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J Med Internet Res. 2010 Dec 19;12(5):e57. doi: 10.2196/jmir.1450.

The ins and outs of an online bipolar education program: a study of program attrition.

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  • 1School of Psychiatry, University of New South Wales and Black Dog Institute, Sydney, Australia.



The science of eHealth interventions is rapidly evolving. However, despite positive outcomes, evaluations of eHealth applications have thus far failed to explain the high attrition rates that are associated with some eHealth programs. Patient adherence remains an issue, and the science of attrition is still in its infancy. To our knowledge, there has been no in-depth qualitative study aimed at identifying the reasons for nonadherence to-and attrition from- online interventions.


This paper explores the predictors of attrition and participant-reported reasons for nonadherence to an online psycho-education program for people newly diagnosed with a bipolar disorder.


As part of an ongoing randomized controlled trial (RCT) evaluating an online psycho-education program for people newly diagnosed with a bipolar disorder, we undertook an in-depth qualitative study to identify participants' reasons for nonadherence to, and attrition from, the online intervention as well as a quantitative study investigating predictors of attrition. Within the RCT, 370 participants were randomly allocated to 1 of 2 active interventions or an attention control condition. Descriptive analyses and chi-square tests were used to explore the completion rates of 358 participants, and standard regression analysis was used to identify predictors of attrition. The data from interviews with a subsample of 39 participants who did not complete the online program were analyzed using "thematic analysis" to identify patterns in reported reasons for attrition.


Overall, 26.5% of the sample did not complete their assigned intervention. Standard multiple regression analysis revealed that young age (P= .004), male gender (P= .001), and clinical recruitment setting (P= .001) were significant predictors of attrition (F(7,330)= 8.08, P< .001). Thematic analysis of interview data from the noncompleter subsample revealed that difficulties associated with the acute phases of bipolar disorder, not wanting to think about one's illness, and program factors such as the information being too general and not personally tailored were the major reasons for nonadherence.


The dropout rate was equivalent to other Internet interventions and to face-to-face therapy. Findings from our qualitative study provide participant-reported reasons for discontinuing the online intervention, which, in conjunction with the quantitative investigations about predictors, add to understanding about Internet interventions. However, further research is needed to determine whether there are systematic differences between those who complete and those who do not complete eHealth interventions. Ultimately, this may lead to the identification of population subgroups that most benefit from eHealth interventions and to informing the development of strategies to improve adherence.


ACTRN12608000411347; (Archived by WebCite at

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