Results of a network meta-analysis indicated that group, telephone-administered and guided self-help — both internet-based and not — cognitive behavioral therapy formats were comparatively effective for depression that could be alternatives to individual CBT.
“It is still not clear whether all treatment formats in CBT have comparable effects. Conventional meta-analyses can only compare two formats in one analysis,” Pim Cuijpers, PhD, professor and head of the department of clinical, neuro and developmental psychology, Vrije Universiteit Amsterdam, told Healio Psychiatry. “By using network meta-analyses all formats can be examined in one large analyses, in which all available evidence (direct and indirect) is used. That has never been done before.”
To determine the most effective delivery format for CBT, the researchers searched relevant clinical databases for randomized clinical trials of CBT for adult depression then compared the five treatment formats with each other and the control conditions (waiting list, care as usual and placebo). For each treatment format, they measured depression severity and acceptability. They conducted pairwise and network meta-analyses and pooled data using a random-effects model.
Overall, 155 trials encompassing 15,191 participants compared the five CBT delivery formats with two control conditions. In half of the studies, patients had a depressive disorder; while in the other half, participants scored above the cutoff point on a self-report measure for depression.
Cuijpers and colleagues found no statistically significant difference in effectiveness between individual, group, telephone and guided self-help CBT for depression. However, all formats were more effective than the unguided self-help CBT (standardized mean difference [SMD] = 0.34-0.59), the waiting list control (SMD = 0.87-1.02) and care as usual control (SMD = 0.47-0.72) conditions.
When evaluating the acceptability of the treatment formats, the investigators found that both individual (RR = 1.44; 95% CI, 1.09-1.89) and group (RR = 1.38; 95% CI, 1.06-1.8) CBT, as well as waiting list (RR = 0.63; 95% CI, 0.52-0.75) and care as usual (RR = 0.72; 95% CI, 0.57-0.9), were better than guided self-help. The overall findings were confirmed with sensitivity analyses.
“The effects of guided self-help are comparable to those of other formats, but acceptability is somewhat lower than in other formats, so that should be carefully monitored when guided self-help is used,” Cuijpers said. “When no professional support is given, the effects of self-help are either small or non-existing.”
Though the differences were small, individual, group, telephone and guided self-help were ranked as the best CBT formats, according to the results. Telephone CBT had the highest ranking for acceptability.
“The most important take home message for clinicians is that CBT does not necessarily have to be delivered in an individual treatment format, but that it can also effectively be delivered in groups, through the telephone, or through guided self-help,” Cuijpers told Healio Psychiatry.
For the future, direct comparative effectiveness studies are needed to help researchers understand which treatment modality is best, and to identify moderators of differential effectiveness and predictors of long-term outcomes, Holly A. Swartz, MD, and Jay Fournier, PhD, from the University of Pittsburgh School of Medicine, wrote in a related editorial.
“In the meantime, patients, clinicians and payers will benefit from insights provided by this study, including provisional support for the hypothesis that all CBT formats are efficacious treatments for adult depression as long as human interaction is involved,” Swartz and Fournier wrote. – by Savannah Demko
Disclosures: Cuijpers reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Swartz and Fournier report numerous disclosures, please see the editorial.