Monday January 21 2013
Cognitive behavioural therapy uses a problem-solving approach
“Prescribing self-help books on the NHS is an effective treatment for depression” BBC News has reported.
The news is based on the results of a randomised controlled trial (RCT) that compared the effectiveness of a self-help book, read in conjunction with support sessions, to normal care for the treatment of depression in Glasgow.
The self-help book was based on the principles of cognitive behavioural therapy (CBT) which is a well-established ‘talking therapy’ for depression.
CBT is based on the principle that you can help manage your problems by changing the way you think and behave.
There is a wide range of good-quality evidence that CBT can benefit people with depression, including this RCT from 2012.
However, access to trained therapists can be limited, so identifying DIY-like approaches to depression treatment could be extremely useful.
The trial found that people assigned to the group using self-help books had significantly greater improvements in their depression than people who received normal care.
This trial has the advantage that it was performed in a community setting, with participants recruited from GP surgeries, mimicking a “real-life” setting.
However, it should be noted that participants with symptoms of depression as well as also having symptoms of impaired concentration and / or motivation were excluded from the study.
This may have lead to some people with significant symptoms of depression being excluded from the study, meaning that the findings may not apply to all people with depression.
Despite this limitation, the results suggest that CBT self-help books could benefit people with depression.
Where did the story come from?
The study was carried out by researchers from the University of Glasgow and was funded by the Chief Scientist Office and NHS Greater Glasgow and Clyde.
The study was published in the peer-reviewed journal Public Library of Science (PLoS) One. PLoS One is an open access journal, meaning that this research article is available free online.
The lead author of this research paper is the author of the self-help book evaluated in this study, and is also a director and shareholder in Five Areas Limited, which markets online and printed self-help resources and training.
While this may represent a potential conflict of interest, the author has made all his data freely available as per PLoS One editorial guidelines on transparency.
This study was well-reported by BBC News.
What kind of research was this?
This randomised controlled trial (RCT) aimed to determine whether a guided self-help CBT book caused greater improvements in mood than normal care (treatment as usual) for people with depression.
It also investigated the hypotheses that the guided self-help CBT book would also improve knowledge of the causes of and treatment for depression, and that guided self-help CBT would be acceptable to patients and staff.
CBT is a well established ‘talking therapy’ for depression, and looks at how your actions are affected by the way you think and feel about things. CBT is already recommended by NICE for the treatment of depression, either as a first-line treatment for mild to moderate depression, or in combination with antidepressants for more severe depression.
However, as CBT is usually provided by specialist therapists, people in some areas may have limited access to treatment.
The purpose of this trial was therefore not so much to see whether CBT is effective in itself, but to see whether it can be effective in a guided self-help book format if people have trouble accessing treatment.
An RCT is the ideal study design to answer this question, as it can demonstrate a direct cause and effect at work (causation).
What did the research involve?
Adults with depression, demonstrated by a Beck Depression Inventory-II (the BDI-II is a widely used multiple-choice questionnaire designed to assess symptoms associated with depression) score of at least 14 (out of 63, with higher scores on this scale indicating greater depression), who attended one of seven general practices in Glasgow, UK, were randomised to either:
- normal treatment (140 participants) provided by their GP – this would normally include monitoring, antidepressant prescription and referral for specialist psychological therapies as recommended by national treatment guidelines
- a combination of the guided self-help CBT book and, in some cases, antidepressants (141 participants)
Participants in both groups could receive antidepressant medication.
People with suicidal intent or who had impaired concentration or motivation were excluded from this study.
Participants who were randomised to the guided self-help CBT group received the book ‘Overcoming Depression: A Five Areas Approach’ plus three or four short face to face sessions of guided support, totalling two hours. The book addresses topics including Practical Problem Solving, Being Assertive, Using Antidepressant Medication, and Overcoming Sleep problems, amongst others.
The support was provided by a non-clinically qualified psychology graduate, and three, 40-minute appointments were scheduled with an additional fourth, optional session, available. Participants in this group could also receive care from their GP.
Participants in the normal treatment group received care from their GP only.
Improvements in mood were monitored by BDI-II score after four months (the primary outcome) and again after 12 months.
Outcomes for participants in the two groups were compared.
The researchers used the ‘intention to treat’ principle, which means they compared participants in the two groups regardless of whether they had followed the treatment plan (in this case used the book and attended the guidance sessions).
Also, if outcomes were missing for participants, the researchers assumed that the patients had the same BDI-II score as at the start of the study.
What were the basic results?
- At both four and 12 months, average (mean) BDI-II scores were significantly lower in the guided self-help CBT group compared to the normal care group, indicating that participants had fewer symptoms of depression.
- At four months and at 12 months, the proportions of participants with a 50% reduction in BDI-II score was significantly greater in the guided self-help CBT group than the normal care group.
- Participants in the guided self-help CBT group also had better knowledge of depression, and scores on the Client Satisfaction Questionnaire were also higher.
How did the researchers interpret the results?
The researchers concluded that guided self-help CBT “is substantially more effective” than normal treatment.
This RCT has found that using a self-help CBT book with some guidance provided – but by a non-clinically qualified psychology graduate and without the level of specialist support you would receive in standard CBT treatments – caused greater improvements in depression symptoms than normal care in people with depression.
The study supports the benefits of CBT – which is already a well established and recommended treatment for depression.
In particular, the study provides evidence that a guided self-help format may be effective for people who may have difficulty in accessing treatment sessions with a specialist therapist.
This trial has the advantage that it was performed in a community setting, mimicking a “real-life” setting.
However, it should be noted that participants with symptoms of depression as well as also having symptoms of impaired concentration and / or motivation were excluded from the study, which the researchers state caused some people with the core symptoms of depression to be excluded. This means that the findings of this study may not apply to all people with depression.
Despite this limitation, this is a well-conducted study that adds weight to the case that a ‘DIY-approach’ to depression may be effective in many cases.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter.