ReviewEfficacy and acceptability of group cognitive behavioral therapy for depression: A systematic review and meta-analysis
Introduction
Depression has a significant impact on individuals and society due to its high prevalence, early-age onset, and high persistence (Kessler, 2012, Murray et al., 2012, Okumura and Higuchi, 2011). Depression is nearly twice as prevalent in individuals with chronic physical health problems as in those without (Kessler, 2012, Okumura and Ito, 2013). Regardless of comorbid physical illness, the treatment guidelines advocate a stepped care model to guide the management of depression (National Institute for Health and Clinical Excellence, 2009b, National Institute for Health and Clinical Excellence, 2009a). In the stepped care model, patients with mild to moderate depression start with low-intensity psychosocial interventions, such as computerized cognitive behavioral therapy (CBT), guided self-help, and physical activity programs. If a patient does not benefit from low-intensity interventions, they are stepped-up to high-intensity interventions, such as medications and/or face-to-face individual psychotherapies. The aim of the stepped care model is to maximize the effectiveness of an intervention considering limited medical resources.
Group CBT is an appealing psychological intervention given its potential cost- and time-effectiveness for treating many patients (Tucker and Oei, 2007). In the stepped care model, group CBT is placed between low-intensity and high-intensity interventions (National Institute for Health and Clinical Excellence, 2009a). Given the duration and staffing of such groups, group CBT for patients with mild depression is viewed as less cost-effective than low-intensity psychosocial interventions and as more cost-effective than individual CBT (National Institute for Health and Clinical Excellence, 2009a). This placement of group CBT, however, is not validated in the stepped care model because relevant data on comparative efficacy and acceptability are lacking.
Recent meta-analyses of randomized controlled trials (RCTs) have revealed the efficacy of group CBT for depression (Cuijpers et al., 2009, Feng et al., 2012, Huntley et al., 2012, Krishna et al., 2013, Krishna et al., 2011). However, there was no distinction between the use of non-active controls, low-intensity, middle-intensity (a term we coined to refer to group-based psychosocial interventions), and high-intensity interventions as comparators in any of these studies. In addition, little attention has been given to acceptability of group CBT (Krishna et al., 2011). Furthermore, two of the meta-analyses focused exclusively on patients aged 50 years or older (Krishna et al., 2013, Krishna et al., 2011) and one of the meta-analyses focused only on a specific protocol of group CBT (Cuijpers et al., 2009). Finally, one of the meta-analyses had questionable validity because they defined some trials of individual CBT as group CBT (Feng et al., 2012).
In the present study, we aimed to systematically review evidence for the efficacy and acceptability of group CBT in patients with depression compared to four intensity levels of psychosocial interventions: non-active, low-intensity, middle-intensity, and high-intensity interventions.
Section snippets
Types of studies
Randomized controlled trials (RCTs), cluster RCTs, and quasi-RCTs were eligible for inclusion in the review. A trial was considered quasi-RCT when treatment allocation was decided through methods such as alternate days of the week. Single group studies and non-randomized studies were excluded.
Types of participants
We included participants aged 18 years or older with depression assessed by standardized clinical interviews, standardized self-report questionnaires, or physicians׳ diagnoses. Our operational definitions
Study selection
Of the 7953 records retrieved from the electronic search, 40 articles were potentially eligible (Fig. 1). Five articles were excluded because they were supplemental studies (Allart-van Dam et al., 2007, Geschwind et al., 2012, Mergl et al., 2011, Peden et al., 2005, Spek et al., 2008). Thirty-five studies met the inclusion criteria (n=3356). One studies did not report sufficient data to calculate effect size (Klausner et al., 1998); therefore, 34 studies were retained for quantitative synthesis
Discussion
This review included 35 studies that examined the efficacy and acceptability of group CBT in patients with depression compared to four intensity levels of psychosocial interventions. Our review showed group CBT had a superior efficacy (SMD=−0.68, 95% CI [−0.83, −0.54]) and a similar acceptability (RR=1.05, 95% CI [0.81, 1.36]) compared to non-active controls. The efficacy on the HAM-D was 2.5 points better in group CBT than in non-active controls; and thus the mean difference almost meets
Limitations
Our review has three important limitations. First, the 35 studies included had several methodological limitations. In particular, over 60% of studies did not report enough information to make judgment about selection bias and selective outcome reporting bias. Second, articles not written in English and published before 1993 were not included in this review, although we conducted the systematic search strategies across four databases. Third, definitions of group CBT varied across studies; most
Conclusion
In conclusion, we found substantial evidence that group CBT has a superior efficacy compared to non-active treatments and a similar acceptability. There was insufficient evidence to conclude whether group CBT has a superior efficacy and a similar acceptability compared to low-intensity or high-intensity interventions. This review highlights the need for enhancing reporting and methodological quality of trials that compare group CBT with low-intensity and high-intensity interventions, to
Role of funding source
Funding for analyzing and writing this article was supported by a Grant-in-Aid for Young Scientists (B) (No.: 23730688) by the Japan Society for the Promotion of Science.
Conflict of interest
None.
Acknowledgments
We would like to thank Drs. Ann Peden, David Hellerstein, Douglas Nance, Geschwind Nicole, Lisa Samstag, Mary Rayens, Roland Mergl, and, Ulrich Hegerl for providing us with unpublished data.
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