Internet-Based Cognitive Behavioral Therapy and its Association With Self-efficacy, Depressive Symptoms, and Physical Activity: Secondary Analysis of a Randomized Controlled Trial in Patients With Cardiovascular Disease

BACKGROUND: In patients with cardiovascular disease (CVD), knowledge about the associations among changes in depressive symptoms, self-efficacy, and self-care activities has been requested. This is because such knowledge can be helpful in the design of behavioral interventions aimed to improve self-efficacy, reduce depressive symptoms, and improve performance of self-care activities in CVD patients. OBJECTIVE: We aim to evaluate if internet-based cognitive behavioral therapy (iCBT) improves self-efficacy and explore the relationships among changes in depressive symptoms, self-efficacy, and physical activity, as well as the influence of iCBT on these relationships. METHODS: This study received funding in January 2015. Participant recruitment took place between January 2017 and February 2018, and the main findings were published in 2019. This study is a secondary analysis of data collected in a randomized controlled study evaluating the effects of a 9-week iCBT program compared to an online discussion forum (ODF) on depressive symptoms in patients with CVD (N=144). Data were collected at baseline and at the 9-week follow-up. Analysis of covariance was used to evaluate the differences in self-efficacy between the iCBT and ODF groups. Structural equation modeling explored the relationships among changes in depressive symptoms, self-efficacy, and physical activity, as well as the influence of iCBT on these relationships. RESULTS: At follow-up, a significant difference in the increase in self-efficacy favoring iCBT was found (P=.04, Cohen d=0.27). We found an indirect association between changes in depressive symptoms and physical activity (β=–.24, P<.01), with the change in self-efficacy acting as a mediator. iCBT had a direct effect on the changes in depressive symptoms, which in turn influenced the changes in self-efficacy (β=.23, P<.001) and physical activity (β=.12, P<.001). CONCLUSIONS: Self-efficacy was improved by iCBT. However, the influence of iCBT on self-efficacy and physical activity was mostly mediated by improvements in depressive symptoms. TRIAL REGISTRATION: ClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074