It has been projected that depression will be the leading cause of disease burden in 2030 . Lifetime prevalence of depression is high  and depressive episodes are frequently persistent and recurrent . Moreover, only a minority of people with depression receive evidence-based treatment .
It is likely that the undertreatment of depression is due in part to lack of availability and accessibility of services , an unwillingness to seek help due to the stigma associated with depression  and a preference among some people with depression for employing self help methods for coping with the condition. One potential means for increasing treatment coverage and reducing burden is to facilitate the large scale dissemination of self help methods which reduce the need for the health workforce involvement and circumvent the stigma associated with seeking face-to-face help.
There is some evidence that self help interventions delivered online can be effective in reducing depressive symptoms . In particular, a number of studies have reported a reduction in depressive symptoms associated with the use of automated online programs in the absence of clinical input (e.g., [8–14]). Online programs have also been demonstrated to reduce the stigma associated with depression [15, 16] and to increase mental health literacy among people with elevated depressive symptoms [8, 17]. Less is known about the effect of these programs on other factors such as empowerment, quality of life, self esteem, disability, and service use. Further, although a frequently cited advantage of online psychological applications is their potential for use with under-served rural populations  there have been no direct comparative studies of the acceptability and effectiveness of these programs in rural compared to metropolitan regions .
Research into the effectiveness of online interventions for depression has been focused primarily on applications designed to deliver psychological skills training. However, the widespread availability of the Internet has stimulated the development of a large number of online 'mutual support' or 'self help support' groups. Such support groups have been estimated by Eysenbach to be used by 'millions' of consumers daily  and there is evidence that they are particularly popular among consumers with depression . However, the efficacy of such Internet support groups (ISGs) has not been established.
A recent systematic review of depression ISGs identified no randomised controlled trials of the effectiveness of the groups, for individuals with depression, in reducing depressive symptoms or in improving other psychological, mental health, service-related or other outcomes . However, there was some evidence that peer-to-peer support groups might be associated with a reduction in depressive symptoms. In particular, in a prospective cohort study, Houston  reported a reduction over 6 months in depressive symptoms among high frequency users of public internet support groups after controlling for initial severity of symptoms. In addition, a systematic review of efficacy trials of ISGs for consumers with a range of health conditions yielded some encouraging evidence that such ISGs may be effective in reducing depressive symptoms among women with breast cancer .
It is possible however, that the primary effect of depression support groups is on outcomes other than symptomatology. For example, it is often claimed that support groups increase consumer empowerment and social support [23, 24]. However, to date there have been no quantitative studies of the effect of depression ISGs on outcomes such as empowerment, self esteem, social support, quality of life or other factors such as depression knowledge and help seeking.
One potential limitation of fully automated online programs is the likelihood of substantial dropout during their unguided use . Automated messages and reminders might reduce attrition rates in such circumstances . It has also possible that participation in an ISG might facilitate adherence to online applications. Indeed, many online chronic disease management programs employ ISGs (e.g., see ). However, to our knowledge, to date there have been no systematic studies of the effect of online peer-to-peer support groups on adherence or outcomes among consumers receiving internet applications.
A final limitation of available research is that the majority of randomised controlled studies of e-mental health programs have employed wait list control groups . A small number of studies have employed an attention control group or a psychoeducational controls. However, these studies have some limitations. For example, Christensen and her collaborators used a telephone attention control but the control group did not receive an internet intervention [8, 9, 15]. Some studies have used an online psychoeducational website as a control (e.g., [28–30]). However, a recent meta-analysis demonstrated that the provision of mental health information may reduce depressive symptoms among adults with depression or depressive symptoms . To date no study of the efficacy of e-mental health intervention has employed an attention control condition which both comprised a website and contained plausible content not containing depressive or anxiety psychoeducational information.
Objectives of the ANU WellBeing study
The primary objectives of the study are to (i) evaluate the efficacy of a depression Internet Support Group (ISG) and an automated psychoeducational and skills Internet Training Program (ITP) for reducing depressive symptoms relative to a plausible Internet Attention Control condition (IAC); to evaluate the relative efficacy of the ITP, ISG and combined ITP and ISG interventions; and (iii) to ascertain if the adherence rates and magnitude of improvement in depressive symptoms is greater for the ISG and ITP interventions combined than for either condition alone.
Secondary objectives of the study are to (i) evaluate the effect of the two experimental interventions on anxiety, disability, social support, loneliness, self-esteem, empowerment, loneliness, depression literacy, stigma and help seeking in people with elevated depressive sympotms; and (ii) to compare the outcomes of these interventions in rural and metropolitan residents.