This chapter covers the case study of iFightDepression® (iFD) Tool, a web-based, guided, self-help tool for individuals with mild-to-moderate depression. The case study includes an assessment of the iFD Tool against the five best practice criteria, policy options to enhance performance and an assessment of its transferability to OECD and EU27 countries.
Mental Health Promotion and Prevention
Best Practices in Public Health
Abstract
Description: iFightDepression® (iFD) Tool is a web-based intervention for people with mild-to-moderate depression, based on the principles of cognitive behavioural therapy (CBT). The content and concept of the tool were originally developed as part of the EU-funded project “Preventing Depression and Improving Awareness Through Networking in the EU (PREDI-NU)”, which ran from 2011 to 2014. The technical updates of the tool were completed in 2016, marking the start of its integration into routine care in Germany. The introduction to iFD Tool is guided by a general practitioner (GP) or a mental health professional who have been trained in the programme. While the use of the tool is self-managed by the user, the healthcare professional remains in contact with them throughout the duration of its use, providing guidance and support as needed. The iFD Tool is free‑of-charge for users and translated into 16 languages, including Ukrainian and Russian. iFD Tool complements therapy, rather than replacing it. The guidance of patients by an iFD-trained professional is key. It is recommended that the patient completes one module per week, for a total of six modules.
Best practice assessment:
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Criteria |
Assessment |
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Effectiveness |
iFD Tool reduces depressive symptoms by 40% more than an active control group after six weeks, while also improving quality of life by 89% after six weeks and 56% after three months. The SPHeP-NCD model estimates that by 2050, expanding the use of iFD Tool would result in:
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Efficiency |
It is estimated that transferring iFD Tool to the 43 OECD and EU27 countries would result in no health expenditure savings in 24 countries, but to statistically significant savings in 19 countries. iFD Tool would be cost saving in three countries, cost-effective in 34 countries and cost-effective at potentially higher threshold in five countries. |
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Equity |
The iFD Tool is free‑of-charge, available in 16 languages, and is accessible via referral by GP or a mental health professional who have been trained in the programme. |
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Evidence‑base |
A randomised controlled trial (RCT) provides strong evidence for iFD, with strong quality in domains such as study design, control for confounders, withdrawals and dropouts, and moderate in data collection methods. |
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Extent of coverage |
Since the initiation of the iFD Tool in Germany in 2016, 9 624 people have been identified and offered the use of iFD by a mental health professional. Around 14% of this target group had actually participated in the initial phase of the intervention, with a smaller proportion completing the whole programme, but data are not available. |
Enhancement options: To enhance effectiveness of iFD Tool it is important to optimise the integration of regular check-ins and feedback mechanisms from healthcare professionals to provide users with timely, personalised feedback and ongoing encouragement. The use of online training for GPs and healthcare professionals can enhance efficiency of iFD Tool. To enhance equity of iFD Tool, target strategies are needed to ensure equal access to the tool and its benefits for all individuals. This includes removing financial barriers and addressing stigma, particularly among vulnerable and underserved groups. To enhance the evidence‑base of iFD Tool, it is essential to establish a systematic and continuous evaluation process, including as RCTs, and implement a robust monitoring system to collect data on iFD usage and outcomes. To enhance the extent of coverage of iFD Tool, efforts should focus on reducing user dropout rates and expanding the recruitment of mental health professionals.
Transferability: The iFD Tool has been successfully transferred and implemented in Bulgaria, Estonia, Greece, Hungary, Ireland, Italy, Poland and Spain through the EU-funded European Alliance Against Depression “EAAD-Best” project. By 2024, the iFD Tool was available in 16 languages, and the website (https://ifightdepression.com/en/) offers content in 21 languages.
Conclusion: iFD Tool has been shown to effectively reduce depressive symptoms in individuals with mild-to-moderate depression and has also been associated with improvements in users’ overall quality of life.
iFightDepression® (iFD) Tool is a non-commercial web-based intervention for people with mild-to-moderate depression, based on the principles of cognitive behavioural therapy (CBT) (Box 4.1). The iFD Tool is free‑of-charge for users and is intended to help individuals to self-manage their symptoms of depression and promote recovery, with support from a trained general practitioner (GP) or mental health professionals.
Cognitive Behavioural Therapy (CBT) is an evidence‑based talking therapy designed to help individuals manage psychological challenges by identifying and changing unhelpful thoughts, beliefs and behaviours. In CBT, patients work collaboratively with a therapist to address negative thinking patterns and develop coping strategies.
CBT is widely used to treat a variety of mental health conditions but is most commonly used to treat anxiety and depression. Research shows that CBT is effective in reducing symptoms of depression and anxiety, with evidence suggesting associated improvements in overall functioning and well-being.
Source: American Psychological Association (2017[1]), “What is cognitive behavioural therapy?”, https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.pdf; Hofmann et al. (2012[2]), “The efficacy of cognitive behavioral therapy: A review of meta‑analyses”, https://doi.org/10.1007/s10608-012-9476-1.
The intervention consists of three parts dedicated to either the patient or the professional who guides the patient while using the tool:
1. a guided, internet-based self-management tool for individuals experiencing mild-to-moderate depression that is free of charge for users and uses the principles of CBT.
2. a website providing detailed information on depression addressed to the general population, young people, family and friends, community workplace managers and colleagues, and healthcare professionals.
3. training materials for healthcare professionals who are interested in implementing iFD Tool in their practice.
iFD is a guided self-help tool. Individuals are typically introduced to the programme by a GP or a psychotherapist who has completed the standardised professional training programme. These trained health professionals provide access to the tool and motivate patients to complete the iFD modules over seven or eight weeks. The guidance aspect is key to achieve better outcomes. Evidence from Germany supports that adherence and clinical outcomes (measured by reduction in depression symptoms) were improved for patients adhering to the guided iFD Tool compared to those using an unguided tool (Oehler et al., 2021[3]).
iFD Tool consists of six modules that focus on increasing daily activity, identifying and challenging negative thought patterns, monitoring mood and sleep. In addition to the six core modules, there are two optional modules for young people and one optional module for both young people and adults, that address related psychosocial issues, namely, relationships, social anxiety, and healthy lifestyle habits. Associated worksheets and exercises encourage users of the tool to practice and consolidate new skills and to promote self-monitoring.
iFD Tool complements therapy, rather than replacing it. The guidance of patients by an iFD trained professional is key. It is recommended that the patient completes one module per week for a total of up to seven or eight weeks (Arensman et al., 2015[4]). The completion of iFD modules aims at reducing the time of a traditional psychological therapy. Furthermore, iFD can be particularly useful for patients who are on waiting list for mental health care, as those people – referred by a GP- can start to receive information and complete exercises of the iFD modules while waiting for an appointment with a mental health professional.
To implement the iFD Tool in a country, a national co‑ordinator is required. This role should be fulfilled by an organisation such as the Ministry of Health, non-governmental organisation, hospital, or university. The national co‑ordinator is responsible for promoting the iFD Tool, organising iFD training sessions for healthcare professionals, and registering them as iFD guides, enabling them to access and offer the tool to their patients. Additionally, organisations interested in becoming a national co‑ordinator are required to contribute an annual fee to support the technical maintenance and adaptation of the iFD Tool.
The concept and content of the iFD Tool were developed as part of the EU-funded project Preventing Depression and Improving Awareness Through Networking in the EU (PREDI-NU), which ran from 2011 to 2014. Technical updates of the tool were completed in 2016, marking the beginning of its integration into routine care in Germany. The tool’s use was later expanded to several European countries through Adapting and Implementing European Alliance Against Depression (EAAD)´s Best Practice Model to Improve Depression Care and Prevent Suicidal Behaviour in Europe – EAAD-Best project (see below section on Previous transfers).
This section analyses iFD Tool against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 4.2 for a high-level assessment). Further details on the OECD Framework can be found in Annex A.
Effectiveness
iFD Tool reduces the duration of the depression episode compared to an active control. After six weeks of therapy, the reduction in depressive symptoms is 40% higher with iFD compared to the active control group.
The increase in quality of life is 89% higher in the iFD group compared to the control group after six weeks, and 56% higher after three months.
The SPHeP-NCD model estimates that by 2050, expanding and transferring iFD Tool would results in a cumulative gain of more than 6 500 DALYs for Germany; and an average of 0.3 and 0.29 DALYs per 100 000 persons per year for OECD and EU27 countries, respectively.
Efficiency
It is estimated that transferring iFD Tool to the 43 OECD and EU27 countries would result in no health expenditure savings in 24 countries, but to statistically significant savings in 19 countries.
iFD Tool would be cost saving in three countries (the Netherlands, Norway and Sweden), cost-effective in 34 countries and cost-effective at potentially higher threshold in five countries.
Equity
iFD Tool is accessible via referral by a GP or a mental health professional who have been trained in the programme.
iFD Tool is free‑of-charge and is available in 16 languages, including Ukrainian and Russian.
Evidence‑base
A randomised controlled trial (RCT) study supports the evidence for iFD (Oehler et al., 2020[5]). This study performs well against the Quality Assessment Tool for Quantitative Studies, in particular in terms of study design, control for confounders, and withdrawals and dropout.
Extent of coverage
Since the initiation of the iFD Tool in Germany in 2016, 9 624 people have been identified and offered the use of iFD Tool by a mental health professional. Around 14% of this target group had actually participated in the initial phase of the intervention, with a smaller proportion completing the whole programme, but data are not available.
Effectiveness
A German Randomised Controlled Trial (RCT) study found that iFD Tool leads to greater reduction in depression symptoms and greater quality of life after six weeks, compared to the control group who received web-based progressive muscle relaxation (Oehler et al., 2020[5]). This study included 348 participants and followed participants at several points in time (after 3 weeks, 6 weeks, 3 months, 6 months, 12 months). The change in depression severity was assessed with the Inventory of Depressive Symptomatology-self-rating (IDS-SR) score (range 0‑84). The change in self-perceived health-related quality of life was assessed with the Short-Form 12 (SF‑12) (both mental and physical score, ranging from 0 to 100), and the possible deterioration in depressive symptoms toward suicidality was assessed with the Patient Health Questionnaire (PHQ‑9).
Depression symptoms
The iFD group shows a significant reduction in depressive symptoms after six weeks and three months compared to the active control group, significantly reducing the duration of the depression episode. The progress achieved after six weeks and after three months was greater in the iFD group compared to the active control group. Specifically, after six weeks, the depression score decreased by 6.7 points (from 27.5 to 20.8 on score scale from 0 to 84, with confidence intervals (CI) of 2.4 to 39.2) compared to a 4.8‑point decrease in the control group, meaning that the reduction in the depression score is 40% higher in the iFD group (Oehler et al., 2020[5]). The depression score further decreased after three months down to 19.3 [CI: ‑3.0; 41.6] compared to 22.0 [CI: ‑0.9; 44.9] in the control group, corresponding to a 39% higher reduction in the iFD group. After 12 months, the depression score decreased in both groups, with no statistical difference between groups. This likely reflects the fact the depression episode lasts for several months and resorbs after a year.
Quality of life
The study by Oehler et al. shows that quality of life significantly improved in both iFD and control groups, with greater improvements in the iFD group after six weeks and three months. The SF‑12 Mental component score in the iFD group increased from 33.6 in the baseline to 38.9 [CI: 19.9; 57.9] after six weeks, and 40.3 [CI: 19.1; 61.5] after three months (the score ranges from 0‑100), whereas the score in the control group increased from 33.3 in the baseline to 36.1 [CI: 16.1; 56.1] after six weeks, and 37.6 [CI: 17.8; 57.4] after three months (Oehler et al., 2020[5]). In other words, the increase in quality of life is 89% higher in the iFD group compared to the control group after six weeks, and respectively 56% higher after three months.
Remission from depression
A Spanish RCT study found that iFD Tool improves the rate of remission from depression within eight weeks. The study focussed on patients with mild-to-moderate depression who followed a therapy, using the Hamilton Depression Rating Scale (HDRS). Remission was defined as a HDRS score below 7. Patients who received a link to a website about depression and were guided to use iFD Tool (intervention group) were more likely to remit from depressive symptoms eight weeks after the intervention than those treated and receiving a link to a website about depression (active control), although the effect was not quantified in the study (Justicia Diaz, 2021[6]). Besides, in the intervention group, the number of modules completed was significantly higher in remitters than in non-remitters, suggesting the adherence to iFD Tool contributed to remission.
Quality of care: Patient satisfaction
The same Spanish RCT study found that patient satisfaction was measured to be higher in the intervention group, according to the Client Satisfaction Questionnaire (CSQ‑8). The mean score was 23.5 in the intervention group compared to 19.5 in the control group (the score ranges from 4 to 32) (Justicia Diaz, 2021[6]).
The OECD’s Strategic Public Health Planning for non-communicable diseases (SPHeP-NCDs) microsimulation model was used to estimate the health and economic impact of expanding iFD Tool across Germany, and across all OECD and non-OECD European countries, assuming that 1.12% of the target population would receive the intervention. Details on the model are in Annex A, while the list of model assumptions are in Annex 4.A at the end of this Chapter.
The rest of this section presents results for Germany, followed by remaining OECD and non-OECD European countries.
Germany
The OECD’s SPHeP-NCD micro-simulation model estimates that the implementation of iFD Tool would lead to gain more than 6 500 disability-adjusted life years (DALYs) between 2025‑2050 in Germany (Figure 4.1). In gross terms, between 2025 and 2050, the number of depression cases are estimated to fall by around 23 000 in Germany.
Note: The black lines represent 95% confidence intervals. Figures are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
OECD and non-OECD European countries
Transferring iFD Tool to all OECD and EU27 countries is estimated to result in 0.3 and 0.29 DALYs gained per 100 000 people, respectively on average per year between 2025 and 2050. This ranges from 0.54 in Finland to 0.07 in Romania (Figure 4.2), although the health impact is non-significant in Romania.
Note: The black lines represent 95% confidence intervals. NS means non significant.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
While preventing mild-to-moderate symptoms of depression, iFD Tool will effectively contribute to prevent cases of depressive disorders. In gross terms, between 2025 and 2050, the SPHeP-NCD model estimates that iFD Tool will reduce depression cases by around 346 000 in OECD countries and by 107 000 cases in EU27 countries. This represents about 0.04% of all cases of depression across OECD and EU27countries.
Efficiency
This section presents the potential impact of the intervention on healthcare expenditure and a cost-effectiveness analysis assuming programme costs as reported in Annex 4.A at the end of this Chapter.
It is estimated that transferring iFD Tool to the 43 OECD and EU27 countries would result in no health expenditure savings in 24 countries, but to statistically significant savings in 19 countries. Country-specific characteristics such as the level of access to treatment by country (see Chapter 2 for treatment coverage) may shape the outcome. For instance, Norway and Sweden have higher levels of treatment coverage than other countries, which could result in higher potential economic savings.
Table 4.1 provides information on interventions costs, total health expenditure savings and the cost per DALY gained local currency for OECD and non-OECD European countries. iFD Tool is cost saving in three countries (the Netherlands, Norway and Sweden). In 34 countries, iFD Tool is considered cost effective with the cost per DALY below the average cost-effectiveness threshold applied in European countries (i.e. EUR 50 000 based on (Vallejo-Torres et al., 2016[7])). In five countries, iFD Tool is considered cost-effective on average, but there is uncertainty since the upper range of the 95% confidence interval is higher than the threshold of EUR 50 000 per DALY. It is estimated that the intervention will be non-effective in Romania.
Note: * Cost per DALY gained is measured using total intervention costs less total health expenditure savings divided by total DALYs gained over the period 2025‑2050. “ns” means not significant. ** On average, the cost per DALY is below EUR 50 000, but uncertainty remains as the upper range of 95% confidence interval is higher. *** The impact on health is non-significant.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
The reduction in depression symptoms resulting from iFD Tool has, in turn, impacts on the labour market participation and productivity, such as increases in employment and reductions in absenteeism and presenteeism. It is estimated that transferring iFD Tool to the 43 OECD and EU27 countries would result in no impact on labour market outcomes in 33 countries, but to statistically significant gains in 10 countries. In these 10 countries, gains would range between 0.08 and 0.24 full-time equivalent (FTE) workers per 100 000 persons per year between 2025 and 2050.
Equity
iFD Tool is affordable to all population groups as it is free‑of-charge for users. It is available in 16 languages, including Ukrainian and Russian, offering mental health support for displaced populations. The acceptability of computerised CBT tool – such as iFD Tool – are shown to be greater for people living in rural areas than in urban participants (Vallury, Jones and Oosterbroek, 2015[8]).
However, the accessibility and the effective use of such digital tools may vary across population groups. For instance, access to iFD Tool usually depends on being introduced to the tool by a GP or a psychotherapist. Individuals who are less likely to access health services, such as displaced people, those with lower socio-economic status or those with lower health literacy (OECD, 2019[9]), may be less likely to benefit from the programme. In addition, there is a higher risk of dropout from web-based interventions – such as iFD Tool – for people with low level of education, who are male and younger (Varga et al., 2024[10]).
Evidence‑base
Results of the effectiveness of iFD Tool are based on an RCT study (Oehler et al., 2020[5]). Details of the study design is described in the study protocol (Oehler et al., 2019[11]). This study included 348 participants and followed participants at several points in time (after 3 weeks, 6 weeks, 3 months, 6 months, 12 months). The change in depression severity was assessed with the IDS-SR score, which has substantial face validity (John Rush, Carmody and Reimitz, 2000[12]). The change in self-perceived health-related quality of life with the SF‑12 both mental and physical scores.
The quality of evidence from the RCT study by Oehler et al. (2020[5]) was assessed using the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project, 1998[13]). The quality of evidence was rated as strong in the domains of “Study design”, “Confounders”, “Withdrawals and dropouts”; moderate in “Data collection methods”; and as weak in “Selection bias” and “Blinding” (Table 4.2) Regarding the unblinding of study assessor, the authors do not consider it as a risk of bias since the results are based on self-ratings only (Oehler et al., 2019[11]).
Source: Effective Public Health Practice Project (1998[13]), “Quality Assessment Tool for Quantitative Studies”, https://www.nccmt.ca/knowledge-repositories/search/14; Oehler et al. (2020[5]), “Efficacy of a guided web-based self-management intervention for depression or dysthymia: Randomized controlled trial with a 12‑month follow-up using an active control condition”, https://doi.org/10.2196/15361.
Extent of coverage
The iFD Tool is designed for individuals aged 15 and older with mild-to-moderate depression, offering a version for adults aged 25 and above and another specifically for young adults aged 15 to 24. The programme was initiated in 2016 and is now in its scale‑up phase. Over the last five years, 1 618 participants on average per year were invited to use the iFD programme.
iFD Tool user data from Germany in 2024 show that since 2016, 9 624 people have been identified and offered the use of iFD Tool by a mental health professional. Some 6 106 people have accepted the invitation and completed the registration process, while only 1 319 people have completed at least two of the six core modules -defined as a minimal dose. These data suggest that around 14% (1 319/9 624) of the target group actually participated in the initial phase of the intervention, although a smaller proportion did complete the whole programme, but data are not available.
Enhancing effectiveness
The effectiveness of iFD Tool can be improved by optimising the integration of regular check-ins and feedback mechanisms from healthcare professionals. By ensuring that users receive timely, personalised feedback and ongoing encouragement, iFD Tool can leverage these benefits to maintain user motivation. While iFD Tool already incorporates guidance from healthcare professionals, increasing the frequency and structure of these interactions can improve user outcomes. Evidence supports this approach, as regular clinician contact has been shown to improve adherence to treatment and to enhance clinical outcomes in digital mental health interventions. Titov et al (2010[14]) showed that both clinician-assisted and technician-assisted iCBT led to greater improvements in users’ mental health compared to those without support. In addition, Kelders et al. (Kelders et al., 2012[15]) found that providing human support in eHealth interventions increased user engagement and adherence. Research on the iFD programme has also yielded similar results, with evidence demonstrating that increasing user guidance, for instance through weekly phone calls with therapists, can yield higher clinical outcomes. However, this will be at a cost. A Hungarian pilot study of 143 participants found a larger reduction in depression symptoms in participants who received iFD and those receiving iFD with additional weekly phone calls by therapists (iFD+phone), compared to the treatment-as-usual group (pharmacotherapy, psychotherapy, or both) (Varga et al., 2024[10]). The study found that iFD is associated with 18 times higher odds in reaching a reliable improvement in depression, and iFD+phone with 126 times higher odds. After six weeks, the average score of depression (measured with PHQ‑9; range 0‑27) decreased by nearly 4 points in the iFD group (from 14.3 to 10.0), and by more than 6 points in the iFD+phone group (from 12.9 to 6.7), while it remained statistically unchanged in the control group. This suggests higher effectiveness of the iFD and iFD+phone treatments compared to treatment as usual.
Enhancing efficiency
Using online guide training (e‑learning via iFD guide website) for GPs and healthcare professionals can enhance the efficiency of iFD Tool. Compared to in-person training, online guide training may offer more flexibility and greater cost effectiveness. To maintain the quality of training, a blended approach can be used, combining e‑learning with face‑to-face or virtual interactive sessions. Regular assessment and feedback within the online training platform can further ensure high standards of training.
Enhancing equity
iFD Tool contains elements promoting a favourable equity impact since the tool is free‑of-charge for users and its content is adapted to country-specific cultural context (e.g. phrasing of questions, explanations and examples are adapted to country’s specificities). Enhancing the equity of iFD Tool involves implementing strategies to ensure that all individuals, regardless of socio-economic status, identity, or background, have equal access to the tool and its benefits. A key aspect of iFD Tool is that it is free‑of-charge for users. Research shows that disadvantaged groups, such as those with lower socio-economic status, are less likely to access the healthcare services they need (OECD, 2019[9]). Providing iFD Tool free‑of-charge to these populations can help removing financial barrier and partly improve access to mental health support.
But beyond financial aspects, inequalities in access can persist for people who are vulnerable to mental health problems, such as LGBTQI+ individuals, indigenous populations, ethnic minorities, and refugees (Vargas Lopes and Llena-Nozal, 2025[16]). These groups often face additional barriers, including discrimination, stigma, and lack of culturally competent care. To address these inequalities, iFD Tool national co‑ordinators can implement targeted outreach and communication strategies that are tailored to these communities. By promoting mental health literacy (Box 4.3) and raising awareness of iFD Tool among these groups, the programme can increase its reach and impact. In addition, developing culturally relevant content and ensuring that the tool is available in multiple languages can make iFD Tool more accessible and effective for diverse populations.
Mental health literacy refers to the knowledge of good mental health and mental health problems, and the understanding of how to seek mental health care when needed.
Decision making about seeking mental health care is influenced by individual’s access to information and their ability to act on it. However, finding information about how to manage health problems is often challenging. A survey conducted across 16 OECD countries from 2019-2021 found that 29% of respondents reported difficulty or extreme difficulty in finding such information (See Chapter 2). This proportion ranged from 19% in Slovenia to over 50% in Bulgaria and Germany.
Many countries put effort to improve mental health literacy. Out of 43 OECD and EU countries, 38 have policies and programmes to improve mental health awareness and literacy either implemented or underway (WHO, 2024[17]). For instance, events and activities around World Mental Health Day appear to be a key part of countries’ efforts to increase mental health literacy, and to tackle stigma around mental health. An exemplary initiative is the annual Yellow Day -usually in September- in Iceland that aims to raise awareness about mental health and suicide prevention.
Source: OECD (2021[18]), A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health, https://doi.org/10.1787/4ed890f6-en.
Enhancing the evidence‑base
To enhance the evidence base, it is essential to establish a systematic and continuous evaluation process, such as RCTs, to ensure the effectiveness and efficacy of the programme. This will provide high-quality evidence on the effectiveness of the programme and identify components that are beneficial and those that require improvement. It is vital that the iFD Tool content is updated regularly in line with the latest research findings into depression treatment. It is also beneficial that iFD Tool is kept up to date with emerging mental health trends and new therapeutic techniques, and that the information within iFD Tool is current and evidence based. Engaging in partnership with academic institutions and research organisations can facilitate these updates.
Implementing a monitoring system that collects data on the use of iFD Tool (e.g. referral, utilisation and dropout) would facilitate the understanding of the utilisation patterns. This would in turn enhance the quality and the effectiveness of the programme. For instance, systematically collecting and examining data of the use of iFD Tool in several European countries, and evaluating the iFD Tool impact on different population groups (e.g. by socio-economic group, and focussing on vulnerable populations, such as LGBTQI+ individuals, indigenous populations, ethnic minorities, and refugees) could provide valuable insights into the programme’s effectiveness across different socio-demographic groups. This would contribute to building a stronger evidence base.
Enhancing extent of coverage
The enhancement of the extent of coverage of iFD Tool can be done by reducing user dropout rates and broadening the recruitment of mental health professionals. To reduce dropout rates, three key options could be advanced:
Improving health literacy: increasing users’ understanding of mental health and the benefits iFD Tool can lead to better engagement and sustained use.
Raising internet accessibility and skills: Many potential users may face barriers related to internet access and digital literacy. Addressing these issues by promoting internet access in underserved areas and providing digital literacy training can help more people use iFD Tool effectively. To achieve this, collaborations with community organisations could be efficient.
Developing an iFD mobile app: creating a mobile application for iFD can enhance its accessibility, particularly among young people who are more likely to use smartphones. A mobile app can offer the same benefits as the web-based version, with added convenience and usability, potentially reducing drop-out rates by making the programme more user-friendly and adaptable to users’ lifestyles. In 2024, initiatives were undertaken to improve the iFD Tool’s smartphone compatibility by shortening its content and enhancing technical features. Building on these efforts, starting in April 2025, the iFD Tool will introduce a more user-friendly interface and improved smartphone accessibility, further enhancing the overall user experience.
Expanding the recruitment of GPs and therapists can be effective to extend the reach of iFD Tool. This can be achieved through:
Reinforced active communication: Actively engaging with GPs and therapists through targeted communication strategies can encourage their participation in iFD Tool. Providing clear information about the benefits of iFD Tool and how it can be integrated into their practice can facilitate their involvement.
Using evidence‑based data: Leveraging evidence‑based data to demonstrate the effectiveness of iFD Tool can be used to convince GPs and therapists to participate. Sharing research findings, effectiveness, and case studies can help healthcare professionals see the value of iFD Tool and make them confident in recommending it to their patients.
This section explores the transferability of iFD Tool and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publicly available data; and 3) additional considerations for policymakers interested in transferring iFD Tool.
Previous transfers
iFD Tool was originally developed within the EU-funded project Preventing Depression and Improving Awareness through Networking in the EU (PREDI-NU). As part of the PREDI-NU project, iFD Tool was implemented in five European pilot regions from Hungary, Estonia, Ireland, Spain and Germany. It has then been successfully transferred and implemented in eight European countries, including Bulgaria, Estonia, Greece, Hungary, Ireland, Italy, Poland and Spain, as part of the EU-funded EAAD-Best project which commenced in 2021. This project was managed by a consortium of 10 partners, including the EAAD and ended in 2024.
Furthermore, as part of the EU-funded Mental Health Support for Ukrainian Refugees (MESUR) project, which ran from 2022 to November 2024, the iFD Tool was culturally adapted and translated into Ukrainian and Russian to support displaced Ukrainians. Additionally, new workshops were specifically developed to provide mental health support to displaced Ukrainians across six EU countries: Bulgaria, Germany, Greece, Estonia, Hungary and Poland. In 2024, the iFD Tool was available in 16 languages and the website in 21 languages.
Transferability assessment
This section outlines the methodological framework to assess transferability followed by analysis results.
Methodological framework
A few indicators to assess the transferability of iFD Tool were identified (see Table 4.3). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.
Results
Results from the transferability assessment using publicly available data are summarised below (see Table 4.4 for results at the country level):
In terms of access to mental health care, 10.9% of the German population reported consulting mental health care or rehabilitative care professionals, compared to around 6% on average across OECD countries. Germany performs well in the Healthcare Access and Quality Index, with a rate higher than the OECD average. More than two‑thirds of OECD countries have a score over 80%.
The analysis shows that the number of psychologists is higher in at least 13 countries, with Germany having 0.5 psychologists for 1 000 inhabitants. In terms of digital literacy, 52% of the German population has at least basic digital skills, compared to 58% in OECD countries on average.
Spending on prevention across OECD countries is typically lower than in Germany, with more than four in five countries presenting lower rates. Likewise, the country’s expenditure on primary healthcare exceeds the OECD average, standing at 1.6% of the total country GDP.
Like most countries, Germany has policies or programmes for mental health promotion, prevention and treatment in primary healthcare, as well as for integrating digital technologies and tools into mental health service delivery, and policies that enable self-care and self-management for people experiencing mental health conditions. A majority of countries have a strategy or action plan to guide implementation of mental health policies, suggesting higher potential for transfer. Germany does not have such a strategy, indicating this is not a prerequisite for the transfer of iFD Tool.
A darker shade indicates iFightDepression® is more suitable for transferral in that particular country
Note: n/a = no available data. The shades of blue represent the distance each country is from the country in which the intervention currently operates, with a darker shade indicating greater transfer potential based on that particular indicator (see Annex A for further methodological details). The full names and details of the indicators can be found in Table 4.3.
Source: Eurostat (n.d.[19]), Share of individuals having at least basic digital skills (%), https://ec.europa.eu/eurostat/databrowser/view/sdg_04_70/default/table; Eurostat (2022[20]), “Self-reported consultation of mental healthcare or rehabilitative care professionals by sex, age and educational attainment level”, https://doi.org/10.2908/HLTH_EHIS_AM6E; OECD (2021[18]), A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health, https://doi.org/10.1787/4ed890f6-en; IHME (2017[21]), Global Burden of Disease Study 2015 (GBD 2015) Healthcare Access and Quality Index Based on Amenable Mortality 1990-2015, https://ghdx.healthdata.org/record/ihme-data/gbd-2015-healthcare-access-and-quality-index-1990-2015; OECD/WHO Regional Office for Europe (2023[22]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to enable mental health promotion, prevention and treatment of mental health conditions in primary health care.
OECD/WHO Regional Office for Europe (2023[23]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes for integrating digital technologies and tools into mental health service delivery; OECD/WHO Regional Office for Europe (2023[24]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes for enabling self-care and self-management for people experiencing mental health conditions; OECD/WHO Regional Office for Europe (2023[25]), Mental Health Systems Capacity Questionnaire 2023 - Strategy or action plan that guide implementation of the mental health policy, OECD, (2024[26]), OECD Data Explorer - Primary health care expenditure as a percentage of GDP; OECD (2019[9]), OECD Data Explorer - Prevention spending as a percentage of GDP.
To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 4.3. Countries in clusters with more positive values have the greatest transfer potential. While this analysis provides a high-level overview assuming some simplifications, it is important to note that countries in lower-scoring clusters may also have the capacity to adopt the intervention successfully. For further details on the methodological approach used, please refer to Annex A.
Key findings from each of the clusters are below with further details in Figure 4.3 and Table 4.5:
Countries in cluster one, including Germany, have population, sector specific, economic and political arrangements in place to transfer iFD Tool. Overall, these countries are less likely to experience issues associated with implementing and operating the programme in their local context. This group includes 22 countries.
Countries in cluster two have political arrangements to support iFD Tool. Prior to transferring the intervention, however, these countries may wish to consider ensuring that the sector is ready to implement the programme and ensure long-term affordability by increasing preventive and primary healthcare expenditure. This group includes 11 countries.
Remaining countries are in cluster three. These should consider whether the intervention aligns with political priorities and might benefit from undertaking further analyses to ensure iFD Tool is affordable and feasible within existing healthcare infrastructures. This group includes nine countries.
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: OECD analysis.
Note: Due to high levels of missing data, the following country was omitted from the analysis: Canada.
Source: OECD analysis.
New indicators to assess transferability
Data from publicly available datasets alone is not ideal to assess the transferability of public health interventions. Box 4.4 outlines several new indicators policymakers could consider before transferring iFD Tool.
In addition to the indicators within the transferability assessment, policymakers are encouraged to collect information for the following indicators:
Population context
What is the population attitude towards internet-based mental health support?
What is the level of health literacy in the population?
Sector specific context
What is professional’s attitude (GP, therapists) towards internet-based support?
What are the main barriers to engage and recruit GP and therapists?
Political context
Has the intervention received political support from key decision makers?
Has the intervention received financial commitment from key decision makers?
iFD Tool is a web-based intervention for people with mild-to-moderate depression based on the principles of CBT. The tool is designed to help people self-manage their symptoms of depression and promote faster recovery, with support from a GP or mental health professional. The tool is free‑of-charge for users and has been translated into 16 languages.
iFD Tool has been effective in reducing depressive symptoms at six weeks and three months compared to an active control group, and significantly reduced the duration of depressive episodes. Using the SPHeP-NCD model, it is estimated that transferring iFD Tool to all OECD and EU countries would be cost-effective in most countries and cost saving in three countries.
The iFD Tool was originally developed as part of the PREDI-NU project and has since been successfully implemented in nine European countries through the EU-funded EAAD-Best project which ran from 2021 to 2024. By 2024, it was available in 16 languages and utilised in 12 countries, including Albania, Bulgaria, Estonia, Germany, Greece, Hungary, Ireland, Italy, Norway, Poland, Spain and Türkiye. OECD analysis shows that iFD Tool is highly transferable to more than 50% of OECD and EU countries with available data (22 out of 42 countries), and intermediately transferable to 11 countries.
Next steps for policymakers and funding agencies to enhance iFD Tool are listed below:
Increase the availability of iFD Tool, ensuring its access to underserved populations.
Raise awareness of iFD Tool among healthcare professionals, potential users, and the general public.
Provide funding for training programmes to equip GPs, therapists, and other healthcare providers with the skills to guide patients in using iFD Tool effectively.
References
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[20] Eurostat (2022), Self-reported consultation of mental healthcare or rehabilitative care professionals by sex, age and educational attainment level, https://doi.org/10.2908/HLTH_EHIS_AM6E.
[19] Eurostat (n.d.), Share of individuals having at least basic digital skills (%), https://ec.europa.eu/eurostat/databrowser/view/sdg_04_70/default/table.
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[9] OECD (2019), Health for Everyone?: Social Inequalities in Health and Health Systems, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/3c8385d0-en.
[24] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes for enabling self-care and self-management for people experiencing mental health conditions.
[23] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes for integrating digital technologies and tools into mental health service delivery.
[22] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to enable mental health promotion, prevention and treatment of mental health conditions in primary health care.
[25] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Strategy or action plan that guide implementation of the mental health policy..
[11] Oehler, C. et al. (2019), “Efficacy of an internet-based self-management intervention for depression or dysthymia - A study protocol of an RCT using an active control condition”, BMC Psychiatry, Vol. 19/1, pp. 1-12, https://doi.org/10.1186/S12888-019-2063-1/TABLES/3.
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[17] WHO (2024), Policies and programmes to improve mental health awareness and literacy.
[28] Xiao, C., Y. Goryakin and M. Cecchini (2019), “Physical Activity Levels and New Public Transit: A Systematic Review and Meta-analysis”, American Journal of Preventive Medicine, Vol. 56/3, pp. 464-473, https://doi.org/10.1016/j.amepre.2018.10.022.
The effectiveness of iFD Tool was evaluated using data from a randomised controlled trial (RCT) (Oehler et al., 2020[5]) and using a Difference‑in-Difference (DiD) analysis to estimate the relative impact of iFD compared to an active control group. The IDS-SR was used as the primary outcome measure (range 0‑84) to assess changes in depression severity. The RCT showed that IDS-SR mean scores decreased from 27.5 to 19.3 in the iFD group, compared to 27.9 to 22 in the active control group from baseline to three month follow up. Using a DiD estimation, iFD Tool was significantly more effective than the active control in reducing symptoms of depression with a change by ‑8.4% (CI: [‑16.4%; ‑0.4%]) in depression score at three months.
A DiD analysis was used to measure the change in IDS-SR score over time for the iFD group relative to the active control group while accounting for baseline differences and trends unrelated to the intervention. The study included both the iFD and the active control group with before‑and-after research design:
) – ()
Where is the mean score in the iFD group at three months, the mean score in the iFD group at baseline, is the mean score in the active control group at three months, and the mean score in the active control group at baseline.
The standard error (SE) of the DiD estimator was calculated following the methods detailed in Xiao et al. (2019[28]) and using the formula:
Where is the estimate of the pooled standard deviation (SD) of the iFD and active control groups.
Where is the sample size of the iFD group and is the sample size of the active control group.
The time to maximum effectiveness for iFD Tool was assumed to be three months (Oehler et al., 2020[5]), with the effect increasing linearly from baseline to its maximum level during this period. Following this, the effect was assumed to decrease linearly, returning to baseline levels at six months.
The target population for iFD include individuals aged 15 years and older with a PHQ‑9 score from 5 to 14 (mild to moderate severity of depression).
It was assumed that 80% of the target population would visit a general practitioner (GP) at least once per year (OECD, 2019[9]). Of those, 10% of GPs were assumed to agree to participate in iFD Tool, based on hypothetical assumption. Among patients attending participating GPs, 14% were assumed to undertake the intervention, according to data provided by the iFD owner. This results in an estimated 1.12% of the target population being exposed to the programme (80%*10%*14%= 1.12%).
The majority of the cost of iFD Tool are covered by the EU-funded EEAD-Best project. Countries who want to implement iFD Tool are responsible for ongoing costs, including administration, training and medical counselling:
Cost of administration: estimated at EUR 13 640 annually in Germany, corresponding to 0.3 full-time equivalent workers. Based on an average of 1 618 users per year, this results in an administrative cost of EUR 8 per treated patient.
Training cost: Based on the 2022 average national wage in Germany (EUR 45 457 per year or EUR 21.9 per hour), the cost of a 90‑minute face‑to-face session is estimated at EUR 31.80. With 30 participants per session, the cost per participant is EUR 1.10. Based on data from Germany, it is assumed that 78% of professionals complete the online E‑learning training, while 22% attend the face‑to-face sessions. This results in an estimated average training cost of EUR 0.24 per participant.
Medical counselling: Estimated at six minutes of a GP’s time per patient to introduce the tool.