The e-CBT care plan consists of 12 weekly sessions of approximately 30 slides and interactive content delivered through OPTT (refer to Multimedia Appendix 1 for the sample module). The e-CBT module content mirrors in-person CBT content, including different weekly topics, general information, skill overviews, and homework. The efficacy of the therapeutic content has previously been tested through email administration and has been shown to reduce depressive symptoms significantly [32]. Participants are instructed to go through the content and complete homework at the end of the session, which helps them practice the skills they learned through that session. Homework is submitted through OPTT and reviewed by the therapist assigned to the participant, who will provide personalized feedback within 3 days of submission. Therapists have access to predesigned session-specific feedback templates to use as a basic structure to write their feedback. By doing so, the time needed to respond to each patient is reduced, and therefore, the number of patients each therapist can handle increases. At the same time, by using a structured format in responding to patients, more standardized quality of care can be ensured. The general structure of the feedback template is as follows: validating the participant’s time and effort, reviewing the event they have used in their homework, summarizing the previous module’s content, and discussing the participant’s homework submission and how they could improve it. In addition to these points, the feedback will emphasize specific content from the participant’s submission, reassuring them that their therapist is reading and understanding their challenges. All feedback submissions are finished with a personalized signature from the therapist, helping to develop a rapport between the therapist and the participant. On average, developing this feedback takes a therapist 15 to 20 minutes per patient. In addition to the weekly feedback, participants have the option to message their therapist through the platform throughout the week regarding any questions or concerns they may have. All technical issues are handled directly by OPTT’s technical support team.

Participants in the in-person CBT group will attend weekly sessions at Hotel Dieu Hospital (12 weeks), where they will receive standardized individual (one-on-one) CBT for MDD from a trained therapist. All content covered and skills taught will mirror the e-CBT program. Similar to the e-CBT group, participants will be assigned weekly homework assignments that they will complete during the week and hand over at the start of their next session. At this time, participants will receive personalized feedback from their therapist for their previous week’s homework.

At the end of the study, a few participants and health care providers (ie, 8 participants and 2 providers) will be recruited for focus groups. The focus group prompts will pertain to experience and expectations of service during the study and how they think the service could be improved.

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