Guided internet-based CBT more effective for depression than unguided form

Guided internet-based cognitive behavioral therapy was more effective among individuals with depression than its unguided form, according to results of a systematic review and network meta-analysis published in JAMA Psychiatry.

“Psychological interventions, such as cognitive behavioral therapy (CBT), are increasingly delivered over the internet (iCBT),” Eirini Karyotaki, PhD, of the department of global health and social medicine at Harvard Medical School, and colleagues wrote. “These interventions can be delivered either with or without therapeutic support, usually termed guided and unguided iCBT. Unguided iCBT is more scalable and affordable, but previous studies have shown that guidance generally results in better outcomes.”

Prior studies largely reported iCBT’s group average effects, which gave little insight into patient attributes that may differentiate outcomes, the researchers noted. In the current study, they aimed to used patient-level information to put forth personalized estimates and short- and long-term relative efficacy of guided and unguided iCBT for depression. They searched four databases for randomized clinical trials published up to January 1, 2019, and included those that compared guided or unguided iCBT with each other or any control intervention among individuals with depression. Further, the researchers collected available individual patient data (IPD) from all eligible studies and assessed depression symptom severity after treatment, 6 months and 12 months after random assignment. They conducted a systematic review and IPD network meta-analysis, and they used IPD network meta-regression to estimate relative treatment effect sizes across various patient characteristics. Main outcomes and measures were Patient Health Questionnaire-9 (PHQ-9) scores.

In the network meta-analysis, the researchers included IPD of 9,751 participants with depression, of which 8,107 IPD were synthesized. Results showed an association between both guided and unguided iCBT and more effectiveness per PHQ-9 scores vs. control treatments over the short term and the long term. Although guided iCBT was linked to more effectiveness than unguided iCBT, the researchers did not find evidence of a difference at 6 or 12 months following random assignment. They noted that baseline depression was the most important modifier of the relative association for efficacy of guided vs. unguided iCBT. Among people with baseline symptoms of subthreshold depression, differences between the two forms were small; however, guided iCBT was linked to overall better outcomes among patients with baseline PHQ-9 greater than nine.

“Personalized treatment selection is possible and very much needed, as one size does not fit all,” Karyotaki and colleagues wrote. “Shared clinical decision-making should involve the patients’ values and preferences, history and any previous or concurrent treatments so as to provide the best and most suitable intervention while maximizing human resources available.”