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Introduction: Rural areas experience marked disparities in cardiac and mental health and access to health care. Rural cardiac patients with depressive symptoms (DS) do not receive needed therapy because of lack of mental health providers, worries about stigma, and difficulty accessing mental health care. Cognitive behavioral therapy (CBT) reduces DS in cardiac patients, but in its traditional form (in-person meetings) is inaccessible to most rural patients. Wireless internet technology has the potential to make CBT more accessible. Hypothesis: Our aim was to determine whether patient perceptions of stigma would moderate the impact on DS of two types of remote-delivery CBT: 1) real-time, face-to-face, video-conferenced CBT with a therapist (vcCBT); and 2) self-administered internet-based CBT without a therapist (iCBT). We hypothesized that patients with high perceptions of stigma would have a better response to iCBT than vcCBT, but that both would be effective in patients with lower perceptions of stigma. Methods: In this randomized controlled trial (N = 303, mean age 58 ± 12 years, 49% women) rural cardiac patients who had at least mild-moderate DS underwent 6-8 weeks of CBT delivered as either vcCBT or iCBT. DS were measured using the Patient Health Questionnare-9. Stigma was measured using the Depression Stigma Scale. Data were collected at baseline, 3, 6 and 12 months. Data were analyzed using mixed models for repeated measures. Results: Patients in the vcCBT compared to the iCBT group had similar levels of DS at baseline (11.2±5 vs 11.3±5, p=0.45; respectively). Patients with higher levels of perceived stigma had worse DS compared to those with lower levels of stigma (10.6±5 vs 11.9±5, p=0.018; respectively). Both intervention groups experienced statistically and clinically significant improvements in DS (Figure), with DS decreasing from moderate levels to non-depressed at 3 months (p<0.001), which was maintained at 12 months. Perceived stigma did not moderate the impact of the intervention, rather, patients with higher levels of perceived stigma demonstrated a lesser response to either intervention. Conclusion: Both types of intervention were effective at managing DS, however, contrary to our hypothesis, high levels of stigma alone rendered patients less responsive to either intervention. Nonetheless, all patients regardless of intervention type of level of stigma experienced meaningful reductions in DS.
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