Effectiveness and Acceptability of Cognitive Behavior Therapy Delivery Formats in Adults With Depression: A Network Meta-analysis | Depressive Disorders | JAMA Psychiatry | JAMA Network
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Barth  J, Munder  T, Gerger  H,  et al.  Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis.  PLoS Med. 2013;10(5):e1001454. doi:10.1371/journal.pmed.1001454PubMedGoogle ScholarCrossref
Cuijpers  P, Berking  M, Andersson  G, Quigley  L, Kleiboer  A, Dobson  KS.  A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments.  Can J Psychiatry. 2013;58(7):376-385. doi:10.1177/070674371305800702PubMedGoogle ScholarCrossref
Cuijpers  P, van Straten  A, Andersson  G, van Oppen  P.  Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies.  J Consult Clin Psychol. 2008;76(6):909-922. doi:10.1037/a0013075PubMedGoogle ScholarCrossref
Beck  AT, Rush  AJ, Shaw  BF, Emery  G.  Cognitive Therapy of Depression. New York, NY: The Guilford Press; 1979.
Feng  C-Y, Chu  H, Chen  C-H,  et al.  The effect of cognitive behavioral group therapy for depression: a meta-analysis 2000-2010.  Worldviews Evid Based Nurs. 2012;9(1):2-17. doi:10.1111/j.1741-6787.2011.00229.xPubMedGoogle ScholarCrossref
Huntley  AL, Araya  R, Salisbury  C.  Group psychological therapies for depression in the community: systematic review and meta-analysis.  Br J Psychiatry. 2012;200(3):184-190. doi:10.1192/bjp.bp.111.092049PubMedGoogle ScholarCrossref
Okumura  Y, Ichikura  K.  Efficacy and acceptability of group cognitive behavioral therapy for depression: a systematic review and meta-analysis.  J Affect Disord. 2014;164:155-164. doi:10.1016/j.jad.2014.04.023PubMedGoogle ScholarCrossref
Andersson  G, Cuijpers  P.  Internet-based and other computerized psychological treatments for adult depression: a meta-analysis.  Cogn Behav Ther. 2009;38(4):196-205. doi:10.1080/16506070903318960PubMedGoogle ScholarCrossref
Karyotaki  E, Riper  H, Twisk  J,  et al.  Efficacy of self-guided internet-based cognitive behavioral therapy in the treatment of depressive symptoms: a meta-analysis of individual participant data.  JAMA Psychiatry. 2017;74(4):351-359. doi:10.1001/jamapsychiatry.2017.0044PubMedGoogle ScholarCrossref
Cuijpers  P, van Straten  A, Warmerdam  L.  Are individual and group treatments equally effective in the treatment of depression in adults? a meta-analysis.  Eur J Psychiatry. 2008;22(1):38-51. doi:10.4321/S0213-61632008000100005Google ScholarCrossref
Burlingame  GM, Seebeck  JD, Janis  RA,  et al.  Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: a 25-year meta-analytic perspective.  Psychotherapy (Chic). 2016;53(4):446-461. doi:10.1037/pst0000090PubMedGoogle ScholarCrossref
Cuijpers  P, Donker  T, van Straten  A, Li  J, Andersson  G.  Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? a systematic review and meta-analysis of comparative outcome studies.  Psychol Med. 2010;40(12):1943-1957. doi:10.1017/S0033291710000772PubMedGoogle ScholarCrossref
Andersson  G, Cuijpers  P, Carlbring  P, Riper  H, Hedman  E.  Guided internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis.  World Psychiatry. 2014;13(3):288-295. doi:10.1002/wps.20151PubMedGoogle ScholarCrossref
Carlbring  P, Andersson  G, Cuijpers  P, Riper  H, Hedman-Lagerlöf  E.  Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis.  Cogn Behav Ther. 2018;47(1):1-18. doi:10.1080/16506073.2017.1401115PubMedGoogle ScholarCrossref
Higgins  JPT, Altman  DG, Gøtzsche  PC,  et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group.  The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.  BMJ. 2011;343:d5928. doi:10.1136/bmj.d5928PubMedGoogle ScholarCrossref
Hamilton  M.  A rating scale for depression.  J Neurol Neurosurg Psychiatry. 1960;23(1):56-62. doi:10.1136/jnnp.23.1.56PubMedGoogle ScholarCrossref
Beck  AT, Ward  CH, Mendelson  M, Mock  J, Erbaugh  J.  An inventory for measuring depression.  Arch Gen Psychiatry. 1961;4(6):561-571. doi:10.1001/archpsyc.1961.01710120031004PubMedGoogle ScholarCrossref
Beck  AT, Steer  RA, Brown  GK.  BDI-II. Beck Depression Inventory. 2nd ed. San Antonio, TX: Psychological Corporation; 1996.
Kroenke  K, Spitzer  RL, Williams  JBW.  The PHQ-9: validity of a brief depression severity measure.  J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.xPubMedGoogle ScholarCrossref
Radloff  LS.  The CES-D scale: a self-report depression scale for research in the general population.  Appl Psychol Meas. 1977;1(3):385-401. doi:10.1177/014662167700100306Google ScholarCrossref
Zigmond  AS, Snaith  RP.  The Hospital Anxiety and Depression Scale.  Acta Psychiatr Scand. 1983;67(6):361-370. doi:10.1111/j.1600-0447.1983.tb09716.xPubMedGoogle ScholarCrossref
Cipriani  A, Furukawa  TA, Salanti  G,  et al.  Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis.  Lancet. 2018;391(10128):1357-1366. doi:10.1016/S0140-6736(17)32802-7PubMedGoogle ScholarCrossref
Ioannidis  JPA, Patsopoulos  NA, Evangelou  E.  Uncertainty in heterogeneity estimates in meta-analyses.  BMJ. 2007;335(7626):914-916. doi:10.1136/bmj.39343.408449.80PubMedGoogle ScholarCrossref
Orsini  N, Bottai  M, Higgins  J, Buchan  I. Heterogi: Stata module to quantify heterogeneity in a meta-analysis. Statistical Software Components. https://ideas.repec.org/c/boc/bocode/s449201.html. Revised January 25, 2006. Accessed March 14, 2019.
Hutton  B, Salanti  G, Caldwell  DM,  et al.  The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.  Ann Intern Med. 2015;162(11):777-784. doi:10.7326/M14-2385PubMedGoogle ScholarCrossref
Salanti  G, Higgins  JP, Ades  AE, Ioannidis  JP.  Evaluation of networks of randomized trials.  Stat Methods Med Res. 2008;17(3):279-301. doi:10.1177/0962280207080643PubMedGoogle ScholarCrossref
Salanti  G.  Indirect and mixed-treatment comparison, network, or multiple-treatments meta-analysis: many names, many benefits, many concerns for the next generation evidence synthesis tool.  Res Synth Methods. 2012;3(2):80-97. doi:10.1002/jrsm.1037PubMedGoogle ScholarCrossref
Chaimani  A, Higgins  JP, Mavridis  D, Spyridonos  P, Salanti  G.  Graphical tools for network meta-analysis in STATA.  PLoS One. 2013;8(10):e76654. doi:10.1371/journal.pone.0076654PubMedGoogle ScholarCrossref
Higgins  JPT, Jackson  D, Barrett  JK, Lu  G, Ades  AE, White  IR.  Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies.  Res Synth Methods. 2012;3(2):98-110. doi:10.1002/jrsm.1044PubMedGoogle ScholarCrossref
Salanti  G, Del Giovane  C, Chaimani  A, Caldwell  DM, Higgins  JP.  Evaluating the quality of evidence from a network meta-analysis.  PLoS One. 2014;9(7):e99682. doi:10.1371/journal.pone.0099682PubMedGoogle ScholarCrossref
CINeMA [computer program]. Version 1.4.1. http://cinema.ispm.ch/. Accessed October 10, 2018.
Gilbody  S, Littlewood  E, Hewitt  C,  et al; REEACT Team.  Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial.  BMJ. 2015;351:h5627. doi:10.1136/bmj.h5627PubMedGoogle ScholarCrossref
Vernmark  K, Lenndin  J, Bjärehed  J,  et al.  Internet administered guided self-help versus individualized e-mail therapy: a randomized trial of two versions of CBT for major depression.  Behav Res Ther. 2010;48(5):368-376. doi:10.1016/j.brat.2010.01.005PubMedGoogle ScholarCrossref
Chaimani  A, Salanti  G, Leucht  S, Geddes  JR, Cipriani  A.  Common pitfalls and mistakes in the set-up, analysis and interpretation of results in network meta-analysis: what clinicians should look for in a published article.  Evid Based Ment Health. 2017;20(3):88-94. doi:10.1136/eb-2017-102753PubMedGoogle ScholarCrossref
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.