Davy De Geeter V8386530
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Module Code:
RMH4008-N-JB2-2018
Module Title:
Evidence Based Practice
Module Leader:
Barbara Neil
Title:
Does the delivery method of CBT impact on the effectiveness in
reducing symptoms for adults with a primary diagnosis of
depression when compared with treatment as usual?
Name:
Davy De Geeter
Student No:
V8386530
Date of
Submission:
06/11/2020
Word Count:
4000
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Table of Contents
Executive summary ................................................................................................................................. 3
Introduction and Background ................................................................................................................. 3
Evidence Based Practice ......................................................................................................................... 5
Ask a question ......................................................................................................................................... 6
Accessing the information ...................................................................................................................... 7
Appraise the article found .................................................................................................................... 10
Internal Validity................................................................................................................................. 11
External validity................................................................................................................................. 13
Discussion of results.......................................................................................................................... 14
Recommendations ............................................................................................................................ 15
Apply the information ........................................................................................................................... 16
Audit ...................................................................................................................................................... 17
Conclusion ............................................................................................................................................. 18
References ............................................................................................................................................ 19
Appendix ............................................................................................................................................... 23
Appendix A: Search results for each database ................................................................................. 23
Appendix B: Chosen research paper ( López-López, et al., 2019)..................................................... 26
Appendix C: CASP Systematic Review Checklist (Critical Appraisal Skills Programme, 2020) ...... 37
Appendix D: Force Field Analysis ...................................................................................................... 40
Appendix E: Change plan .................................................................................................................. 40
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Executive summary
NICE guidelines (2009) show us that depression affects more than 300 million people globally. It is
considered a leading cause for disability as well as one of the most common psychiatric conditions,
as concluded by data from the World Health Organisation (2018). Studies such as those conducted
by Public Health England have shown that the prevalence of diagnosed depression in the North East
is 10% with lower rates in Newcastle, Hartlepool and Middlesbrough. It is suspected that these lower
rates are due to a higher rate of undiagnosed depression. Currently there is wide amount of
research available that shows that therapeutic intervention is effective for depression, especially
cognitive behavioral therapy (National Institute for Health and Care Excellence, 2009). This therapy
was founded and based upon the work of Beck (1974) who suggest that the maintenance and root of
depression lies with the cognitive triad, more specifically a negative view of oneself, the world and
the future.
This report aims to reach a conclusion on the question: Does the delivery method of CBT impact on
the effectiveness in reducing symptoms for adults with a primary diagnosis of
depression when compared with treatment as usual? Following a structured search, a systemic
review by López-López et al. (2019) was chosen as the most effective way of answering this
question. The study concluded that strong evidence was found that CBT interventions yielded a
larger decrease in symptom scores in the short term when compared with treatment as usual. There
were however some issues with both the internal and external validity of the study as well as it
being unclear which combination of content components and delivery formats are effective. This
suggests that results need to be interpreted cautiously. Nevertheless, suggestions can be made how
to effectively implement these suggestions into local therapeutic practice.
Introduction and Background
Depression is an enduring low mood that can affect your everyday life ranging from mild symptoms
that have an effect on your motivation to very severe impairment linked with suicidality (Mind,
2019). When considering the DSM 5 diagnosis criteria (American Psychiatric Association, 2013), we
see further support for the psychological impact of depression as well as adding the potential for
physical symptoms like fatigue, a decrease or increase in appetite and a slowing down of thoughts
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and movements. Depression can take on a relapsing and remitting course and thus be episodic. This
is further supported by the findings of Judd (1997) which estimate that the risk of repeated episodes
is higher than 80% and most clients will on average experience 4 major depressive episodes in their
lifetime. It is critical to stress that this is a factor in why mood disorders take a particularly important
place in the risk factors for suicide. Findings by Harris and Barraclough (1997) show that mortality
rates are on average 60% higher and their life expectancy 10 years shorter. They conclude that
suicide is the main cause of this higher mortality rate and estimate the risk of suicide 20 times higher
in people who suffer from severe depression. It is therefore imperative that good quality treatment
is available for this group.
The treatment of depression for clients diagnosed with the condition is happening for the most part
within the primary care setting. 80% of this group is either receiving care from a GP or their primary
care mental health team (Louch, 2009). It was however recognized by Lovell and Richards (2000)
that only a minority was receiving the treatment they require. Further studies even go as far to
suggest that 56% of clients with major depression receive no treatment at all ( (Fernández, et al.,
2007) (Kohn, et al., 2004)). They conclude that barriers to care and ability to reach out for help are
among those factors that contribute to this. It is for this reason that the stepped care model was
brought into existence. The Improving Access to Psychological Therapies stepped care model (The
National Collaborating Centre for Mental Health, 2020) and the services which have been set up in
accordance with this model provide evidence based therapy for people mainly diagnosed with
depression and anxiety disorders. The model works according to the principle that the least intrusive
intervention should be offered for their needs first. The appropriate choice of the level of treatment
is informed by specific NICE guidelines for each disorder (National Institute for Health and Care
Excellence, 2020). In the case of depression NICE (2009) recommends Cognitive Behavioural Therapy
(CBT).
CBT has been established as a effective treatment for a wide variety of mental health disorders
including depression (Whitfield & Williams, 2003). In a study conducted by Cuijpers et al. (2013) the
enduring effect of CBT after termination of the acute treatment was confirmed and found as
effective as continuation of pharmacotherapy in the 18 month follow up. Such studies, however, fail
to address that good quality research such as randomized controlled trials (RCTs) with long follow
ups beyond the two years are rare as is shown in research by Steinert et al. (2014). Their findings
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continue by suggesting that relapse rates after 4 years are considerably high and thus further
developments need to be made to enhance relapse prevention strategies. CBT interventions are
complex and our chosen systematic review and meta-analysis for this report delves further in the
effectiveness of both the components and different delivery methods that are utilized in current
practice ( López-López, et al., 2019).
Evidence Based Practice
Evidence Based Practice (EBP) aims to close the distance between actual clinical care and best
practice by applying the evidence gained from robust research studies and adding in the therapist’s
experience and clinical decision-making skills as well as the client’s own preferences and ideals
(Fineout-Overholt, et al., 2005). A more detailed definition is given by Sackett et al. (1996) who
describes EBP as “the conscientious, explicit and judicious use of current best evidence, based on
systematic review of all available evidence- including patient reported, clinician observed and
research derived evidence- in making and carrying out decisions about the care of individual
patients”. To emphasize the importance of integrating these different aspects Hoffman et al. (2010)
stress the importance of structuring this approach rather than it remaining a vague concept. This can
be achieved by following the five steps set out in Strauss et al. (2019):
1) Convert your information needs into an answerable clinical question
2) Find the best evidence to answer your clinical question
3) Critically appraise the evidence for its validity, impact and applicability
4) Integrate the evidence with clinical expertise, the client’s values and circumstances, and
information from the practice context.
5) Evaluate the effectiveness and efficiency with which steps 1-4 were carried out and think
about ways to improve your performance of them next time.
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This process is explained in Hoffman et al. (2010) as the process of the 5 A’s:
1) Ask a question
2) Access the information
3) Appraise the articles found
4) Apply the information
5) Audit
This process will be used throughout this report to inform and structure our approach.
Ask a question
To ensure this important first step of our process is well defined, specific and clear, we will be using
the PICO framework which is suggested and supported by various authors ( (Cooke, et al., 2012)
(Brettle & Grant, 2004)).
Population:
Adults with a primary diagnosis of depression
Intervention:
Cognitive Behavioral Therapy
Comparison:
Treatment as usual
Outcome:
Reducing the symptoms experienced
Our question will thus be structured as follows: Does the delivery method of CBT impact on the
effectiveness in reducing symptoms for adults with a primary diagnosis of depression when
compared with treatment as usual?
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Accessing the information
To prevent problems arising in the future a good literature review will be conducted to underpin the
entire problem solving process (Craig & Smyth, 2007). This is supported by Strauss et al. (2019) who
stress that by taken an appropriate amount of time and making sure that the evidence is recent and
up to date a structured and skilled search can be better achieved. To ensure this, Tomlin et al. (2002)
suggest the identified research question is divided into its PICO/PIO component parts as can be seen
in table 1 below. The different components have been listed below and account for spelling
variations and synonyms of the used search terms as to not only include evidence that uses the UK
spelling of certain words.
Table 1: PIO structure
Population
Intervention
Outcome
Depressi*
CBT
Effective
Depressive disorders
Cognitive Behavio* Therapy
Reduction
Adults
Delivery method
Relapse
Symptoms
To ensure the search contained the combination of all these required details, we have made use of
the Boolean operators ‘AND’ and ‘OR’. These can be defined as logical connectors used to formulate
a search query and are now widely used in database searches to make these more specific to the
query (Burris, 2018). Table 2 is an updated table 1 with Boolean operators included.
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Table 2: PIO components with Boolean operators
Population
Intervention
Outcome
CBT
Depressi*
‘OR’
Depressive
disorders
Effective
‘
‘
‘OR’
A
A
N
D
‘OR’
‘
N
Cognitive Behavio*
Therapy
D
‘
‘OR’
Adults
‘OR’
Reduction
‘OR’
Relapse
‘OR’
Symptoms
Delivery method
A search strategy was utilized to guarantee that the results found in each of the 3 databases
(Psycinfo, Cochrane Library Online and CINAHL) were of a good quality and a relevant nature
(Holland, 2007). First each individual term was searched, however due to the vast amount of
research this returned, an adjustment was made to start the search strategy for each database with
a single component of the PIO structure linked together by the Boolean operator ‘OR’. Population
was searched first, followed by Intervention and finally Outcome. Each database was then searched
by combining the three different PIO components using the Boolean operator ‘AND’. This resulted
initially in 5 journal articles on Psycinfo, 13 trials on the Cochrane Library and 3880 results on the
CINAHL database. To reduce the amount of results in the CINAHL database filter criteria were
utilized as shown in Table 3 and resulted in 11 applicable journal articles found. All search results can
be found in Appendix A
Table 3 Database filter criteria
Publication date
Main subject
Location
The studies needed to
The main subjects of the
The studies needed to
be published in the last
studies needed to be
have been conducted in
two years
depression and CBT
the UK and/or Ireland
Age
The studies were limited
to ‘all adults’
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The screening of the remaining results involved reading the titles for applicability to our research
question followed by ranking the quality of the remaining papers by utilizing the hierarchy of
evidence (Sackett, et al., 1996)(figure 1) and the Critical Appraisal Skills Programme (CASP)
systematic review checklist (Critical Appraisal Skills Programme, 2020)(Appendix C).
Figure 1: Hierarchy of Evidence
After considering the above factors, the following systematic review was chosen to be critically
appraised in this report: The process and delivery of CBT for depression in adults: a systematic review
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and network meta-analysis ( López-López, et al., 2019). This systematic review had significant
relevance to the posed research question. The authors conduct a systematic review of randomised
controlled trials (RCTs) in which a CBT intervention was used for treatment of adults with a primary
diagnosis of depression ( López-López, et al., 2019).
Appraise the article found
The purpose of the López-López et al. (2019) study was to conduct a systematic review on RCTs in
adults with a primary diagnosis of depression, where a CBT intervention was used. After screening
and selection according to criteria, 91 studies were used to show the effectiveness of both the
therapeutic delivery method, components and combination of components in CBT compared to
treatment as usual (TAU). However, there was a substantial variation on how TAU was defined
across the RCTs examined and thus findings would have to be interpreted with caution.
Following the hierarchy of evidence (Sackett, et al., 1996), systemic reviews are considered the
highest standard in terms of quality. However, this doesn’t automatically imply that each systemic
review is of a high quality and thus validity, results and applicability still have to be critically
appraised (Haber & LoBiondo-Wood, 2018). Critical appraisal is defined by O'Mathúna (2010) as the
process of carefully and transparently evaluating the quality of published research reports and their
relevance to a particular context. This definition can be achieved by utilising an appraisal tool so that
the critical appraisal will be done in a structural way. However it is important to signify the
experience and understanding of the appraiser of systematic reviews and how these can be best
combined with the available structural tools (Evans & Pearson, 2001).
The Critical Appraisal Skills Programme (2020) has over the years proven to be effective as an aid to
appraising research literature and has been continuously updated by a team of experts with specific
experience relating to each checklist. It was, however, recently reiterated via a user survey that the
basic format continues to be appropriate and useful in practice. The specific systematic review
checklist will be used to support the critical appraisal in this section to inform the discussion about
internal and external validity of the chosen study. It has been added in Appendix C for reference.
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Internal Validity
Internal validity can be defined as the extent to which a study establishes a reliable cause-and-effect
relationship between a treatment and an outcome (Haber & LoBiondo-Wood, 2018). The application
to our current study means that an appraisal would be made to which extent the application of CBT
therapy methods and components would reduce the symptoms of an adult diagnosed with
depression compared to TAU. The concept also means that possible alternative explanations can be
excluded based on that finding (Haber & LoBiondo-Wood, 2018).
López-López et al. (2019) chose to include all RCTs where the effectiveness of a CBT therapy
technique was compared with TAU. This means that a wide array of techniques was accrued and
thus techniques from both group and individual therapy as well as different delivery methods were
pooled together. Initially this would seem that internal validity would be compromised due to not
being able to effectively pinpoint which element of the techniques is effective in reducing symptoms
(Coolican, 2009). The authors compensate for this decrease by using both Network meta-analysis
(NMA) (Dias, et al., 2013) and component-level NMA (Welton, et al., 2009). NMA (Dias, et al., 2013)
allows for multiple interventions to be pooled together from a set of RCTs and then compared on
the level of two or more of those interventions. This would mean that if each combination of
delivery method and components is considered a separate intervention, these interventions then
could compared at the same time ( López-López, et al., 2019). The authors, however, rightly
acknowledge that this wouldn’t be possible with a NMA due to the complexity of a CBT intervention.
On the other hand, component-level NMA (Welton, et al., 2009) is succesful in comparing at this
complex level and thus holds the possibility to address which aspect of the intervention has caused
the specific decrease in symptoms. Implementation of NMA and component-level NMA should have
mitigated some of the implications for our internal validity, however this would only be the case if all
CBT interventions examined would be sufficiently detailed which wasn’t the case in some RCTs
where only vague descriptions were available. Ultimately this means there is an adverse impact on
internal validity due to this limitation.
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High levels of performance bias (blinding of participants and personnel) and detection bias (blinding
of outcome assessment) were accounted for in most RCTs ( López-López, et al., 2019). This can be
explained due to the nature of the therapeutic interventions and subsequently collaborative nature
of the interaction between therapist and client. The client may change his responses to outcome
measures due to being aware of his intervention and similarly, a therapist could incorporate his
values or beliefs about a certain intervention. In both cases this would increase the possibility of
heterogeneity of treatment results and thus this would negatively impact on the internal validity our
systematic review (Haber & LoBiondo-Wood, 2018). The authors acknowledge this limitation,
however, no measures were added to mitigate this effect.
Internal validity was improved due to the presence of two authors independently screening
abstracts and titles for eligibility for inclusion. If additional information was necessary, authors
would be contacted for this purpose ( López-López, et al., 2019). In addition to this, both authors
made use of the Cochrane risk of bias tool developed by Higgins et al. (2011) independently to assess
risk of bias. The findings of Whiffin and Hasselder (2013) support the importance of the presence of
two independently working reviewers and conclude this has a positive effect on both reducing the
bias and improving the internal validity.
Finally, additional uncertainty was introduced due to a combination of TAU definitions varying
substantially both within and across studies, and the often not reported intensity of TAU in studies (
López-López, et al., 2019). One major drawback of this uncertainty is the impact on intervention
effectiveness when compared and thus the significant negative effect on internal validity.
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External validity
External validity can be seen as a process to enable individual clinicians to reach conclusions as to
whether it is relevant how they apply it to their own area of practice (Brettle & Grant, 2004). As a
concept it deals with the applicability and generalizability of the study to other settings and thus is
more tricky to quantify than internal validity (Hoffman, et al., 2010).
The participants in this study are all adults above 18 who have a primary diagnosis of depression (
López-López, et al., 2019). The authors explain that to cover the broad spectrum of severity of
depression symptoms for clients receiving therapy in outpatient settings, studies were both included
with standardised diagnostic criteria like the different versions of the DSM (American Psychiatric
Association, 2013) and validated depression questionnaires with a threshold to identify depression.
The population presented in these studies can be seen as applicable to the population presenting at
an IAPT service. An IAPT service also uses specific questionnaires like the PHQ-9 to ascertain whether
a lower mood is classed as significant to receive therapy (The National Collaborating Centre for
Mental Health, 2020). Even though the questionnaires used in the RCTs are different from the once
used in an IAPT service, they are all validated outcome measures that have been empirically tested
and therefore can be used to make similar assumptions about symptom reduction (Choi, et al.,
2014). The external validity is reinforced due to the applicability of this population and is further
reinforced due to most of the RCTs being conducted in the UK as well as excluding studies that
focused on inpatients ( López-López, et al., 2019).
On the other hand, the broad nature of the interventions offered is not applicable to a typical IAPT
setting where NICE guidelines are followed for the treatment of depression (National Institute for
Health and Care Excellence, 2009). The guidelines inform which CBT interventions should be
implemented at certain severity level and treatment resistance of experienced depression
symptoms. However, the CBT interventions in this systematic review are pooled together and
include interventions both at low intensity and high intensity level, considering them equally
effective on a broad range of depression symptoms at different severity levels ( López-López, et al.,
2019). This would lower the applicability and implementation of the offered interventions and thus
the external validity due to these not being specific enough to ascertain which to use at either low
intensity or high intensity level.
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Discussion of results
There was strong evidence present that CBT interventions provide a more significant decrease in
depression scores at short term when compared to TAU ( López-López, et al., 2019). There was little
evidence found of differential effectiveness of face-to-face compared to multimedia CBT
interventions, additionally there was no strong evidence found of specific effects of any content
components or combinations of components. Emphasis needs to be on the substantial uncertainty
around effect estimates found for most intervention comparisons and outcomes including
psychological placebo/attention.
Once more the overall beneficial effect of CBT interventions have been shown to improve depressive
symptoms and this has been replicated before in other studies (Richards and Richardson, 2012;
Cuijpers and Gentili, 2017). Furthermore, multimedia CBT was found to be similarly effective as faceto-face CBT, although it is important to emphasise the considerable uncertainty in the treatment
effect estimates showing no difference between face-to-face and multimedia CBT and thus caution
needs to be exercised to see if the findings in regards to delivery method are clinically worthwhile to
implement (Herbert, 2000).
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Recommendations
The results provide sufficient evidence to make recommendations on how to implement changes in
day to day practice in terms of the delivery method for CBT interventions for clients with a primary
diagnosis of depression. It is, however, important to remain aware of the uncertainty in treatment
effect sizes and small sample sizes and even though the report will continue to formulate a plan for
implementation in the service, that is done under the premise that the following shortcomings have
been addressed ( López-López, et al., 2019):
1) Large sample sizes will be needed in further studies when comparing face to face CBT with
multimedia and hybrid CBT to account for the potential small differences expected.
2) Some of the complexity of CBT interventions have been addressed in the systematic review,
however a further qualitative inquiry should be made to maximise the strength and
possibilities of Cognitive Behavioral Therapy.
3) An economic analysis can be done to make sure that the proposed changes would be cost
effective for the service and beneficial for clients presenting with depressive symptoms.
4) Clinical tests to be done in a more ‘naturalistic’ environment like a local IAPT service.
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Apply the information
The knowledge we have obtained needs to now be transferred into clinical practice. It is important
that any change made to IAPT services should only be started when it is founded on evidence based
findings and first and foremost with the interests of clients at its heart (National Institute for Health
and Care Excellence, 2020).
To implement change, we need to understand the process of change and how to manage this. A
variety of models are available to help implement these changes. Lewin’s (1951) Model of
Organisational Change explains how barriers to change results in a ‘frozen’ state. To identify driving
and restraining forces the ‘Unfreezing’ state is involved and this leads subsequently to a proposed
guidance for the management part. Finally, successful implementation of the management part
allows the change to happen which will then become the new ‘frozen’ state.
Figure 2: Process of Organisational Change Lewin (1951)
Old State
FROZEN
Un-freeze
Change
Re-freeze
New State
FROZEN
The driving and restraining forces that support the unfreezing state are researched and applied in a
Force Field Analysis (Lewin, 1951) (Appendix D). This will make sure that when a change plan
(Appendix E) is implemented the adoption of new practices informed by EBP will be made more
smooth due to already being aware and having measures ready for reducing difficult situations
(Winch, et al., 2005).
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Audit
There are however many potential difficulties to the application of research into practice. For
example, resistance to change in practice may arise from both the clinician and patient, if the
patient’s needs are not holistically being met (Couvillion, 2005). Ongoing evaluation is therefore
important because it allows the monitoring of the change and gives the opportunity to make
changes if things are not working (Haber & LoBiondo-Wood, 2018).
The change can be monitored by collecting the outcomes from the PHQ-9 (The National
Collaborating Centre for Mental Health, 2020) in a systematic way and evaluating these for the
effectiveness of the different delivery methods. It is important to include revisiting of the research in
this cycle to ensure that new information can be used to make the implemented changes not
outdated (Craig & Smyth, 2007).
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Conclusion
By answering our research question we have been able to conclude that other delivery methods
than face to face are potentially as effective. As stressed before, it is important to keep the
limitations of the study in mind and to apply further research and evidence before implementing this
fully into practice ( López-López, et al., 2019). When making these recommendations, it was felt that
these limitations could be addressed and the potential benefits for clients and colleagues alike could
be felt as a positive change and cost effective intervention within the service.
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Appendix
Appendix A: Search results for each database
Psychinfo
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The Cochrane Library Online
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CINAHL
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Appendix B: Chosen research paper ( López-López, et al., 2019)
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Appendix C: CASP Systematic Review Checklist (Critical Appraisal Skills Programme, 2020)
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Appendix D: Force Field Analysis
Driving forces
Restraining forces

NICE guidelines


Minimal staff training needed


Cost effective alternatives

Research that has been critically
examined

Good amount of staff available

All change is difficult and staff might be
resistant
Even though it will be more cost
effective, money will have to be spent
to make the changes
Quality of the research had further
recommendations before
implementation was possible
Appendix E: Change plan
1) Arrange meeting to discuss evidence and suggested changes to clinical practice with
leadership team.
2) Assess and discuss potential costs for implementing this change if first approval given.
3) Get approval from leadership team for implementation of digital CBT.
4) Inquire if colleagues would be interested in joining a task force to set up the change if
previous step is accepted
5) Lead of task force to propose further research to be discussed and assessed before
implementation of clinical practice and to inform practical changes.
6) Design and implement new guidance for digital therapy. Make sure to seek ideas from both
the task force as well as leadership team and other colleagues to prevent smooth
implementation and non involvement.
7) Implement digital therapy with small team and collect PHQ-9 outcomes over a period of 3
months.
8) Evaluate outcomes and review further steps if needed.
9) Continue step 2-8 as needed for further implementation and to make impact in wider team.
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