Different CBT Formats Shown to Be as Effective as Individual CBT

Cognitive-behavioral therapy (CBT) is effective for patients with depression, but not everyone has access to individual, face-to-face CBT. Other formats of CBT are available, including group sessions, telephone-based CBT, and self-help modules that people can do at home (either with some guidance from a professional or on their own). A meta-analysis published in JAMA Psychiatry suggests that these different modalities are equally effective. The one exception was unguided self-help CBT, which was slightly less effective at treating depression than the other formats, likely due to a lack of human interaction.

Pim Cuijpers, Ph.D., a professor of clinical psychology at Vrije University in Amsterdam, and colleagues used a network meta-analysis to compare 155 clinical trials (which included more than 15,000 participants) involving five common formats of CBT for the treatment of depression. A network meta-analysis uses multiple direct and indirect comparisons to stratify different treatments; for example, if one study compares A and B, a second A and C, and a third B and C, then a network analysis can analyze these to rank A, B, and C in some order.

The researchers compared two outcomes of these trials. The first was effectiveness (how well these therapies improve depressive symptoms), and the second was acceptability (how favorably participants view the CBT format). The latter is important since low acceptability increases the risk of patients dropping out of treatment.

The analysis showed that individual, group, guided self-help, and telephone-based CBT were similarly effective, and more effective than unguided self-help CBT.

Individual, group, telephone, and unguided self-help CBT had similar levels of acceptability, while guided self-help CBT was considered less acceptable than the other formats.

“It is not clear why the acceptability of guided self-help CBT was lower compared with that of the other formats,” Cuijpers and colleagues wrote. “Maybe the absence of direct contact with a professional makes it easier to stop the treatment because there is less personal-relationship pressure to continue with the treatment or the study. However, lower acceptability would then also be expected to happen in unguided CBT, which we did not find. More research is needed to examine this issue.”

“These findings make sense since other research has shown that you need to provide some level of human guidance to get the most out of these therapies,” said Bruce Rollman, M.D., director of the Center for Behavioral Health and Smart Technology at the University of Pittsburgh Medical Center. Rollman was not involved in this meta-analysis.

Human guidance does not have to come strictly from an expert, added Rollman. He believes it’s just important that human interaction be included to keep patients engaged with therapy. He recently completed a study demonstrating that an online CBT program called Beating the Blues was effective at improving depression and anxiety compared with usual primary care. Beating the Blues is a guided, self-help program with guidance from college graduates who have minimal psychotherapy experience. “They just had good empathy and communication skills,” he said.

Rollman also was encouraged that telephone-based CBT proved as effective as other formats. While there is a movement to increase video-based, telepsychiatry, the use of video is difficult in poor, rural communities. Finding that CBT can be effectively delivered via a mobile phone or landline will ensure these communities have some means of receiving evidence-based mental health care.

The authors reported no funding information for this study. ■