Impact of support on the effectiveness of written cognitive behavioural self-help: A systematic review and meta-analysis of randomised controlled trials
Highlights
► Written CBT self-help results in a medium effect size. ► Effectiveness did not vary by type of support. ► Effectiveness may vary by mental health condition with different types of support. ► Larger effect sizes were associated with higher baseline severity for depression. ► There were a number of significant clinical and methodological moderators.
Introduction
Attempts to increase access to evidence based psychological therapies for common mental health problems are resulting in a paradigm shift in the way cognitive behavioural therapy (CBT) is delivered (Bennett-Levy et al., 2010). This shift is away from the delivery of face-to-face ‘high intensity’ CBT by experienced and specialist mental health professionals towards the inclusion of low intensity CBT (Bennett-Levy & Farrand, 2010). On the basis of the developing evidence base CBT self-help is currently emerging as a key low intensity CBT intervention for the treatment of depression (Anderson et al., 2005, Cuijpers, 1997, Gellatly et al., 2007); anxiety (Hirai and Clum, 2006, van Boeijen et al., 2005); anxiety and depression (Couell and Morris, 2011, Cuijpers, Donker, van Straten, Li and Andersson, 2010, Van't Hof et al., 2009); insomnia (van Straten & Cuijpers, 2009); bulimia nervosa and binge eating disorder (Stefano et al., 2006, Sysko and Walsh, 2008). Several of these meta-analyses however have highlighted limiting CBT self-help for use amongst patients presenting with symptoms of mild to moderate severity only (Couell and Morris, 2011, Van't Hof et al., 2009).
CBT self-help commonly takes the form of books, computerised cognitive behavioural therapy (cCBT), audiotape and videotape (Hirai and Clum, 2006, Marks et al., 2007) with written formats the most commonly employed (McKenna, Hevey, & Martin, 2010). To overcome potential difficulties concerning lack of knowledge or motivation that may be encountered when using CBT self-help (Bendelin et al., 2011) support may also be provided, which can be face-to-face, by telephone or based around e-mail (Bennett-Levy et al., 2010). The content of such support often takes the form of a practitioner providing information regarding the CBT self-help approach alongside regular updates to monitor progress. Large differences however exist in the amount and nature of support being provided. This can vary from no support being provided at all, to infrequent ‘check-ins’ to regular scheduled support sessions, whereby the practitioner may also support the patient in making recommendations about use of the self-help materials or support problem solving in the event the patient is struggling (Carlbring & Andersson, 2006).
A taxonomy has been developed (Glasgow & Rosen, 1978) to help classify variations in the nature and type of support that may be provided for CBT self-help. This taxonomy distinguishes between three types of support — self-administered, in which the patient uses the self-help materials exclusively on their own with the exception of contact for data collection purposes only; minimal contact in which the patient relies upon the self-help materials but has irregular, often non face-to-face contact with a practitioner and therapist administered in which the patient receives regular and scheduled meetings with a practitioner whose role is to support them using the self-help materials (Glasgow & Rosen, 1978). This taxonomy has recently been updated within a literature review of technology-assisted self-help for depression and anxiety to better account for the wider variations in the type of support provided across studies (Newman, Szkodny, Llera, & Przeworski, 2011).
Unfortunately the application of a taxonomy used to specify the nature of support being provided for CBT self-help has been poorly adopted within research studies and highlights wider criticisms regarding the reporting of intervention content in published research (Abraham and Michie, 2008, Michie and Abraham, 2004). This makes it difficult to reach conclusions regarding the extent to which support for self-help may be impacting upon effectiveness. For example, several systematic reviews examining CBT self-help have adopted support as a moderator and highlighted a strong association between support and effectiveness (Andersson and Cuijpers, 2009, Gellatly et al., 2007, Hirai and Clum, 2006, Spek et al., 2007, van Straten and Cuijpers, 2009). However within these systematic reviews the moderator analysis compared supported against self-administered self-help which fails to take account of the wide variations regarding content and type of support (Glasgow and Rosen, 1978, Newman et al., 2011). Consequently it becomes difficult to reach conclusions regarding the optimal level of support to provide.
Furthermore research is by no means unequivocal in highlighting a relationship between support and effectiveness for self-help. For example, a systematic review examining the effectiveness of CBT self-help across a range of common mental health difficulties, also including habit disturbances and skills-orientated problems, reported no additional benefit of providing support for self-help in comparison to it being self-administered (Gould & Clum, 1993). Additionally, a number of experimental studies directly comparing supported versus self-administered self-help for social phobia (Berger, Caspar, et al., 2011, Furmark et al., 2009, Titov et al., 2009) and binge eating disorder (Loeb, Wilson, Gilbert, & Labouvie, 2000) reported no clear benefit in effectiveness for supported CBT self-help. However a benefit did arise for supported self-help when the mental health condition being studied was depression (Berger, Hämmerli, Gubser, Andersson, & Caspar, 2011) and perfectionism (Pleva & Wade, 2007). Such differences highlight the possibility that the impact of support for CBT self-help may also vary by mental health condition being treated.
This study is the first of its kind to address two main questions with respect to the impact of support upon CBT self-help. Following a systematic review of the literature, support provided within each study will be classified according to an adapted Glasgow and Rosen (1978) taxonomy. This will form the basis of a moderator analysis examining the effectiveness of CBT self-help by support type. Second, that the literature highlights the potential that effectiveness may differ across mental health condition by support, planned comparisons will be undertaken examining effectiveness for mental health condition by each type of support separately. Planned moderator analysis will also be undertaken both across all studies, and by support type, to examine the extent to which variability in effect size is accounted for by various clinical and methodological characteristics. Baseline severity will constitute one such moderator given that the effectiveness of CBT self-help is often identified as being limited to common mental health difficulties of mild to moderate severity only (Couell and Morris, 2011, Van't Hof et al., 2009). In an attempt to minimise heterogeneity and confidence intervals, and thereby reduce dangers associated with over-interpreting the data (Thompson, 1994), the review will be restricted to written CBT self-help only. Furthermore, unlike previous systematic reviews in this area (Anderson et al., 2005, Cuijpers, 1997, Glasgow and Rosen, 1978), study inclusion will be restricted to randomised controlled studies with at least moderate to high internal validity. This will address a critique of systematic reviews examining psychological treatments of depression whereby inclusion of studies with lower levels of internal validity was associated with higher effect sizes (Cuijpers, van Straten, et al., 2010). Restricting studies in this way will hopefully increase the validity of any conclusions reached (Hartling et al., 2009, Verhagen et al., 2001).
Section snippets
Study type
Randomised controlled trials where written self-help CBT interventions were compared with a ‘control’ group in the treatment of affective or common emotional disorders. CBT self-help books, in and out of print, and written booklets developed for individual studies were included. Control groups included a range of comparators including treatment as usual, waiting-list and attention placebo. All included published and unpublished studies were produced between 1990 and December 2011 and in the
Study selection
A total of 7428 possible studies were identified through searching the following databases: CENTRAL (2713); EMBASE (1716); MEDLINE (1489); PSYCHOINFO (965) and CINAHL (545). In order to identify unpublished trials databases of conference proceedings (Index to Scientific and Technical Proceedings; Web of Science with Conference Proceedings) and grey literature were also searched identifying two potential studies. A further 31 possible studies were identified through reference and citation
Discussion
This review extends the current evidence base by applying the taxonomy of support devised by Glasgow and Rosen (1978) and examining the impact that type of support — guided, minimal contact and self-administered — has upon the effectiveness of written CBT self-help. Several clinical and trial methodological characteristics were included as moderators to examine their impact on effect size overall, and also that reported separately by type of support. Summarising the findings of 38 RCTs this
Acknowledgements
This study was undertaken without financial support. Dr Farrand was responsible for the initial conception of the study and jointly responsible for the design, aided in the analysis and interpretation of the data and lead on writing the final paper. Joanne Woodford made substantial contributions to the design of the study, lead the data collection with joint responsibility for analysis and data interpretation and contributed to the writing of the paper. We are very grateful to Karolina
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