From the Editor

“It changed my life.”

A few years ago, a patient described to me how helpful cognitive behavioural therapy was for him. CBT wasn’t his only treatment – he had a couple of medication trials – but he found the psychotherapy to be very helpful.

Others have had a similar experience, but CBT isn’t widely available in Canada; Puyat et al. found in a Canadian Journal of Psychiatry paper that the vast majority of people with depression don’t receive any form of psychotherapy or counseling. How can we address this access gap? Could different forms of CBT work including those that are less resource intensive? What to make of self-help?

In this Reading, we consider a new paper by Vrije Universiteit Amsterdam’s Pim Cuijpers and his co-authors that seeks to answer these questions. They use a network meta-analysis to compare five treatment formats with each other and control conditions (waiting list, care as usual, and pill placebo). Their conclusion: “This study suggests that group, telephone, and guided self-help treatments are effective interventions that may be considered as alternatives to individual CBT.”

dr-aaron-beck-at-work-595048284-5af62b4dae9ab80036aca7faAaron Beck: How to deliver the CBT he has championed (and should we all wear a bow tie)?

In this Reading, we consider the big paper and its big result, and the accompanying editorial by the University of Pittsburgh’s Dr. Holly A. Swartz and Jay Fournier.



CBT and Effectiveness and Acceptability

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

Pim Cuijpers, Hisashi Noma, Eirini Karyotaki, Andrea Cipriani, Toshi A. Furukawa

JAMA Psychiatry, 17 April 2019  Online First

Randomized clinical trials have shown that cognitive behavior therapy (CBT) is effective in treating depression and at least as effective as any other type of psychotherapy. Although CBT was developed as an individual therapy, it is also available as a group, telephone-administered, and self-help therapy in which patients work through a standardized protocol independently. The protocol can be in book format or available on the internet. Self-help therapy can either be guided (ie, involving a professional therapist) or unguided (ie, providing no professional guidance to the patient using the materials).

Many meta-analyses have examined these CBT delivery formats. Overall, the effects of individual, group, telephone-administered, and guided self-help (internet based or not) formats seem to be comparable in magnitude to the control conditions, whereas the unguided self-help format seems to make a small but substantial difference and to be less effective than the individual, group, telephone, and guided self-help formats.

However, conventional pairwise meta-analyses can only compare 2 treatment formats at a time, and only through network meta-analysis can we examine all formats simultaneously in a single analysis. Because network meta-analysis can combine direct and indirect evidence, it can assess the relative effectiveness of the different CBT delivery formats. To date, no previous network meta-analysis has examined these treatment formats.

pimkuipersklein-jpgPim Cuijpers

So begins a paper by Cuijpers et al.

Here’s what they did:

  • They drew on randomized clinical trials examining psychological treatment of depression, doing a literature search of PubMed, PsycINFO, Embase, and the Cochrane Library (from January 1, 1966, to January 1, 2018) using index and text words.
  • “We included studies in which CBT was examined in the following formats: individual, group, telephone, guided self-help (administered through the internet or other media, such as a book), and unguided self-help (internet-based or not). For the control groups, we included waiting list, care as usual, and pill placebo.”
  • Exclusion criteria included anxiety, inpatients, and substance use disorders.
  • Outcome measures included the Beck Depression Inventory I and II, and the Patient Health Questionnaire 9.
  • Statistical analyses were conducted, including pairwise and network meta-analyses.

Here’s what they found:

  • They examined 19 982 abstracts and retrieved 2343 full-text papers for further consideration.
  • “In total, 155 studies with 15 191 patients met the inclusion criteria.”
  • “The 155 studies included 57 individual, 45 group, 46 guided self-help, 10 telephone, and 21 unguided self-help arms as well as 71 waiting list, 71 care as usual, and 2 pill placebo arms.”
  • Network plot: see the figure below.
  • “Overall, the network was well connected. The most examined comparisons were between individual, group, and guided self-help formats as well as the waiting list and care as usual control conditions.”
  • Ranking: see figure below.




The results of this network meta-analysis suggest that individual, group, telephone-administered, and guided self-help (internet-based or not) treatment formats have comparable effectiveness in the treatment of depression and that the effectiveness does not differ statistically significantly across formats. The effect sizes of these treatment formats compared with the care as usual control condition were moderate or large when compared with the waiting list control condition. Although guided self-help CBT was as effective as individual, group, and telephone CBT, it was less acceptable as the other formats. This finding was statistically significant when guided self-help was compared with individual and group CBT.


A few thoughts:

  1. This is a good paper.
  1. This is an important paper.
  1. This is a practical paper. As we look to expand access, Cuijpers et al. provide a path forward. They conclude: “Applying effective and acceptable CBT in a range of different formats will make CBT easier to implement, disseminate, and deliver across different settings and diverse patient populations.”
  1. The paper runs with a thoughtful editorial written by the University of Pittsburgh’s Dr. Holly A. Swartz and Jay Fournier, “Can Network Meta-analysis Substitute for Direct Comparisons in Psychotherapy Trials?”

They note the larger problems with access:

Although many could potentially benefit from psychotherapy, too few receive it. Only one-third of affected individuals receive care for depression, and less than one-third of those receive psychotherapy. Despite its efficacy and desirability, individual psychotherapy, which traditionally is provided weekly by highly trained clinicians, appears to be impractical for many. Multiple factors likely contribute to the inability of patients with depression to access psychotherapies, but investigators have identified structural barriers, such as costs, transportation difficulties, and time constraints, as primary impediments to receipt of psychological services. To address these barriers, efforts have been made to make psychotherapies more efficient, less dependent on face-to-face sessions, and more accessible to patients. Therapies have moved from reliance on therapists in brick-and-mortar clinics to remote delivery systems, self-help models, and group-based care. Preliminary evidence suggests that these novel delivery systems work well, but no one is sure whether they are as good as the traditional psychotherapies they have been designed to replace.

holly-swartz_2Holly A. Swartz

Dr. Swartz and Fournier summarize the findings:

This finding is consistent with other reports suggesting that individuals with depression benefit more from psychotherapy when there is at least a modicum of human interaction. Group and remote delivery of CBT appear to work as well as face-to-face therapy – unless they are completely stripped of their humanity.

  1. What to make of the fact that this is a network analysis? Dr. Swartz and Fournier write:

One of the key findings of this work is the graphical depiction showing just how little direct comparative evidence has been collected to date… In lieu of this evidence, Cuijpers et al harness information contained in extant CBT trials and conduct a network meta-analysis (NMA) examining the relative effects of individual, group, telephone, GSH (internet based or not), and USH for adults with depression. Network meta-analysis methods use both direct comparisons of interventions from randomized clinical trials and indirect comparisons across trials based on shared common comparators, thereby permitting a series of contrasts between modalities within the same analysis. But the quality of the evidence from such models is constrained by the maturity of the field to which they are applied and the sparsity of the direct comparisons available in the network. The authors recognize this, of course, and declare low or very low confidence in two-thirds of the comparisons reported.

Well said.

The editorial can be found here:

  1. It’s reasonable then to find these results helpful, but not definitive.
  1. This selection is very different from last week’s, Dr. Doidge’s essay on public funding for psychotherapy (including psychoanalysis). But in some ways, these two selections and the conversations that they spark represent two sides of the same coin – consideration of how we organize and fund mental-health services for our patients.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.