Guided self-help CBT, for whom is it effective?

Cognitive behavioural therapy (CBT) can effectively treat common mental disorders, such as depression, anxiety, insomnia and stress-related disorders. However, access to treatment is low and few patients receive adequate treatment. Studies show that CBT is an effective treatment also when delivered as guided self-help, where therapists give support to some extent. In guided self-help, patients work actively with the treatment via for example a book, read texts, do exercises, records thoughts and behaviours, and get feedback from their therapist. This format has shown similar effects as CBT with traditional face-to-face sessions and could be a way to offer treatment to a wider population. It can also save time for patients and increase their autonomy. However, it is important to study for whom guided self-help is an effective treatment. This knowledge can lead to improved and individually tailored treatment recommendations.

In a previous clinical trial at four primary care clinics in Stockholm, 396 patients with depression, anxiety, insomnia and stress-related disorders were treated with guided self-help CBT. Patients met a psychologist for initial assessment and then worked with a book during nine weeks accompanied by two face-to-face sessions with the psychologist. After treatment, effects on decreased depression, anxiety and stress were strong, 40% of patients rated that they no longer had elevated psychiatric symptoms, and 49% of patients had a decrease of symptoms.

In the present study, we investigated what variables and patient characteristics were associated to treatment outcome. Results showed that among patient characteristics, higher educational level and higher quality of life ratings predicted better treatment response. Perhaps educational level has an impact on reading ability and the capacity to work independently with text material. The link between quality of life ratings before treatment and treatment response is less obvious, but possibly higher or more normal quality of life ratings indicate a more stable life situation concerning for example work and living circumstances, which could give a more favourable base to read and work with behavioural changes.

Several therapy-related variables were studied and had a strong association to treatment outcome. Patients who at baseline viewed the treatment as credible and had higher expectancy of treatment also improved to a higher extent. Patients that came to the scheduled sessions, and completed more homework assignments had better effect of treatment. The therapists’ estimation of treatment response also predicted outcome.

The results suggest that guided self-help CBT may be more effective for patients with higher educational level, and higher quality of life ratings. Results also suggest that patients’ view of treatment is important and has a predictive value as well as clinicians’ assessment of patients’ ability to benefit from guided self-help. Lastly, when initiating guided self-help CBT, adherence to treatment should be emphasized, supported and followed closely. More large-scale studies are needed to replicate these findings and further investigate aspects that may predict successful outcome in guided self-help CBT.

Read the full paper: Salomonsson, S., Santoft, F., Lindsäter, E., Ejeby, K., Ingvar, M., Öst, L. G., Lekander, M., Ljótsson, B., & Hedman-Lagerlöf, E. (in press). Predictors of outcome in guided self-help cognitive behavioural therapy for common mental disorders in primary care. Cognitive Behaviour Therapy. doi: 10.1080/16506073.2019.1669701

Photo by: Paul Keller

Pictured: Dr. Sigrid Salomonsson


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