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Original Investigation
April 17, 2019

Effectiveness and Acceptability of Cognitive Behavior Therapy Delivery Formats in Adults With Depression: A Network Meta-analysis

Author Affiliations
  • 1Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, the Netherlands
  • 2Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
  • 3Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
  • 4Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
  • 5Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine, School of Public Health, Kyoto, Japan
JAMA Psychiatry. 2019;76(7):700-707. doi:10.1001/jamapsychiatry.2019.0268
Key Points

Question  Which cognitive behavior therapy delivery format is most effective and acceptable for the treatment of acute depression?

Findings  In this network meta-analysis of 155 trials involving 15 191 patients, no statistically significant differences in effectiveness were found among individual, group, telephone, and guided self-help treatment formats, although acceptability may be somewhat lower for guided self-help format. Unguided self-help therapy was not more effective than care as usual.

Meaning  For acute symptoms of depression, group, telephone-administered, and guided self-help (internet-based or not) cognitive behavior therapy appeared to be effective and may be considered as alternatives to individual therapy.


Importance  Cognitive behavior therapy (CBT) has been shown to be effective in the treatment of acute depression. However, whether CBT can be effectively delivered in individual, group, telephone-administered, guided self-help, and unguided self-help formats remains unclear.

Objective  To examine the most effective delivery format for CBT via a network meta-analysis.

Data Sources  A database updated yearly from PubMed, PsycINFO, Embase, and the Cochrane Library. Literature search dates encompassed January 1, 1966, to January 1, 2018.

Study Selection  Randomized clinical trials of CBT for adult depression. The 5 treatment formats were compared with each other and the control conditions (waiting list, care as usual, and pill placebo).

Data Extraction and Synthesis  PRISMA guidelines were used when extracting data and assessing data quality. Data were pooled using a random-effects model. Pairwise and network meta-analyses were conducted.

Main Outcomes and Measures  Severity of depression and acceptability of the treatment formats.

Results  A total of 155 trials with 15 191 participants compared 5 CBT delivery formats with 2 control conditions. In half of the studies (78 [50.3%]), patients met the criteria for a depressive disorder; in the other half (77 [49.7%]), participants scored above the cutoff point on a self-report measure. The effectiveness of individual, group, telephone, and guided self-help CBT did not differ statistically significantly from each other. These formats were statistically significantly more effective than the waiting list (standardized mean differences [SMDs], 0.87-1.02) and care as usual (SMDs, 0.47-0.72) control conditions as well as the unguided self-help CBT (SMDs, 0.34-0.59). In terms of acceptability (dropout for any reason), individual (relative risk [RR] = 1.44; 95% CI, 1.09-1.89) and group (RR = 1.38; 95% CI, 1.06-1.80) CBT were significantly better than guided self-help. Guided self-help was also less acceptable than being on a waiting list (RR = 0.63; 95% CI, 0.52-0.75) and care as usual (RR = 0.72; 95% CI, 0.57-0.90). Sensitivity analyses supported the overall findings.

Conclusions and Relevance  For acute symptoms of depression, group, telephone, and guided self-help treatment formats appeared to be effective interventions, which may be considered as alternatives to individual CBT; although there were few indications of significant differences in efficacy between treatments with human support, guided self-help CBT may be less acceptable for patients than individual, group, or telephone formats.