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Group, Phone and Guided Self-help CBT Seem Effective for Depression

April 24, 2019

By Marilynn Larkin

NEW YORK—For individuals with acute symptoms of depression, effective alternatives to individual cognitive behavior therapy (CBT) include group, telephone and guided self-help formats, researchers say.

"Previous research suggested that all treatment formats have comparable effects, but this evidence was all scattered," Dr. Pim Cuijpers of Vrije Universiteit Amsterdam told Reuters Health by email. "By getting it together in one big network meta-analysis, we bring all the direct and indirect evidence together. Now we are much more certain about treatment formats."

Dr. Cuijpers and colleagues analyzed randomized clinical trials from 1966-2018 on CBT for adult depression. Studies compared five different treatment formats - individual, group, telephone, guided self-help, and unguided self-help - with each other and with control conditions (wait list, care as usual).

As reported online April 17 in JAMA Psychiatry, 155 trials with 15,191 participants were included in the meta-analysis. Patients met the criteria for depressive disorder after a diagnostic interview in half the studies; for the other half, participants scored above the cutoff point for depression on a self-report measure.

With regard to risk of bias, 39.4% of studies met all the quality criteria, 37.4% met two or three criteria, and the rest (23.2%) met one or none. Among the comparisons, certainty of evidence was moderate for individual compared with guided self-help CBT and for guided self-help compared with telephone CBT. However, it was low for the comparisons between individual CBT and usual-care controls; group and guided self-help CBT; and telephone CBT and waiting list or usual care.

The effectiveness of individual, group, telephone, and guided self-help CBT did not differ significantly from each other; however, these formats were significantly more effective than the waiting list (standardized mean differences, 0.87-1.02) and care as usual (SMDs, 0.47-0.72), as well as unguided self-help CBT (SMDs, 0.34-0.59).

With respect to acceptability (dropout for any reason), individual (relative risk = 1.44) and group (RR = 1.38) CBT were significantly better than guided self-help.

Guided self-help was also less acceptable to participants than being on a waiting list (RR = 0.63) and care as usual (RR = 0.72). Three sensitivity analyses - one including only studies with low risk of bias, one excluding outliers, and one including only internet-based guided and unguided self-help - supported the overall findings.

Dr. Holly Swartz of the University of Pittsburgh School of Medicine, coauthor of an editorial published with the network meta-analysis (NMA), commented by email, "Psychotherapy is an effective treatment for depression but too few people receive it. Little is known about whether therapy modalities that overcome barriers to care (i.e., remote delivery, technology-enabled delivery) are as good as gold standard, face-to-face, individual psychotherapy."

"In the absence of information from direct comparisons of psychotherapy modalities, an NMA is a useful tool for comparing information across trials--with the caveat that the conclusions drawn will be limited by the quality of the data on which the NMA is based," she told Reuters Health. "For this study, the authors had low confidence in most comparisons used for the NMA, which means that caution must be used when interpreting these findings."

"Nevertheless, the NMA suggests that...CBT works across delivery systems as long as human contact is involved," she said. "This hypothesis should be best tested in prospective, randomized controlled trials."

"Given the great public health burden related to untreated depression, many of us hoped that technology would solve the problem of lack of access to evidence-based psychotherapy, and at a fraction of the cost of face-to-face interventions," she added. "This NMA suggests that the non-specific factors that are provided in the context of a human relationship make a difference in terms of CBT effectiveness and acceptability. Although technology extends the reach of CBT, it does not take the place of human support."


JAMA Psychiatry 2019.

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