Is CBT effective compared with antidepressants?

Quality assessmentSummary of findingsImportance
No. of patientsEffectQuality
No. of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsCBTADRelative (95% CI)Absolute
Leaving the study early
14randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone146/686 (21.3%)0%RR 0.75 (0.63 to 0.91)0 fewer per 1000 (from 0 fewer to 0 fewer)⊕⊕⊕⊕
HIGH
CRITICAL
Relapse at post-treatment
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none4/14 (28.6%)0%RR 0.86 (0.27 to 2.71)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
Relapse up to 12 months (with continuation treatment) (follow-up mean 12 months)
2randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone2/29 (6.9%)0%RR 0.26 (0.06 to 1.21)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕⊕⊕
HIGH
CRITICAL
Relapse up to 12 months (no continuation treatment) (follow-up mean 12 months)
4randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone12/95 (12.6%)0%RR 0.59 (0.3 to 1.14)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕⊕⊕
HIGH
CRITICAL
Relapse at 18 months (no continuation treatment) (follow-up mean 18 months)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none3/15 (20%)0%RR 0.40 (0.12 to 1.31)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
⊕⊕○○
LOW
CRITICAL
Relapse at 24 months (no continuation treatment) (follow-up mean 24 months)
2randomised trialsno serious limitationsserious2no serious indirectnessno serious imprecisionnone8/22 (36.4%)0%RR 0.69 (0.34 to 1.4)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
MODERATE
CRITICAL
Relapse at 24 months (with continuation treatment) (follow-up mean 24 months)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none2/7 (28.6%)0%RR 0.67 (0.16 to 2.84)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
Depression scores: continuous measures at post-treatment: self-report (Better indicated by lower values)
8randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone246234-SMD 0.06 lower (0.24 lower to 0.12 higher)⊕⊕⊕⊕
HIGH
CRITICAL
Depression scores: continuous measures at post-treatment: clinician-rated (Better indicated by lower values)
13randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone698705-SMD 0.05 higher (0.06 lower to 0.15 higher)⊕⊕⊕⊕
HIGH
CRITICAL
Depression score: dichotomous measures: clinician-rated
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none35/60 (58.3%)0%RR 1.00 (0.77 to 1.3)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
Depression scores: dichotomous measures: self-report
3randomised trialsno serious limitationsserious2no serious indirectnessno serious imprecisionnone46/94 (48.9%)0%RR 0.81 (0.46 to 1.42)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
No. not achieving remission
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none36/60 (60%)0%RR 1.11 (0.85 to 1.44)0 more per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
HRSD-17>6 & HRSD-24>8 at end of treatment
5randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone283/424 (66.7%)0%RR 1.00 (0.86 to 1.15)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕⊕⊕
HIGH
CRITICAL
50% decrease in BDI scores
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none16/30 (53.3%)0%RR 1.45 (0.82 to 2.59)0 more per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
Depression scores: continuous measures at follow-up ( 1 month): clinician-rated (follow-up mean 1 months; Better indicated by lower values)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none1916-SMD 0.08 higher (0.59 lower to 0.74 higher)⊕⊕○○
LOW
CRITICAL
Depression scores: continuous measures at follow-up (12 months): clinician-rated (Better indicated by lower values)
3randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone7364-SMD 0.50 lower (0.84 to 0.15 lower)⊕⊕⊕⊕
HIGH
CRITICAL
Depression scores: continuous measures at follow-up (24 months): clinician-rated (follow-up mean 24 months; Better indicated by lower values)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none00-SMD 0.37 lower (0.98 lower to 0.23 higher)⊕⊕○○
LOW
CRITICAL
Depression scores: continuous measures at follow-up (12 months): self-report (follow-up mean 12 months; Better indicated by lower values)
3randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone7064-SMD 0.41 lower (0.76 to 0.07 lower)⊕⊕⊕⊕
HIGH
CRITICAL
Depression scores: continuous measures at follow-up (24 months): self-report (follow-up mean 24 months; Better indicated by lower values)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none2220-SMD 0.40 lower (1.01 lower to 0.22 higher)⊕⊕○○
LOW
CRITICAL
Depression scores: continuous measures (clinican-rated) after 6 months maintenance (follow-up mean 6 months; Better indicated by lower values)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none136-SMD 0.41 higher (0.57 lower to 1.39 higher)⊕⊕○○
LOW
CRITICAL
Depression scores: continuous measures (self-report) after 6 months maintenance (follow-up mean 6 months; Better indicated by lower values)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none146-SMD 0.03 higher (0.92 lower to 0.99 higher)⊕⊕○○
LOW
CRITICAL
Depression scores: dichotomous measures (self-report) at follow-up (1 year) (follow-up mean 1 years)
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessvery serious1none16/24 (66.7%)0%RR 0.76 (0.55 to 1.05)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
By severity: Moderate or moderate/severe: Leaving the study early
5randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious3none80/349 (22.9%)0%RR 0.83 (0.64 to 1.07)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe: Leaving the study early
3randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious3none30/110 (27.3%)0%RR 1.04 (0.68 to 1.61)0 more per 1000 (from 0 fewer to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe/very severe: Leaving the study early
2randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone15/66 (22.7%)0%RR 0.55 (0.32 to 0.94)0 fewer per 1000 (from 0 fewer to 0 fewer)⊕⊕⊕⊕
HIGH
CRITICAL
By severity: Moderate or moderate/severe: Depression scores: continuous measures (self-report) (Better indicated by lower values)
4randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious3none108121-SMD 0.07 lower (0.33 lower to 0.2 higher)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe: Depression scores: continuous measures (self-report) (Better indicated by lower values)
3randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious3none10196-SMD 0.03 lower (0.38 lower to 0.31 higher)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe/very severe: Depression scores: continuous measures (self-report) (Better indicated by lower values)
3randomised trialsno serious limitationsserious2no serious indirectnessserious3none7583-SMD 0.06 higher (0.42 lower to 0.53 higher)⊕⊕○○
LOW
CRITICAL
By severity: Moderate or moderate/severe: Depression scores: continuous measures (clinician-report) (Better indicated by lower values)
7randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious3none451459-SMD 0.04 higher (0.09 lower to 0.17 higher)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe: Depression scores: continuous measures (clinician-rated) (Better indicated by lower values)
4randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious3none151196-SMD 0.02 higher (0.2 lower to 0.24 higher)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe/very severe: continuous measures (clinician-rated) (Better indicated by lower values)
3randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious3none7684-SMD 0.90 lower (0.4 lower to 0.23 higher)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Moderate or moderate/severe: continuous measures at 16-week follow-up (self-report) (Better indicated by lower values)
1randomised trialsno serious limitationsvery serious1no serious indirectnessno serious imprecisionnone1722-SMD 0.25 higher (0.38 lower to 0.89 higher)⊕⊕○○
LOW
CRITICAL
By severity: Moderate or moderate/severe: continuous measures at 16-week follow-up (clinician-rated) (Better indicated by lower values)
1randomised trialsno serious limitationsserious1no serious indirectnessno serious imprecisionnone1622-SMD 0.26 lower (0.9 lower to 0.39 higher)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe and severe/very severe: continuous measures at 16-week follow-up (self-report) (Better indicated by lower values)
1randomised trialsno serious limitationsvery serious1no serious indirectnessno serious imprecisionnone1827-SMD 0.23 higher (0.37 lower to 0.83 higher)⊕⊕○○
LOW
CRITICAL
By severity: Severe and severe/very severe: continuous measures at 16-week follow-up (clinician-rated) (Better indicated by lower values)
1randomised trialsno serious limitationsvery serious1no serious indirectnessno serious imprecisionnone1827-SMD 0.23 higher (0.05 lower to 0.57 higher)⊕⊕○○
LOW
CRITICAL
By severity: Moderate or moderate/severe: dichotomous outcomes (self-report)
2randomised trialsno serious limitationsserious3no serious indirectnessvery serious4none16/35 (45.7%)0%RR 0.50 (0.11 to 2.3)0 fewer per 1000 (from 0 fewer to 0 more)⊕○○○
VERY LOW
CRITICAL
By severity: Severe: dichotomous outcomes (self-report)
1randomised trialsno serious limitationsvery serious1no serious indirectnessno serious imprecisionnone30/59 (50.8%)0%RR 1.07 (0.74 to 1.56)0 more per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
By severity: Moderate or moderate/severe: dichotomous (clinician-rated)
4randomised trialsno serious limitationsserious3no serious indirectnessserious2none231/353 (65.4%)0%RR 0.94 (0.71 to 1.24)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
By severity: Severe: dichotomous (clinician-rated)
2randomised trialsno serious limitationsserious3no serious indirectnessno serious imprecisionnone53/82 (64.6%)0%RR 1.02 (0.81 to 1.29)0 more per 1000 (from 0 fewer to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Moderate: Relapse post-treatment
1randomised trialsno serious limitationsvery serious1no serious indirectnessno serious imprecisionnone4/14 (28.6%)0%RR 0.86 (0.27 to 2.71)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
By severity: Moderate/severe: Relapse up to 12 months
2randomised trialsno serious limitationsserious3no serious indirectnessno serious imprecisionnone9/46 (19.6%)0%RR 0.66 (0.28 to 1.56)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Moderate/severe: Relapse at 18 months
1randomised trialsno serious limitationsvery serious1no serious indirectnessno serious imprecisionnone3/15 (20%)0%RR 0.40 (0.12 to 1.31)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
By severity: Moderate/severe: Relapse at 24 months
2randomised trialsno serious limitationsserious3no serious indirectnessserious2none8/22 (36.4%)0%RR 0.74 (0.24 to 2.26)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
By severity: Moderate: Relapse at 24 months
1randomised trialsno serious limitationsvery serious1no serious indirectnessno serious imprecisionnone2/7 (28.6%)0%RR 0.67 (0.16 to 2.84)0 fewer per 1000 (from 0 fewer to 0 more)⊕⊕○○
LOW
CRITICAL
By severity: Severe: No. not achieving remission (self-report)
1randomised trialsno serious limitationsserious5no serious indirectnessno serious imprecisionnone29/45 (64.4%)0%RR 2.01 (1.41 to 2.88)0 more per 1000 (from 0 more to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Severe: No. not achieving remission (clinician-rated)
1randomised trialsno serious limitationsserious5no serious indirectnessno serious imprecisionnone30/45 (66.7%)0%RR 1.55 (1.14 to 2.11)0 more per 1000 (from 0 more to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Less severe: No. not achieving remission (self-report)
1randomised trialsno serious limitationsserious5no serious indirectnessno serious imprecisionnone28/45 (62.2%)0%RR 1.64 (1.17 to 2.3)0 more per 1000 (from 0 more to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
By severity: Less severe: No. not achieving remission (clinician-rated)
1randomised trialsno serious limitationsserious5no serious indirectnessno serious imprecisionnone29/45 (64.4%)0%RR 2.15 (1.48 to 3.11)0 more per 1000 (from 0 more to 0 more)⊕⊕⊕○
MODERATE
CRITICAL
1

Single study; inconclusive effect size

2

Heterogeneity > 50%

3

Inconclusive effect size

4

Heterogeneity >80%

5

Single study

From: APPENDIX 16, CLINICAL EVIDENCE PROFILES

Cover of Depression
Depression: The Treatment and Management of Depression in Adults (Updated Edition).
NICE Clinical Guidelines, No. 90.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society; 2010.
Copyright © The British Psychological Society & The Royal College of Psychiatrists, 2010.

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