ipaq.ki.se/scoring.pdf Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 1219. 12PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t Johansson, R., & Andersson, G. (2012). Internetbased psychological treatments for depression. Expert Rev Neurother, 12(7), 861869; quiz 870. doi: 10.1586/ern.12.63 Johansson, R., Ekbladh, S., Hebert, A., Lindstrom, M., Moller, S., Petitt, E., . . . Andersson, G. (2012). Psychodynamic Guided SelfHelp for Adult Depression through the Internet: A Randomised Controlled Trial. PLoS One, 7(5). doi: ARTN e38021 DOI 10.1371/journal.pone.0038021 Kesaniemi, Y. K., Danforth, E., Jr., Jensen, M. D., Kopelman, P. G., Lefebvre, P., & Reeder, B. A. (2001). Doseresponse issues concerning physical activity and health: an evidencebased symposium. Med Sci Sports Exerc, 33(6 Suppl), S351358. Lindner, P., Andersson, G., \u00d6st, L.G., & Carlbring, P. (in press). Validation of the Internetadministered Quality of Life Inventory (QOLI) in different psychiatric conditions. Cognitive Behaviour Therapy. Lundh, L. G. (2009). What makes therapy work? A multifaceted question. Cogn Behav Ther, 38 Suppl 1, 37. doi: 10.1080/16506070902981503 Mendes, R., Sousa, N., & Barata, J. L. (2011). [Physical activity and public health: recommendations for exercise prescription]. Acta Med Port, 24(6), 10251030. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: preparing people for change. New York: Guilford Press. Newman, M. G., Szkodny, L. E., Llera, S. J., & Przeworski, A. (2011). A review of technologyassisted selfhelp and minimal contact therapies for anxiety and depression: is human contact necessary for therapeutic efficacy? Clin Psychol Rev, 31(1), 89103. doi: 10.1016/j.cpr.2010.09.008 Newnham, E. A., Hooke, G. R., & Page, A. C. (2010). Progress monitoring and feedback in psychiatric care reduces depressive symptoms. J Affect Disord, 127(13), 139146. doi: 10.1016/j.jad.2010.05.003 Palmqvist, B., Carlbring, P., & Andersson, G. (2007). Internetdelivered treatments with or without therapist input: does the therapist factor have implications for efficacy and cost? Expert Rev Pharmacoecon Outcomes Res, 7, 291297. Posternak, M. A., & Zimmerman, M. (2007). Therapeutic effect of followup assessments on antidepressant and placebo response rates in antidepressant efficacy trials: metaanalysis. Br J Psychiatry, 190, 287292. doi: 10.1192/bjp.bp.106.028555 Richards, D., & Richardson, T. (2012). Computerbased psychological treatments for depression: A systematic review and metaanalysis. Clinical Psychology Review, 32(4), 329342. doi: DOI 10.1016/j.cpr.2012.02.004 Silveira, H., Moraes, H., Oliveira, N., Coutinho, E. S., Laks, J., & Deslandes, A. (2013). Physical exercise and clinically depressed patients: a systematic review and metaanalysis. Neuropsychobiology, 67(2), 6168. doi: 10.1159/000345160 13PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t Sliwinski, J., & Elkins, G. R. (2013). Enhancing placebo effects: insights from social psychology. Am J Clin Hypn, 55(3), 236248. Spek, V., Cuijpers, P., Nyklicek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internetbased cognitive behaviour therapy for symptoms of depression and anxiety: a metaanalysis. Psychol Med, 37(3), 319328. doi: 10.1017/S0033291706008944 Sprinkle, S. D., Lurie, D., Insko, S. L., Atkinson, G., Jones, G. L., Logan, A. R., & Bissada, N. N. (2002). Criterion validity, severity cut scores, and testretest reliability of the Beck Depression InventoryII in a university counseling center sample. Journal of Counseling Psychology, 49(3), 381385. doi: Doi 10.1037//00220167.49.3.381 Svanborg, P., & \u00c5sberg, M. (2001). A comparison between the Beck Depression Inventory (BDI) and the selfrating version of the Montgomery Asberg Depression Rating Scale (MADRS). Journal of Affective Disorders, 64(23), 203216. Titov, N. (2011). Internetdelivered psychotherapy for depression in adults. Curr Opin Psychiatry, 24(1), 1823. doi: 10.1097/YCO.0b013e32833ed18f Waller, R., & Gilbody, S. (2009). Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence. Psychol Med, 39(5), 705712. doi: 10.1017/S0033291708004224 World Health Organization. (2001). The World Health Report 2001\u2013Mental Health: New Understanding, New Hope Retrieved from http://www.who.int/whr/2001/en/whr01_en.pdf 14PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t intervention : The treatment used in this study was a guided selfhelp program administered through an Internetbased system. The program consisted of nine text modules developed by the authors, consisting of 72 pages in total. Participants were given one text module every Monday over nine weeks. At the end of each week, the therapists gave written feedback on home assignments included in the modules. Message exchange and the delivery of the treatment modules used were transmitted via an encrypted webbased system. Some material, such as the pedometer given participants in the treatment condition, and the written form of consent, were sent using the postal service. The modules consisted of selfhelp texts about how to become more physically active. Each module ended with 35 essay questions where the participant was asked to report on the progress and the weekly planning of the exercise. The core principles of the program were inspired by Haase and coworkers (2010) and were intended to: 1) maximize the likelihood for participants to increase and maintain physical activity; 2) maximize the likelihood of participants remaining engaged in the program; 3) focus on the participants\u2019 preferences and needs, taking particular notice of the challenges faced by people with major depression; 4) promote physical activity in a broad sense in accordance with the WHO\u00b4s guidelines for physical activity (Mendes, Sousa, & Barata, 2011), including all types of activity in everyday life; 5) increase selfefficacy for physical activity; and 6) help participants to master challenges faced with when trying to get more active. The study was examined and approved by the regional 4PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t ethical committee at Ume\u00e5, Sweden (201114531 \u00d6), and is registered in Clinical Trials (NCT01573130). Statistical analysis The data were analyzed using the statistical programming language R, version 3.0.0. Reproducible code can be found in the supplemented file (Progredi.Rmd). Significance testing of group differences regarding demographic data in Table 1 and pretreatment measurements was conducted using Welch\u2019s two sample ttest for continuous data and chi2tests for nominal data. Differences between the groups in pre and postmeasurements were analyzed using a twoway mixed analysis of variance model (ANOVA), with treatment condition and time used as independent variables. Data was analyzed using an intentiontotreat approach. The response rate for all outcome measures was 100% (48 of 48) for pre and posttreatment measurements, and 87.5% (21 of 24) for the 6month followup. Due to the small number of missing data, we did not impute the missing data at 6month followup, but used baseline carried forward as an estimate for the three missing data points. Participants who changed their medication or began psychological treatment during the study were considered unchanged in the analysis to control for effects from other treatments (treatment n = 1, control n = 3, NS). Two participants gave inadequate answers on the IPAQ pretreatment, and were therefore excluded from the analysis on that measure. Clinically significant change on the main outcome measure, BDIII, was calculated according to Jacobson and Truax (1991), with testretest data from Sprinkle et al. (2002), and clinical cutoff scores in accordance with the BDIII manual (Beck & Steer, 1996). Reliable change (RC) was calculated with 95 % confidence intervals. method : Information about the study was advertised in a major Swedish newspaper, online with Google AdWords, and at an online service site containing information about ongoing research projects on Internet therapy. The participants were recruited between January and February 2012. Exclusion was based on the following criteria: subclinical depressive symptoms, severe depressive symptoms, dysthymia as a primary diagnosis, elevated suicide risk, high levels of physical activity prior to treatment, recent changes in medication and/or somatic illness making physical exercise inappropriate. The eligibility screening process consisted of selfreport questionnaires regarding depressive symptoms, anxiety, and level of physical activity, and a clinical interview via telephone to investigate the primary diagnoses of the participants. The screening questionnaires used were the MADRSS, BAI, and IPAQ. The telephone interview was based on the Structured Clinical Interview for DSMIV: Clinical version (SCIDICV; First, Gibbon, Spitzer, & Williams, 1997). A full description of participant recruitment is included in Figure 1, and a demographic description of the participants at pretreatment is presented in Table 1. INSERT TABLE 1 ABOUT HERE INSERT FIGURE 1 ABOUT HERE The study included 48 participants meeting the criteria for MDD. A person 3PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t independent of the research group, using a true random number service on the Internet (www.random.org) randomly allocated the participants to two conditions: treatment intervention or waitinglist control . Participants\u2019 levels of depression as well as anxiety, physical activity, and quality of life were measured at pre and posttreatment, as well as at a 6months followup. The study was conducted between February and April 2012, and the followup measurements were collected in October 2012. The main outcome measure for the assessments of depression and depressive symptoms was the BDIII with reported reliability estimates (coefficient \u03b1) for Swedish samples between \u03b1= .88 and \u03b1 = .92 (Per Carlbring et al., 2007). As a secondary measure of depression, we used the MADRSS, which has a reported reliability estimate of \u03b1=.84 (Fantino & Moore, 2009). The psychometric properties of the Internet versions of these instruments have proved to be equivalent to the paperandpencil versions (Hollandare, Andersson, & Engstrom, 2010). For evaluating changes in anxiety, physical activity, and quality of life, the BAI, IPAQ, and QOLI were administered; all of them showed satisfactory psychometric properties (Lindner, Andersson, \u00d6st, & Carlbring, in press; Ekelund et al., 2006). internet-based self-help. : Trial Registration: The trial was registered at ClinicalTrials.gov (NCT01573130). PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t Morgan Str\u00f6m1 CarlJohan Uckelstam1 Gerhard Andersson2,3 Peter Hassm\u00e9n1 G\u00f6ran Umefjord1 Per Carlbring4 1 Department of Psychology, Ume\u00e5 University, Sweden 2 Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden 3 Department of Behavioural Sciences and Learning, Psychology, Swedish Institute for Disability Research, Link\u00f6ping University, Sweden 4 Department of Psychology, Stockholm University, Sweden Address of correspondence: Per Carlbring Department of Psychology, Stockholm University, Sweden Tel: +49 (0) 8 16 39 20 Email: per@carlbring.se PeerJ reviewing PDF | (v2013:07:662:0:0:NEW 19 Jul 2013) R ev ie w in g M an us cr ip t",
"url": "https://peerj.com/articles/179/reviews/",
"review_1": "David Roberts \u00b7 Sep 18, 2013 \u00b7 Academic Editor\nACCEPT\nThanks for swiftly implementing the corrections. I did note that you spelt extirpation wrong in the first sentence but the rest of the text is fine. This can be corrected at the proof stage but it is worth a good look over the proof when it arrives.",
"review_2": "David Roberts \u00b7 Aug 19, 2013 \u00b7 Academic Editor\nMINOR REVISIONS\nThe reviewers suggest a few minor corrections clarifying certain elements of the paper and related to the figures which I'm confident came be dealt with swiftly.",
"review_3": "Michael Patten \u00b7 Aug 19, 2013\nBasic reporting\nThe authors analyzed mist net captures gathered at various times between 1973 and 2004 to deduce population changes in bird species in the Sierra de los Tuxtlas in southeastern Mexico. On the basis of these data, coupled with presence/absence data from direct detection in the field (i.e., records of species not mist netted but detected during the netting effort), they conclude that a dozen species have declined or been extirpated from the Tuxtlas.\n\nMy comments are relatively minor given that this manuscript is straightforward in its goals and results. For example, I could see merit, somewhere in the second paragraph of the Introduction, in bringing in ecological notions of resistence and resilience, notions that may help to guide predictions. Otherwise, my thoughts center on what I see a need to be clearer with some of the methods, chiefly to aid repeatability.\nExperimental design\nKey among my concerns is the specific meaning of \u201capparently declining or increasing rates\u201d (line 174). Because not all species were tested, it is imperative that anyone who wishes to repeat the results understands what \u201capparent declines\u201d are. Was this, for instance, a monotonic decrease in capture frequency? Or was there a need for gaps in the capture record? And what is meant by use of only \u201cfirst-time captures\u201d (l. 183): was this within a season (in which case I understand the policy) or over the life of the study (in which case I do not)? If the latter, a bird banded in, say, 1995 would not be counted if it was recaptured in 2002, even though its very presence indicates persistence.\n\nIf I had any criticism that tended toward \u201cmajor\u201d it concerns the seasonality of the effort. A perusal of Table 1 shows that the mist net data were gathered in both the wet and dry seasons in the 1970s, chiefly during the wet season in the 1980s and in 1992-1993, in both in 1993\u20131994, in the wet season in 1994\u20131995, and in the dry season in the 2000s. There is an enormous amount of intra-tropical movement of birds in Middle America with respect to timing of wet and dry seasons. Some species barely move, whereas others (e.g., many hummingbirds, Cotinga amabilis, Hylomanes momotula, etc.) may be largely absent from a site during the wet season but conspicuous during the dry, or vice versa. The authors acknowledge this effect in some cases, as when they puzzle over the apparent decline of Elaenia flavogaster (l. 254). I would be hard pressed to predict extirpation of this species given that it readily occupies human settlements, so seasonal shifts are a plausible reason for the apparent trend. To what extent might such shifts\u2014about which we know little more many species\u2014account for at least some of the patterns reported in Table 2?\nValidity of the findings\nno comments (but see those seasonality, above)\nAdditional comments\nl. 32: I think of the term \u201cextinction\u201d as a absolute, just like \u201cpregnant\u201d and \u201cunique.\u201d Hence, I would prefer use of the term \u201cextinction\u201d to be restricted to bona fide extinction (i.e., the utter disappearance of a species). To my way of thinking, \u201cextirpation\u201d is a term that means \u201clocal extinction\u201d and so can be used in its place. But this may be little more than a pet peeve or a bucking against an unchangeable trend, so the authors are free to ignore this comment if they feel strongly otherwise.\n\nl. 64: change \u201chow\u201d to \u201chow or if\u201d\n\nl. 158: spell our Schiffornis (and update the specific name to conform to the latest AOU supplement)\n\nl. 183: Does \u201csimple linear regression\u201d mean \u201cordinary least squares regression\u201d? If so, the latter is the standard term.\n\nl. 199+: Rarefaction would have been superior to simple accumulation curves.\n\nl. 206 (and throughout): correct spelling of striigularis (delete the first \u201cl\u201d)\n\nl. 269: I don\u2019t mean to nitpick, and perhaps it is only a difference in judgement, but I do not think of Taraba major as a forest bird. I agree that it occurs in closed-canopy forests, but I find it just as often at edges or in second growth, including, at least on occasion, in isolated patches of vegetation in fields.\nCite this review as\nPatten M (2013) Peer Review #1 of \"Decadal changes and delayed avian species losses due to deforestation in the northern Neotropics (v0.1)\". PeerJ https://doi.org/10.7287/peerj.179v0.1/reviews/1",
"review_4": "Stuart Pimm \u00b7 Aug 8, 2013\nBasic reporting\nOne of my few concerns about this paper is the figures, particularly the grey scale satellite images. Since, this is an online journal, having those in colour would add nothing to the cost of production. Doing so, would greatly enhance the extraordinary story that this paper tells. As I explain below, habitat fragmentation is the major driver of species extinctions and the authors have one of a handful of very well documented cases. So, please, more images and, if possible of intermediate years. Second, if the images could be larger ones, then good. Third, and vitally important, the paper needs better connections to the summary maps of where the study sites are found. It's not clear to me where figure 2 is in relationship to figure 3 \u2014 I think it's off to the east. Then, I don't know where figure 3 is in relationship to figure 2 either.\nExperimental design\nHabitat loss and fragmentation is the major driver of species extinction. But it's a large-scale, long-term process so the numbers of good studies one can count on the fingers of one hand. This is one of them! It's an extraordinary experiment; albeit of a serendipitous kind. The field work is unusually extensive. It involves a massive amount of field work, conducted over decades.\nValidity of the findings\nThis is very important paper, with implications for the species in forest fragments worldwide. The authors provide detailed, but approrpriate, comparisons with the few other similar studies done elsewhere.\nAdditional comments\nExcellent job, but telling the history of land use change in this area needs the very best you can do with satellite imagery and GIS.\nCite this review as\nPimm SL (2013) Peer Review #2 of \"Decadal changes and delayed avian species losses due to deforestation in the northern Neotropics (v0.1)\". PeerJ https://doi.org/10.7287/peerj.179v0.1/reviews/2",
"pdf_1": "https://peerj.com/articles/179v0.2/submission",
"pdf_2": "https://peerj.com/articles/179v0.1/submission",
"all_reviews": "Review 1: David Roberts \u00b7 Sep 18, 2013 \u00b7 Academic Editor\nACCEPT\nThanks for swiftly implementing the corrections. I did note that you spelt extirpation wrong in the first sentence but the rest of the text is fine. This can be corrected at the proof stage but it is worth a good look over the proof when it arrives.\nReview 2: David Roberts \u00b7 Aug 19, 2013 \u00b7 Academic Editor\nMINOR REVISIONS\nThe reviewers suggest a few minor corrections clarifying certain elements of the paper and related to the figures which I'm confident came be dealt with swiftly.\nReview 3: Michael Patten \u00b7 Aug 19, 2013\nBasic reporting\nThe authors analyzed mist net captures gathered at various times between 1973 and 2004 to deduce population changes in bird species in the Sierra de los Tuxtlas in southeastern Mexico. On the basis of these data, coupled with presence/absence data from direct detection in the field (i.e., records of species not mist netted but detected during the netting effort), they conclude that a dozen species have declined or been extirpated from the Tuxtlas.\n\nMy comments are relatively minor given that this manuscript is straightforward in its goals and results. For example, I could see merit, somewhere in the second paragraph of the Introduction, in bringing in ecological notions of resistence and resilience, notions that may help to guide predictions. Otherwise, my thoughts center on what I see a need to be clearer with some of the methods, chiefly to aid repeatability.\nExperimental design\nKey among my concerns is the specific meaning of \u201capparently declining or increasing rates\u201d (line 174). Because not all species were tested, it is imperative that anyone who wishes to repeat the results understands what \u201capparent declines\u201d are. Was this, for instance, a monotonic decrease in capture frequency? Or was there a need for gaps in the capture record? And what is meant by use of only \u201cfirst-time captures\u201d (l. 183): was this within a season (in which case I understand the policy) or over the life of the study (in which case I do not)? If the latter, a bird banded in, say, 1995 would not be counted if it was recaptured in 2002, even though its very presence indicates persistence.\n\nIf I had any criticism that tended toward \u201cmajor\u201d it concerns the seasonality of the effort. A perusal of Table 1 shows that the mist net data were gathered in both the wet and dry seasons in the 1970s, chiefly during the wet season in the 1980s and in 1992-1993, in both in 1993\u20131994, in the wet season in 1994\u20131995, and in the dry season in the 2000s. There is an enormous amount of intra-tropical movement of birds in Middle America with respect to timing of wet and dry seasons. Some species barely move, whereas others (e.g., many hummingbirds, Cotinga amabilis, Hylomanes momotula, etc.) may be largely absent from a site during the wet season but conspicuous during the dry, or vice versa. The authors acknowledge this effect in some cases, as when they puzzle over the apparent decline of Elaenia flavogaster (l. 254). I would be hard pressed to predict extirpation of this species given that it readily occupies human settlements, so seasonal shifts are a plausible reason for the apparent trend. To what extent might such shifts\u2014about which we know little more many species\u2014account for at least some of the patterns reported in Table 2?\nValidity of the findings\nno comments (but see those seasonality, above)\nAdditional comments\nl. 32: I think of the term \u201cextinction\u201d as a absolute, just like \u201cpregnant\u201d and \u201cunique.\u201d Hence, I would prefer use of the term \u201cextinction\u201d to be restricted to bona fide extinction (i.e., the utter disappearance of a species). To my way of thinking, \u201cextirpation\u201d is a term that means \u201clocal extinction\u201d and so can be used in its place. But this may be little more than a pet peeve or a bucking against an unchangeable trend, so the authors are free to ignore this comment if they feel strongly otherwise.\n\nl. 64: change \u201chow\u201d to \u201chow or if\u201d\n\nl. 158: spell our Schiffornis (and update the specific name to conform to the latest AOU supplement)\n\nl. 183: Does \u201csimple linear regression\u201d mean \u201cordinary least squares regression\u201d? If so, the latter is the standard term.\n\nl. 199+: Rarefaction would have been superior to simple accumulation curves.\n\nl. 206 (and throughout): correct spelling of striigularis (delete the first \u201cl\u201d)\n\nl. 269: I don\u2019t mean to nitpick, and perhaps it is only a difference in judgement, but I do not think of Taraba major as a forest bird. I agree that it occurs in closed-canopy forests, but I find it just as often at edges or in second growth, including, at least on occasion, in isolated patches of vegetation in fields.\nCite this review as\nPatten M (2013) Peer Review #1 of \"Decadal changes and delayed avian species losses due to deforestation in the northern Neotropics (v0.1)\". PeerJ https://doi.org/10.7287/peerj.179v0.1/reviews/1\nReview 4: Stuart Pimm \u00b7 Aug 8, 2013\nBasic reporting\nOne of my few concerns about this paper is the figures, particularly the grey scale satellite images. Since, this is an online journal, having those in colour would add nothing to the cost of production. Doing so, would greatly enhance the extraordinary story that this paper tells. As I explain below, habitat fragmentation is the major driver of species extinctions and the authors have one of a handful of very well documented cases. So, please, more images and, if possible of intermediate years. Second, if the images could be larger ones, then good. Third, and vitally important, the paper needs better connections to the summary maps of where the study sites are found. It's not clear to me where figure 2 is in relationship to figure 3 \u2014 I think it's off to the east. Then, I don't know where figure 3 is in relationship to figure 2 either.\nExperimental design\nHabitat loss and fragmentation is the major driver of species extinction. But it's a large-scale, long-term process so the numbers of good studies one can count on the fingers of one hand. This is one of them! It's an extraordinary experiment; albeit of a serendipitous kind. The field work is unusually extensive. It involves a massive amount of field work, conducted over decades.\nValidity of the findings\nThis is very important paper, with implications for the species in forest fragments worldwide. The authors provide detailed, but approrpriate, comparisons with the few other similar studies done elsewhere.\nAdditional comments\nExcellent job, but telling the history of land use change in this area needs the very best you can do with satellite imagery and GIS.\nCite this review as\nPimm SL (2013) Peer Review #2 of \"Decadal changes and delayed avian species losses due to deforestation in the northern Neotropics (v0.1)\". PeerJ https://doi.org/10.7287/peerj.179v0.1/reviews/2\nReview 5: nan\nReview 6: \n",
"LLM_extracted_review": "['Review 1: The spelling of \"extirpation\" is incorrect in the first sentence, but the rest of the text is fine. It should be corrected at the proof stage.\\n\\nReview 2: Minor corrections are needed to clarify certain elements of the paper and figures.\\n\\nReview 3: The manuscript is straightforward, but there is a need for clearer methods to aid repeatability. The meaning of \u201capparently declining or increasing rates\u201d needs clarification, particularly regarding capture frequency and the definition of \u201cfirst-time captures.\u201d The seasonality of data collection raises concerns about the apparent trends in species populations, as intra-tropical movement may affect results. The use of \"extinction\" should be restricted to bona fide extinction, and \"extirpation\" should be used for local extinction. Several specific corrections are suggested, including spelling and terminology.\\n\\nReview 4: The figures, especially the grey scale satellite images, should be in color to enhance the paper\\'s story. Larger images and better connections to summary maps are needed for clarity. The study is an extraordinary experiment with extensive fieldwork, and it has important implications for species in forest fragments. The history of land use change should be represented with the best possible satellite imagery and GIS.\\n\\nReview 5: nan\\n\\nReview 6: ']"
} |