The process and delivery of CBT for depression in adults: a systematic review and network meta-analysis

Abstract

Cognitive-behavioural therapy (CBT) is an effective treatment for depressed adults. CBT interventions are complex, as they include multiple content components and can be delivered in different ways. We compared the effectiveness of different types of therapy, different components and combinations of components and aspects of delivery used in CBT interventions for adult depression. We conducted a systematic review of randomised controlled trials in adults with a primary diagnosis of depression, which included a CBT intervention. Outcomes were pooled using a component-level network meta-analysis. Our primary analysis classified interventions according to the type of therapy and delivery mode. We also fitted more advanced models to examine the effectiveness of each content component or combination of components. We included 91 studies and found strong evidence that CBT interventions yielded a larger short-term decrease in depression scores compared to treatment-as-usual, with a standardised difference in mean change of -1.11 (95% credible interval -1.62 to -0.60) for face-to-face CBT, -1.06 (-2.05 to -0.08) for hybrid CBT, and -0.59 (-1.20 to 0.02) for multimedia CBT, whereas wait list control showed a detrimental effect of 0.72 (0.09 to 1.35). We found no evidence of specific effects of any content components or combinations of components. Technology is increasingly used in the context of CBT interventions for depression. Multimedia and hybrid CBT might be as effective as face-to-face CBT, although results need to be interpreted cautiously. The effectiveness of specific combinations of content components and delivery formats remain unclear. Wait list controls should be avoided if possible.

Keywords: Cognitive-behavioural therapy; depression; multimedia; network meta-analysis; systematic review.

Fig. 1.

Flow chart of the systematic review process.

Fig. 2.

Network plots (panels a–c) and NMA results (panels d–f) for depression at short term, depression at mid term, and quality of life at short term (Therapy Effects model), respectively. Intervention effects are standardised differences in mean change from baseline, relative to TAU. (a) Network plot for depression at short term. (b) NMA results for depression at short term. (c) Network plot for depression at mid term. (d) NMA results for depression at mid term. (e) Network plot for quality of life at short term. (f) NMA results for quality of life at short term. TAU, treatment as usual; F2F CBT, face-to-face cognitive behavioural therapy; sDIMC, standardised difference in mean change; CrI, credible interval.

Fig. 3.

Network plots (panels a–c) and NMA results (panels d–f) for remission, response, and attrition at short term (Therapy Effects model), respectively. Intervention effects are odds ratios relative to TAU. (a) Network plot for remission at short term. (b) NMA results for remission at short term. (c) Network plot for response at short term. (d) NMA results for response at short term. (e) Network plot for attrition at short term. (f) NMA results for attrition at short term. TAU, treatment as usual; F2F CBT, face-to-face cognitive behavioural therapy; OR, odds ratio; CrI, credible interval.

Fig. 4.

Component-level NMA results for depression at short term (Main Effects model). Therapy effects for No treatment, Wait list, Placebo, and CBT are standardised differences in mean change from baseline, relative to TAU. Main effects for the CBT effect are interpreted as the additional effects for CBT interventions that contain that effect modifier (adjusted for all other effect modifiers). TAU, treatment as usual; CBT, cognitive behavioural therapy; sDIMC, standardised difference in mean change; CrI, credible interval.