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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Can paraprofessionals deliver cognitive-behavioral therapy to treat anxiety and depressive symptoms?

EC Montgomery, ME Kunik, N Wilson, MA Stanley, and B Weiss.

Review published: 2010.

CRD summary

The authors concluded that paraprofessionals could effectively deliver cognitive-behavioural therapy to patients with depression or anxiety with outcomes comparable to professionals. The authors’ conclusions relied on a few small studies that had mixed results and hence caution is warranted when interpreting the authors’ findings.

Authors' objectives

To examine the literature on paraprofessionals using cognitive behavioural therapy (CBT) to treat patients with depression or anxiety compared with professionals.


MEDLINE, PsycINFO, Academic Search Premier, The Cochrane Library and ERIC were searched to September 2005 for articles published in English. Search terms were reported. Reference lists of review articles were searched.

Study selection

Studies that compared professional versus paraprofessional treatment using cognitive and/or behaviour therapy as the primary treatment for symptoms of anxiety or depression were eligible for inclusion. Outcomes included symptom reduction, quality of life, functionality changes and satisfaction. Studies that used self-help groups or peer-help groups were excluded.

The included studies explored CBT (five to 10 sessions), mutual support groups or group desensitisation given by professionals versus paraprofessionals. Professionals were defined as primarily PhD level psychologists as well as master’s level psychologists. Paraprofessionals were defined as no advanced degree, undergraduate level or no formal mental health training. All studies used manualised group therapies. Most patients did not have severe mood or anxiety disorders. Reported outcomes included personal report of confidence as a speaker (PRCS), S-R inventory of anxiety, Beck depression inventory (BDI), Hamilton rating scale for depression (HRSD), Suinn Test Anxiety Behaviour Score (STABS) and life satisfaction index.

One author initially screened papers and three authors independently undertook study selection at the full paper stage.

Assessment of study quality

Quality assessment was undertaken by three reviewers independently using a validity scale adapted from the Evidence Based Medicine Working Group, which assessed 5 quality factors: randomisation, differences at baseline; equal treatment of groups; blinding; complete follow-up or intention to treat.

Data extraction

The authors did not state how data were extracted.

Methods of synthesis

The authors did not state a plan for data analysis. A narrative synthesis was presented.

Results of the review

Four studies (n=249 participants) published between 1976 and 1999 were included in the review. The number of participants in the studies ranged from 45 to 98. Study quality of the included trials varied from 2 to 5 out of 5; three studies scoring at least 4. The main quality problems were a lack of randomisation, differences at baseline and/or a lack of complete follow-up/intention-to-treat analysis.

Three studies (n=153 participants) that scored at least 4 on the quality scale found comparable outcomes for paraprofessionals compared with professionals in terms of HRSD, PCRS, BDI or STABS. Two studies (n=194 participants) that scored between 2 and 5 on the quality scale showed better outcomes with professionals compared with paraprofessionals in terms of BDI, life satisfaction index, social contact or self-assessment of overall improvement.

Authors' conclusions

Paraprofessionals can be effective in delivering CBT to patients with depression or anxiety, with outcomes comparable to professionals.

CRD commentary

Inclusion criteria for the review were broadly defined and several relevant databases were searched. There was potential for both language and publication bias as only published English-language articles were eligible for inclusion; publication bias was not assessed. Three authors undertook study selection and quality assessment, which should have minimised error and bias in the review. Quality assessment indicated variable quality in the included studies, which the authors acknowledged. A narrative synthesis was presented, but no grouping was undertaken, which made interpreting the results difficult.

Overall, the authors’ conclusions relied on a few small studies that had mixed results and hence caution is warranted when interpreting the authors’ findings.

Implications of the review for practice and research

Practice: The authors stated that stepped care (lower cost and less intensive therapies first and higher cost more intensive therapies offered after first-line therapies failed) could be applied to CBT with paraprofessionals used first followed by a step-up to professionals if needed.

Research: The authors stated that further studies were needed to elucidate the specifics of when and how paraprofessionals can most effectively be used to enhance delivery and outcomes in mental health care.


This work was part of a larger project supported by the Houston Centre for Quality of Care & Utilisation Studies, Health Research and Development Service, Office of Research and Development, Department of Veterans Affairs.

Bibliographic details

Montgomery EC, Kunik ME, Wilson N, Stanley MA, Weiss B. Can paraprofessionals deliver cognitive-behavioral therapy to treat anxiety and depressive symptoms? Bulletin of the Menninger Clinic 2010; 74(1): 45-62. [PubMed: 20235623]



Indexing Status

Subject indexing assigned by NLM


Anxiety Disorders /diagnosis /psychology /therapy; Cognitive Therapy /methods; Depressive Disorder /diagnosis /psychology /therapy; Health Personnel /statistics & numerical data; Humans; Professional Competence



Date bibliographic record published


Date abstract record published


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 20235623

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