A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review
- PMID: 38188230
- PMCID: PMC10771715
- DOI: 10.1002/cl2.1376
A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review
Abstract
Background: Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.
Objectives: The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).
Search methods: The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.
Selection criteria: Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.
Data collection and analysis: Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.
Main results: Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.
Authors' conclusions: At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.
© 2024 The Authors. Campbell Systematic Reviews published by John Wiley & Sons Ltd on behalf of The Campbell Collaboration.
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Vuthiarpa 2012 {published data only}
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- * Vuthiarpa, S. , Sethabouppha, H. , Soivong, P. , & Williams, R. (2012). Effectiveness of a school‐based cognitive behavioral therapy program for Thai adolescents with depressive symptoms. Pacific Rim International Journal of Nursing Research, 16(3), 206–221.
Wijnhoven 2014 {published data only}
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- * Wijnhoven, L. A. M. W. , Creemers, D. H. M. , Vermulst, A. A. , Scholte, R. H. J. , & Engels, R. C. M. E. (2014). Randomized controlled trial testing the effectiveness of a depression prevention program (‘Op Volle Kracht’) among adolescent girls with elevated depressive symptoms. Journal of Abnormal Child Psychology, 42(2), 217–228. - PubMed
Woods 2011 {published data only}
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- * Woods, B. , & Jose, P. E. (2011). Effectiveness of a school‐based indicated early intervention program for Maori and Pacific adolescents. Journal of Pacific Rim Psychology, 5(1), 40–50.
Wright 2019 {published data only}
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- Wright, B. , Tindall, L. , Littlewood, E. , Adamson, J. , Allgar, V. , Bennett, S. , Gilbody, S. , Verduyn, C. , Alderson‐Day, B. , Dyson, L. , Trepel, D. , & Ali, S. (2014). Computerised cognitive behaviour therapy for depression in adolescents: Study protocol for a feasibility randomised controlled trial. BMJ Open, 4, e006488. - PMC - PubMed
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Bass 2006 {published data only}
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- * Bass, J. , Neugebauer, R. , Clougherty, K. F. , Verdeli, H. , Wickramaratne, P. , Ndogoni, L. , Speelman, L. , Weissman, M. , & Bolton, P. (2006). Group interpersonal psychotherapy for depression in rural Uganda: 6‐month outcomes: Randomised controlled trial. British Journal of Psychiatry, 188(JUNE), 567–573. - PubMed
Beattie 2009 {published data only}
Bedoya 2014 {published data only}
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- * Bedoya, C. A. , Traeger, L. , Trinh, N. H. , Chang, T. E. , Brill, C. D. , Hails, K. , Hagan, P. N. , Flaherty, K. , & Yeung, A. (2014). Impact of a culturally focused psychiatric consultation on depressive symptoms among Latinos in primary care. Psychiatric Services, 65(10), 1256–1262. - PubMed
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Bernal 2005 {published data only}
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- * Brent, D. A. , Roth, C. M. , Holder, D. P. , Kolko, D. J. , Birmaher, B. , Johnson, B. A. , & Schweers, J. A. (1996). Psychosocial interventions for treating adolescent suicidal depression: A comparison of three psychosocial interventions. In Hibbs E. D., & Jensen P. S. (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 187–206). American Psychological Association. 10.1037/10196-008 - DOI
Brent 1997a {published data only}
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- * Brent, D. (1997). A clinical trial comparing three psychotherapies for adolescent depression: Differential efficacy and predictors of outcome. In WPA Thematic Conference. Jerusalem.
Brent 1998 {published data only}
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- * Brent, D. A. , Kolko, D. J. , Birmaher, B. , Baugher, M. , Bridge, J. , Roth, C. , & Holder, D. (1998). Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. Journal of the Academy of Child and Adolescent Psychiatry, 37(9), 906–914. - PubMed
Brent 1999 {published data only}
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- * Brent, D. A. , Kolko, D. J. , Birmaher, B. , Baugher, M. , & Bridge, J. (1999). A clinical trial for adolescent depression: Predictors of additional treatment in the acute and follow‐up phases of the trial. Journal of the Academy of Child and Adolescent Psychiatiry, 38(3), 263–270. - PubMed
Brent 2015 {published data only}
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- * Brent, D. A. , Brunwasser, S. M. , Hollon, S. D. , Weersing, V. R. , Clarke, G. N. , Dickerson, J. F. , Beardslee, W. R. , Gladstone, T. R. G. , Porta, G. , Lynch, F. L. , Iyengar, S. , & Garber, J. (2015). Effect of a cognitive‐behavioral prevention program on depression 6 years after implementation among at‐risk adolescents: A randomized clinical trial. JAMA Psychiatry, 72(11), 1110–1118. - PMC - PubMed
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Brière 2016 {published data only}
Browning 2011 {published data only}
Bruijniks 2015 {published data only}
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Burns 2014 {published data only}
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Buszewicz 2010 {published data only}
Butler 1980 {published data only}
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Cabiya 2008 {published data only}
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Calear 2009 {published data only}
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- * Calear, A. L. , Christensen, H. , Mackinnon, A. , Griffiths, K. M. , & O'Kearney, R. (2009). The YouthMood project: A cluster randomized controlled trial of an online cognitive behavioral program with adolescents. Journal of Consulting and Clinical Psychology, 77(6), 1021. - PubMed
Calear 2013 {published data only}
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- * Calear, A. L. , Christensen, H. , Mackinnon, A. , & Griffiths, K. M. (2013). Adherence to the MoodGYM program: Outcomes and predictors for an adolescent school‐based population. Journal of Affective Disorders, 147(1–3), 338–344. - PubMed
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Carta 2012 {published data only}
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- * Carta, M. G. , Petretto, D. , Adamo, S. , Bhat, K. M. , Lecca, M. E. , Mura, G. , Carta, V. , Angermeyer, M. , & Moro, M. F. (2012). Counseling in primary care improves depression and quality of life. Clinical Practice and Epidemiology in Mental Health, 8, 152–157. 10.2174/1745017901208010152 - DOI - PMC - PubMed
Carty 2001 {published data only}
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- * Carty, J. A. (2001). An examination of the relative effectiveness of three cognitive behavioral group treatments for depression in an Australian treatment‐resistant population [thesis]. Dissertation Abstracts International, 62(1–B), 539.
Cavanagh 2006 {published data only}
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- * Cavanagh, K. , Shapiro, D. A. , Van Den Berg, S. , Swain, S. , Barkham, M. , & Proudfoot, J. (2006). The effectiveness of computerized cognitive behavioural therapy in routine care. British Journal of Clinical Psychology, 45(4), 499–514. - PubMed
Cavanagh 2011 {published data only}
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- * Cavanagh, K. , Seccombe, N. , & Lidbetter, N. (2011). The implementation of computerized cognitive behavioural therapies in a service user‐led, third sector self help clinic. Behavioural and Cognitive Psychotherapy, 39(4), 427–442. - PubMed
Chan 2015 {published data only}
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- * Chan, S. W. , Lau, J. Y. , & Reynolds, S. A. (2015). Is cognitive bias modification training truly beneficial for adolescents? Journal of Child Psychology and Psychiatry, 56(11), 1239–1248. - PubMed
Chaplin 2006 {published data only}
Chen 2015 {published data only}
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- * Chen, Y. L. , Pan, A. W. , Hsiung, P. C. , Chung, L. , Lai, J. S. , Shur‐Fen Gau, S. , & Chen, T. J. (2015). Life adaptation skills training (LAST) for persons with depression: A randomized controlled study. Journal of Affective Disorders, 185, 108–114. - PubMed
Chen 2018 {published data only}
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- * Chen, C. Y. (2018). A study of group intervention on depression in urban college students. Basic and Clincal Pharmacology and Toxicology, 122(Supplment 2), 17–18.
ChiCTR1900023145 {unpublished data only}
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- *ChiCTR1900023145 . Evaluation of a prevention program for depression among high school adolescent in mainland china: A cluster randomized controlled trial. Retrieved 13 May 2019. http://www.chictr.org.cn/showproj.aspx?proj=39002
Chirita 2006 {published data only}
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- * Chirita, V. , Ilinca, M. , Chirita, R. , Bisca, M. , & Chele, G. (2006). Virtual therapy in patients with depression. Preliminary observation. Annual Review of CyberTherapy and Telemedicine, 4, 181–185.
Christensen 2004 {published data only}
Christensen 2006 {published data only}
Christensen 2013 {published data only}
Chu 2016 {published data only}
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- * Chu, B. C. , Crocco, S. T. , Esseling, P. , Areizaga, M. J. , Lindner, A. M. , & Skriner, L. C. (2016). Transdiagnostic group behavioral activation and exposure therapy for youth anxiety and depression: Initial randomized controlled trial. Behaviour Research and Therapy, 76, 65–75. - PubMed
Clarke 1992 {published data only}
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- * Clarke, G. , Hops, H. , Lewinsohn, P. M. , Andrews, J. , Seeley, J. R. , & Williams, J. (1992). Cognitive‐behavioral group treatment of adolescent depression: Prediction of outcome. Behavior Therapy, 23(3), 341–354.
Clarke 2001a {published data only}
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- * Clarke, G. (2001). Cognitive‐behavioral treatment and prevention of adolescent depression. In 154th Annual Meeting of the American Psychiatric Association May 5–10. New Orleans, LA, 22F.
Clarke 2005 {published data only}
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- * Clarke, G. , DeBar, L. , Lynch, F. , Powell, J. , Gale, J. , O'Connor, E. , Ludman, E. , Bush, T. , Lin, E. H. B. , Von Korff, M. , & Hertert, S. (2005). A randomized effectiveness trial of brief cognitive‐behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9), 888–898. - PubMed
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Clarke 2014 {published data only}
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- * Clarke, J. , Proudfoot, J. , Birch, M. R. , Whitton, A. E. , Parker, G. , Manicavasagar, V. , Harrison, V. , Christensen, H. , & Hadzi‐Pavlovic, D. (2014). Effects of mental health self‐efficacy on outcomes of a mobile phone and web intervention for mild‐to‐moderate depression, anxiety and stress: Secondary analysis of a randomised controlled trial. BMC Psychiatry, 14(1), 272. - PMC - PubMed
Coats 1982 {published data only}
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- * Coats Kevin, I. (1982). An experimental investigation of a cognitive‐behavioural treatment for depression with adolescents. The University of Wisconsin – Madison.
Collado 2016 {published data only}
Compas 2011 {published data only}
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- * Compas, B. E. , Forehand, R. , Thigpen, J. C. , Keller, G. , Hardcastle, E. J. , Cole, D. A. , Potts, J. , Watson, K. H. , Rakow, A. , Colletti, C. , Reeslund, K. , Fear, J. , Garai, E. , McKee, L. , Merchant, M. J. , & Roberts, L. (2011). Family group cognitive‐behavioral preventive intervention for families of depressed parents: 18‐ and 24‐month outcomes. Journal of Consulting and Clinical Psychology, 79(4), 488–499. - PMC - PubMed
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- * Compas, B. E. , Forehand, R. , Thigpen, J. , Hardcastle, E. , Garai, E. , McKee, L. , Keller, G. , Dunbar, J. P. , Watson, K. H. , Rakow, A. , Bettis, A. , Reising, M. , Cole, D. , & Sterba, S. (2015). Efficacy and moderators of a family group cognitive‐behavioral preventive intervention for children of parents with depression. Journal of Consulting and Clinical Psychology, 83(3), 541–553. - PMC - PubMed
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- * Cook, L. , & Watkins, E. (2016). Guided, internet‐based, rumination‐focused cognitive behavioural therapy (i‐RFCBT) versus a no‐intervention control to prevent depression in high‐ruminating young adults, along with an adjunct assessment of the feasibility of unguided i‐RFCBT, in the REducing Stress and Preventing Depression trial (RESPOND): Study protocol for a phase III randomised controlled trial. Trials, 17(1), 1–11. - PMC - PubMed
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- *CTRI/2012/10/003043 . To develop and evaluate computer assisted cognitive behavior therapy compared to treatment as usual on adolescents with depression. Retrieved 5 October 2012. http://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=4840
Curry 2006 {published data only}
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- * Curry, J. , Rohde, P. , Simons, A. , Silva, S. , Vitiello, B. , Kratochvil, C. , Reinecke, M. , Feeny, N. , Wells, K. , Pathak, S. , Weller, E. , Rosenberg, D. , Kennard, B. , Robins, M. , Ginsburg, G. , & March, J. (2006). Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). Journal of the American Academy of Child and Adolescent Psychiatry, 45(12), 1427–1439. - PubMed
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- Curry, J. , Silva, S. , Rohde, P. , Ginsburg, G. , Kratochvil, C. , Simons, A. , Kirchner, J. , May, D. , Kennard, B. , Mayes, T. , Feeny, N. , Albano, A. M. , Lavanier, S. , Reinecke, M. , Jacobs, R. , Becker‐Weidman, E. , Weller, E. , Emslie, G. , Walkup, J. , Kastelic, E. , Burns, B. , Wells, K. , & March, J. (2011). Recovery and recurrence following treatment for adolescent major depression. Archives of General Psychiatry, 68(3), 263–269. - PMC - PubMed
Dana 1998 {published data only}
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David 2018 {published data only}
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- * David, O. A. , Cardos, R. A. I. , & Matu, S. (2019). Changes in irrational beliefs are responsible for the efficacy of the REThink therapeutic game in preventing emotional disorders in children and adolescents: Mechanisms of change analysis of a randomized clinical trial. European Child & Adolescent Psychiatry, 28(3), 307–318. - PubMed
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- * David, O. A. , Cardoș, R. A. I. , & Matu, S. (2019). Is REThink therapeutic game effective in preventing emotional disorders in children and adolescents? Outcomes of a randomized clinical trial. European Child & Adolescent Psychiatry, 28(1), 111–122. - PubMed
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- * Dear, B. F. , Fogliati, V. J. , Fogliati, R. , Johnson, B. , Boyle, O. , Karin, E. , Gandy, M. , Kayrouz, R. , Staples, L. G. , & Titov, N. (2018). Treating anxiety and depression in young adults: A randomised controlled trial comparing clinician‐guided versus self‐guided Internet‐delivered cognitive behavioural therapy. Australian and New Zealand Journal of Psychiatry, 52(7), 668–679. - PubMed
de Graaf 2009 {published data only}
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- * de Graaf, L. E. , Gerhards, S. A. , Arntz, A. , Riper, H. , Metsemakers, J. F. , Evers, S. M. , Severens, J. L. , Widdershoven, G. , & Huibers, M. J. (2009). Clinical effectiveness of online computerised cognitive‐behavioural therapy without support for depression in primary care: Randomised trial. British Journal of Psychiatry, 195(1), 73–80. - PubMed
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- * de Graaf, L. E. , Hollon, S. D. , & Huibers, M. J. H. (2010). Predicting outcome in computerized cognitive behavioral therapy for depression in primary care: A randomized trial. Journal of Consulting and Clincial Psychology, 78(2), 184–189. - PubMed
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Dietz 2014 {published data only}
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Donker 2013 {published data only}
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Gladstone 2020 {published data only}
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REFERENCES TO STUDIES AWAITING ASSESSMENT
Demir 2019 {published data only}
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- * Demir, S. (2019). Cognitive behavioral therapy‐based group counseling (CBTBGC). ClinicalTrials.gov Identifier: NCT04192721.
NCT04111887 {published data only}
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- *NCT04111887 . Pilot study comparing two versions of group cognitive‐behavioral indicated prevention programs. Retrieved 1 October 2019. https://clinicaltrials.gov/ct2/show/NCT04111887
NCT04117789 {published data only}
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- *NCT04117789 . Feasibility of internet‐delivered cbt for adolescents with depression. Retrieved 7 October 2019. https://clinicaltrials.gov/ct2/show/NCT04117789
NCT04192721 {published data only}
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- *NCT04192721 . Cognitive behavioral therapy‐based group counseling. Retrieved 10 December 2019. https://clinicaltrials.gov/ct2/show/NCT04192721
Oregon Research Institute 2018 {published data only}
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- *Oregon Research Institute . (2018). Pilot study comparing two versions of group cognitive‐behavioral indicated prevention programs. ClinicalTrials.gov Identifier: NCT04111887.
Salamanca‐Sanabria 2018 {published data only}
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- * Salamanca‐Sanabria, A. , Richards, D. , Timulak, L. , Castro‐Camacho, L. , Mojica‐Perilla, M. , & Parra‐Villa, Y. (2018). Assessing the efficacy of a culturally adapted cognitive behavioural internetdelivered treatment for depression: Protocol for a randomised controlled trial. BMC Psychiatry, 18, 53. 10.1186/s12888-018-1634-x - DOI - PMC - PubMed
Yokomitsu 2020 {published data only}
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- * Yokomitsu, K. , Tomonari, I. , Sekiguchi, M. , Shimizu, A. , Matsuoka, H. , Merry, S. N. , & Stasiak, K. (2020). Gamified mobile computerized cognitive behavioral therapy for Japanese university students with depressive symptoms: Protocol for a randomized controlled trial. JMIR Research Protocols, 9(4), e15164. 10.2196/15164 - DOI - PMC - PubMed
REFERENCES TO ONGOING STUDIES
Baldofski 2019 {unpublished data only}
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- * Baldofski, S. , Kohls, E. , Bauer, S. , Becker, K. , Bilic, S. , Eschenbeck, H. , Kaess, M. , Moessner, M. , Salize, H. J. , Diestelkamp, S. , Vob, E. , Rummel‐Kluge, C. , & the ProHEAD consortium . (2019). Efficacy and cost‐effectiveness of two online interventions for children and adolescents at risk for depression (E.motion trial): Study protocol for a randomized controlled trial within the ProHEAD consortium. Trials, 20, 53. 10.1186/s13063-018-3156-8 - DOI - PMC - PubMed
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- DRKS00014668 . ProHEAD – Promoting Help‐seeking using E‐technology for Adolescents. Sub‐project 4: Efficacy and cost‐effectiveness of two online interventions for children and adolescents at risk for depression [ProHEAD – Promoting Help‐seeking using E‐technology for Adolescents. Sub‐project 4: Efficacy and cost‐effectiveness of two online interventions for children and adolescents at risk for depression – E.motion trial]. Retrieved 4 May 2018. http://www.drks.de/DRKS00014668
IRCT20160404027216N7 {unpublished data only}
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- *IRCT20160404027216N7 . Effect of Cognitive‐Behavior Therapy on the prevention of depression [The Effect of Cognitive‐Behavior Therapy on the prevention of depression in nursing students]. Retrieved 8 December 2018. http://en.irct.ir/trial/33315
IRCT20171231038158N1 {published data only}
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- *IRCT20171231038158N1 . A comparative study on the efficacy of a positive cognitive‐behavioral therapy and a cognitive behavioral therapy, in depression, subjective well‐being, resiliency, self‐efficacy and self‐esteem for adolescences with depression signs. Retrieved 11 January 2018. https://en.irct.ir/trial/28734
ADDITIONAL REFERENCES
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