Group psychological therapies for depression in the community:

systematic review and meta-analysis

Alyson L. Huntley, Ricardo Araya and Chris Salisbury
BJP 2012, 200:184-190.
Access the most recent version at DOI: 10.1192/bjp.bp.111.092049

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 The British Journal of Psychiatry (2012)
200, 184–190. doi: 10.1192/bjp.bp.111.092049
Review article
Group psychological therapies for depression
in the community: systematic review
and meta-analysis
Alyson L. Huntley, Ricardo Araya and Chris Salisbury
Background
Psychological therapies have been shown to be effective in
the treatment of depression. However, evidence is focused
on individually delivered therapies, with less evidence for
group-based therapies.
Aims
To conduct a systematic review and meta-analysis of the
efficacy of group-based psychological therapies for
depression in primary care and the community.
Method
We searched MEDLINE, Embase, PsycINFO, the Cochrane
Central Register of Controlled Trials and the Cochrane
Collaboration Depression, Anxiety and Neurosis Review
Group database from inception to July 2010. The Cochrane
risk of bias methodology was applied.
Results
Twenty-three studies were included. The majority showed
considerable risk of bias. Analysis of group
cognitive7behavioural therapy (CBT) v. usual care alone
(14 studies) showed a significant effect in favour of group
CBT immediately post-treatment (standardised mean
Various types of psychological therapy have been shown to be
effective in the treatment of depression of which the most popular
is cognitive–behavioural therapy (CBT). In a climate of limited
resources and long waiting lists, it is not surprising that there is
an emphasis on ensuring that psychological treatments are cost-
effective. The most recent UK National Institute for Health and
Clinical Excellence (NICE) guidance on depression recommends
psychological therapies as one of two first-line treatment options
(the other being an antidepressant) for people with persistent
subthreshold depressive symptoms or mild to moderate severity
depression who have not benefited from receiving a low-intensity
psychosocial intervention.1 The evidence also shows that there is
broad equivalence of effect between psychological therapies (such
as CBT) and antidepressants over a range of depression severities.1
Much of the evidence about psychological therapies pertains to
individual approaches. There is a paucity of evidence for group-
based therapies. At present, NICE guidance acknowledges a lack of
evidence for group-based therapies but recommends that group
CBT should be considered for people with persistent subthreshold
depressive symptoms or mild to moderate depression who have
declined low-intensity psychosocial interventions. Our aim was to
conduct a systematic review and meta-analysis of the efficacy of
group-based psychological therapies for depression, with a
particular focus on treatment in primary care and in the community.
Method
Types of studies
Randomised controlled trials (RCTs, individual or cluster
randomised) based in primary care or in the community in any
184
difference (SMD) 70.55 (95% CI 70.78 to 70.32)). There
was some evidence of benefit being maintained at short-
term (SMD = 70.47 (95% CI 71.06 to 0.12)) and medium- to
long-term follow-up (SMD = 70.47 (95% CI 7 0.87 to 70.08)).
Studies of group CBT v. individually delivered CBT therapy
(7 studies) showed a moderate treatment effect in favour
of individually delivered CBT immediately post-treatment
(SMD = 0.38 (95% CI 0.0970.66)) but no evidence of
difference at short- or medium- to long-term follow-up.
Four studies described comparisons for three other types of
group psychological therapies.
Conclusions
Group CBT confers benefit for individuals who are clinically
depressed over that of usual care alone. Individually
delivered CBT is more effective than group CBT immediately
following treatment but after 3 months there is no evidence
of difference. The quality of evidence is poor. Evidence about
group psychological therapies not based on CBT is
particularly limited.
Declaration of interest
None.
country were included. Quasi-randomised trials as defined by
the Cochrane Collaboration Depression, Anxiety and Neurosis
Review Group (CCDAN) were excluded. There were no
language restrictions.
Types of participants
Adults (aged 18 or over) of either gender with a primary diagnosis
of depression were included, whether or not this diagnosis had
been established by criteria such as DSM–IV2 or ICD–103 or
confirmed by a standardised clinician assessment. Studies were
included if 550% of participants were classified as clinically
depressed.
Studies were excluded if their inclusion criteria required any of
the following: a specific comorbid physical illness, self-harm, post-
traumatic stress disorder, seasonal affective disorder, eating
disorder, obsessive–compulsive disorder, phobia, panic attacks,
drug use, alcohol misuse, personality disorder, psychosis,
schizophrenia, pregnancy, postnatal women or grief. Studies
specifically of children and adolescents (under the age of 18)
and hospital in-patients were excluded. Studies in which
individuals were in remission from depression or when an
intervention was conducted as a preventative measure for
depression were excluded.
Types of interventions
We included any group intervention based on any form of
psychological therapy. The definition of psychological therapy
was based on that established by the CCDAN, and included

CBT, behavioural therapy, cognitive therapy, interpersonal
therapy, problem-solving therapy, non-directive counselling
therapy, supportive therapy, psychodynamic therapy and
variations thereof. We defined CBT as an intervention based on
cognitive restructuring training and/or promoting behavioural
change. In line with the CCDAN, we included problem-solving
and self-control approaches within the CBT category.
We found no formal definition of group therapy in either the
NICE guidance or related reviews, so for the purposes of this
review we defined group therapy as consisting of three or more
participants. Studies were included regardless of any concomitant
psychotropic medication regimes.
Types of outcome measures
Outcomes were categorised as immediately post-treatment (within
1 week of end of treatment), short term (41 week to 3 months
inclusive) and medium to long term (43 months) following
completion of intervention. Any studies with a follow-up period
of 1 month or less duration from randomisation were excluded.
Primary outcome
The primary outcome was clinical improvement in depression,
measured using a validated self-report or interview-based measure
expressed as a continuous outcome using validated depression
questionnaires or rating scales. If multiple measures were used,
we used clinician-rated scales such as the Hamilton Rating Scale
for Depression (HRSD)4 as first choice for data extraction if
available.
Secondary outcomes
We extracted data about cost-effectiveness as a secondary
outcome.
Search methods
We searched MEDLINE, Embase, PsycINFO, the Cochrane
Central Register of Controlled Trials and the CCDAN databases
from inception until July 2010. In addition, we inspected the
references of all selected studies for published reports, citations
of unpublished reports and relevant review papers. To ensure all
RCTs were identified, we contacted the authors of the trials
included and other experts in the field.
Data management and analysis
Selection of studies
One reviewer (A.L.H.) screened the abstracts of all publications
obtained by the search strategy, in order to exclude the obviously
irrelevant studies. Two authors screened the remaining relevant
abstracts to identify those that were potentially eligible. Using
the full text of these papers, eligibility based on the inclusion
and exclusion criteria was assessed independently by two authors.
Disagreements were resolved by consensus and where necessary by
involving a third author. Records were kept of reasons for
exclusion. References were managed using Reference Manager
version 12.0 on Windows.
Data extraction
We collected the items of data described above in addition to
general study characteristics for each included study (online Table
DS1). Data were managed using Revman software 5.01 on
Group psychological therapies for depression in the community
Windows. One author extracted data independently and a second
checked these for accuracy. Disagreements were resolved by
consensus and where necessary by involving a third reviewer.
Assessment of risk of bias
We assessed the quality of included studies using the Cochrane
Collaboration’s domain-based evaluation tool for assessing risk
of bias.5 This consists of six questions: two assess the applicability
of the randomisation process; one assesses the analysis of
incomplete data; and the remaining questions cover incomplete
data, selective reporting and other biases. These are answered
no, yes or unclear.
Measures of treatment effect
We made the following comparisons: group-based psychological
therapy intervention v. (a) usual care or (b) psychological therapy
delivered individually. We made each comparison at baseline,
immediately post-treatment, after short-term and after medium-
to long-term follow-up.
Data synthesis
Meta-analysis was considered appropriate if there were at least
three similar studies (similar in terms of patient type, setting
and intervention). The purpose of the meta-analysis was to
determine any differences in treatment effect of group-based
psychological therapies in comparison with other standard
treatments for depression in primary care or out-patient settings.
Continuous data were meta-analysed using the standardised mean
difference (SMD), as different psychometric scales were used in
different primary studies. If heterogeneity was 450%, a fixed-
effects model was used. If heterogeneity was 450%, then we
explored heterogeneity using subgroup analysis and then applied
a random-effects model. For consistency in comparisons, a
negative SMD indicates lower depression scores in the group
therapy arm.
Results
The database searches resulted in 13 303 records being identified
(online Fig. DS1). Following title screening for obvious
irrelevance, 185 records remained. After abstract screening, 90 full
text articles were read to assess their eligibility, of which 29 articles
were included describing 23 original studies, with 1 follow-up
paper.6–34 Of these, 12 studies investigated group CBT plus usual
care v. usual care alone,6,8–18 5 studies compared group CBT v.
individually delivered CBT therapy,19,20,22,24,25 2 studies had both
of the latter comparisons in a three-arm design,26,27 and 4 studies
published in 5 papers described comparisons for dialectical
behaviour therapy (DBT) (n = 2), interpersonal therapy or self-
control therapy v. usual care.28–30,32,34 No quasi-randomised trials
were identified.
Risk of bias in studies
The first three questions of the risk of bias tool were easy to apply
to the studies in this review (Fig. 1). However, the remaining three
questions posed difficulties. Due to the nature of the intervention,
masking of the participants was not possible, thus all studies were
scored as ‘no’. Selective reporting was difficult to assess since the
majority of studies were conducted prior to the introduction of
trial registration sites that contain protocols and predefined
outcome measures. Thus, we assessed whether the outcome
measures described in the method of the paper were reported in
185
Huntley et al

the results section of the paper. Unsurprisingly, all studies scored Because there were only two comparisons with more than two
‘yes’. The final question asked whether the studies were free of included studies, we have focused the presentation of results on
other biases. This was sometimes difficult to assess because of these: (a) group CBT plus usual care v. usual care alone (n = 14
limitations in how studies were reported. studies) and (b) group CBT v. individual CBT (n = 7 studies).
There were four further comparisons describing three other
distinct psychological therapies.

Incomplete outcome data addressed?

Adequate sequence generation?
Studies describing group CBT plus usual care v. usual care alone

Free of selective reporting?

Allocation concealment?
In total, 5 out of the 14 studies described adequate sequence
generation for randomisation and described details of allocation

Free of other bias?

concealment. The remaining studies provided insufficient data
to judge how randomisation was performed. Of the 14 studies,
all but 3 included details of individuals who had dropped out.
Binding?

Seven studies performed intention-to-treat analysis; three were

described as being analysed according to treatment arm and four
gave no details.
Araya et al (2003)6 q q q q

Banken (1993)19 ]
? q q Individual CBT v. group CBT
None of the seven studies provided sufficient information to judge
Bolton et al (2003)30 ]
? q q ]
? whether there was adequate sequence generation or allocation
concealment during randomisation. In addition, one study stated
Brown & Lewinsohn (1984)26 ? ]
] ? ]
? q that anyone dropping out would lead to ‘replacement depending
on format availability’.19 Three of the studies reported details of
Epstein (1986)8 ? ]
] ? q q individuals who had dropped out, addressed incomplete data
and how participants were analysed. For the remaining four
Feldman et al (2009)29 ]
? q q q studies there were no details on individuals who had dropped
out, missing data or whether analysis was on an ‘intention-to-
Hamamci (2006)9 ? ]
] ? ]
? q treat’ basis.
Hamdan-Mansour et al (2009)10 q q q q
Remaining studies
Hautzinger & Welz (2004)11 ? ]
] ? q q
Reporting of these studies suggested methodological weaknesses.
12
q q q q q All studies provided insufficient information to assess whether
Hegerl et al (2010)
there was adequate sequence generation or allocation concealment
during randomisation, with the exception of Feldman et al who
Lynch et al (2003)28 ]
? q q
described the randomisation method.29 Bolton et al stated that
Nezu (1986)13 ? ]
] ? q q some participants were excluded post-randomisation ‘if their
age would skew data’.30 Lynch et al randomised participants using
Ravindran et al (1999)14 q ]
? q q ]
? the ‘toss of a coin’.28 All four studies described individuals who
dropped out but only two described intention-to-treat analysis
Rehm et al (1981)34 ]
? ]
? ]
? q and the remaining two gave insufficient detail.

Schmidt & Miller (1983)27 ]

Shaffer et al (1981)20
Teri & Lewinsohn (1986)22
Wierzbicki & Barlett (1987)24
Wollersheim & Wilson (1991)15
Wong (2008)16
? ]
? q q
Study size
]
? ]
? q q Another common methodological problem was the very small
number of participants in some studies. Ten studies (43%) had
]
? ]
? ]
? q less than 15 participants in the intervention study arm(s), eight
studies (35%) had 16–50 participants per arm and only five
]
? ]
? ]
? q studies (22%) had 51 or more participants per arm. It is of note
that for the two main comparisons, the 14 studies of group
]
? ]
? ]
? q CBT v. usual care had a total number of 1217 participants, whereas
the 7 studies of group CBT v. individual CBT had a total of only
]
? q q q 211 participants.

Wong (2008)17 ]
? q q q
Effects of interventions
Yang et al (2009)18 ]
? q q q Depression was measured in the majority of studies using the Beck
Depression Inventory (BDI) (n = 13) and eight studies used the
Zettle et al (1992)25 ]
? ]
? q q HRSD. Some used both of these measures but as per the protocol,
HRSD was used for the analysis. The remaining two studies used
Fig. 1 Risk of bias. +, low risk of bias; 7, high risk of bias;
the Hopkins Symptom Checklist and the Geriatric Depression
?, unclear risk of bias. Scale. Data were continuous and so were subject to calculation
of standardised mean differences.

186
 Group psychological therapies for depression in the community

Group CBT plus usual care v. usual care alone
For the 14 studies in the group CBT plus usual care v. usual care
alone (total n = 1217), analysis data for depression scores showed
no evidence of difference at baseline between participants for all
studies combined.6,8–18,26,27 Immediately post-treatment, there
was a significant treatment effect in favour of group CBT plus
usual care v. usual care alone (n = 14 studies; SMD =70.55
(95% CI 70.78 to 70.32)) (Fig. 2(a)). In a sensitivity analysis
we excluded the Araya et al study, which was based on a CBT group
intervention but included attention to other aspects of care as well.6
This made no difference to the findings.
Few studies provided data beyond the immediate post-
treatment phase. At short-term and medium- to long-term
follow-up (n = 3 studies each), data suggests a positive effect of
group CBT over usual care alone (SMD =70.47 (95% CI 71.06
to 0.12) and SMD =70.47 (95% CI 70.87 to 70.08)
respectively), but confidence intervals are wide so a definitive
statement is not possible (Fig. 2(b) and (c)).
Group CBT v. individual CBT therapy
For the seven studies in the group CBT v. individual CBT therapy
analysis (total n = 211) there was no evidence of difference at
baseline for all studies combined.19,20,22,24–27 Immediately post-
treatment (n = 7 studies), there was a moderate treatment effect
in favour of individual CBT v. group CBT (SMD = 0.38 (95%
CI 0.09–0.66)) (Fig. 3(a)). Both short- and medium- to long-term
follow-up data (n = 3 studies each) showed no evidence of
difference in effect between group CBT and CBT delivered
individually (SMD =70.10 (95% CI 70.80 to 0.60) and
SMD =70.11 (95% CI 70.52 to 0.30) respectively (Fig. 3(b)
and (c)).
Other studies
There were four studies in five papers describing comparisons for
DBT (two studies), interpersonal therapy and self-control therapy
with usual care (Table 1).28–30,32,34 All showed a positive treatment

(a)
Group CBT Usual care SMD SMD
Study or subgroup Mean s.d. Total Mean s.d. Total Weight IV, Random, 95% CI IV, Random, 95% CI
Araya et al (2003)6 10.55 9.7 102 19.61 9.9 109 11.3% 70.92 (71.21 to 70.64)
Brown & Lewinsohn (1984)26 15.48 12.28 25 18.18 11.29 11 6.0% 70.22 (70.93 to 0.49)
Epstein (1986)8 14.57 8.34 9 18.49 8.25 10 4.4% 70.44 (71.35 to 0.47)
Hamamci (2006)9 10.3 8.09 10 23.18 9.36 11 4.0% 71.41 (72.39 to 70.43)
Hamdan-Mansour et al (2009)10 13.5 7.1 44 18 7 40 9.1% 70.63 (71.07 to 70.19)
Hautzinger & Welz (2004)11 13.55 6.67 55 17.73 5.86 30 8.9% 70.65 (71.10 to 70.19)
Hegerl et al (2010)12 9.32 5.05 41 9.48 7.62 61 9.7% 70.02 (70.42 to 0.37)
Nezu (1986)13 9.82 4.71 11 21 6.27 6 2.7% 72.01 (73.27 to 70.75)
Ravindran et al (1999)14 12 4.91 24 14 6.23 24 7.5% 70.35 (70.92 to 0.22)
Schmidt & Miller (1983)27 16 7.3 11 21.7 9 10 4.6% 70.67 (71.56 to 0.21)
Wollersheim & Wilson (1991)15 20 13.73 8 18.25 7.55 8 4.0% 0.15 (70.83 to 1.13)
Wong (2008)16 0.54 0.48 163 0.9 0.49 159 12.0% 70.74 (70.97 to 70.51)
Wong (2008)17 13.1 11.1 48 22.4 13.3 40 9.2% 70.76 (71.19 to 70.32)
Yang et al (2009)18 26.4 14.28 17 20.57 13.56 19 6.5% 0.41 (70.25 to 1.07)

Total (95% CI) 568 538 100.0% 70.55 (70.78 to 70.32)

Heterogeneity: t2 = 0.11; w2 = 35.59, d.f. = 13 (P = 0.0007); I 2 = 63%
74 72 0 2 4
Test for overall effect Z = 4.61 (P50.00001) Favours experimental Favours control

(b)
Group CBT Usual care SMD SMD
Study or subgroup Mean s.d. Total Mean s.d. Total Weight IV, Random, 95% CI IV, Random, 95% CI
Araya et al (2003)6 6.75 8.2 104 15.7 10.7 107 38.2% 70.93 (71.22 to 70.65)
Hamdan-Mansour et al (2009)10 12.7 9.4 44 17.8 9.9 40 34.1% 70.52 (70.96 to 70.09)
Yang et al (2009)18 21.59 16.61 17 18.05 3.57 19 27.7% 0.23 (70.43 to 0.89)

Total (95% CI) 165 166 100.0% 70.47 (71.06 to 0.12)

Heterogeneity: t2 = 0.22; w2 = 10.91, d.f. = 2 (P = 0.004); I 2 = 82%
74 72 0 2 4
Test for overall effect Z = 1.56 (P = 0.12) Favours experimental Favours control

(c)
Group CBT Usual care SMD SMD
Study or subgroup Mean s.d. Total Mean s.d. Total Weight IV, Random, 95% CI IV, Random, 95% CI
Hamamci (2006)9 10.1 6.6 10 14.54 11.16 11 20.4% 70.46 (71.33 to 0.41)
Hautzinger & Welz (2004)11 13.5 6.9 50 17.73 5.86 23 60.6% 70.63 (71.14 to 70.13)
Schmidt & Miller (1983)27 13.4 7.2 10 13.2 10.3 9 19.0% 0.02 (70.88 to 0.92)

Total (95% CI) 70 43 100.0% 70.47 (70.87 to 70.08)

Heterogeneity: w2 = 1.55, d.f. = 2 (P = 0.46); I 2 = 0%
Test for overall effect Z = 2.36 (P = 0.02) 74 72 0 2 4
Favours experimental Favours control

Fig. 2 Group cognitive–behavioural therapy (CBT) plus usual care v. usual care alone (a) immediate post-treatment, (b) short-term
follow-up, (c) medium- to long-term follow-up. SMD, standardised mean difference.

187
Huntley et al

effect for the psychological therapies over the usual care post-
treatment but due to the small number of studies and their
evident methodological weaknesses, no firm conclusions can be
reached.
Cost-effectiveness data
Cost-effectiveness was reported by Araya et al based on their 2003
trial conducted in Chile.7 They reported that their group CBT
intervention achieved 50 more depression-free days at 6 months
than the usual care group after adjusting for age, presence of
chronic disease and initial severity of depression. This improved
clinical outcome was achieved at an additional cost of US$37.6
over that of usual care alone. The incremental cost-effectiveness
ratio was US$0.75 that is one extra depression-free day was
achieved with group CBT therapy relative to usual care at a cost
of US$0.75. The authors concluded that the group CBT therapy
was significantly more effective and marginally more expensive
than usual care alone in the treatment of women with depression
in primary care in Chile.
Siskin and colleagues33 used the data from the Ugandan
study30,32 cited in this review, in combination with other data
from depression studies from low- and middle-income countries,
to develop a Markov cohort model of depression and evaluate the
health benefits and costs associated with group CBT with and
without booster sessions. These calculations showed that group
CBT in Uganda decreased the number of depressive episodes by
6.2% without or 15.8% with booster sessions. The incremental
cost-effectiveness ratio for group CBT with booster sessions was
$1.150 international dollars per quality-adjusted life year compared
with no intervention. This incremental cost-effectiveness ratio
for group CBT with booster sessions falls below the threshold
for cost-effectiveness in Uganda.
Discussion
Main findings
The purpose of this review was to assess the benefits of group-
based psychological therapies compared with the main alternatives
that may be available in primary care settings. Despite the
Improving Access to Psychological Therapies initiative in
England, the availability of individual therapy remains limited
and very few people receive individual CBT in the form
recommended by NICE (16–18 sessions from a trained
therapist).35 For most people the most relevant comparison is
between group-based therapy or usual primary care alone.
Although acknowledging that the volume of papers is small
and the quality of data variable, with many studies showing
considerable risk of bias and other methodological problems,
the results show that group CBT does indeed confer some
immediate benefit to individuals with depression above that
of usual care alone. By the short- and medium- to long-term

(a)
Group CBT Individual CBT SMD SMD
Study or subgroup Mean s.d. Total Mean s.d. Total Weight IV, Random, 95% CI IV, Random, 95% CI
Banken (1993)19 4.8 3.05 10 4.71 2.29 7 8.9% 0.03 (70.94 to 1.00)
Brown & Lewinsohn (1984)26 15.48 12.28 25 15.08 10.43 13 18.5% 0.03 (70.64 to 0.70)
Schmidt & Miller (1983)27 16 7.3 11 7.3 6.4 12 10.1% 1.23 (0.32 to 2.13)
Shaffer et al (1981)20 5.1 4.6 10 7.2 4.2 12 11.4% 70.46 (71.31 to 0.39)
Teri & Lewinsohn (1986)22 5.5 5.25 47 2.29 3.33 19 27.9% 0.66 (0.12 to 1.21)
Wierzbicki & Barlett (1987)24 11.78 9.3 9 5.78 3.6 9 8.8% 0.81 (70.16 to 1.78)
Zettle et al (1992)25 15.96 5.9 14 14.15 6.77 13 14.4% 0.28 (70.48 to 1.04)

Total (95% CI) 126 85 100.0% 0.38 (0.09 to 0.66)

Heterogeneity: w2 = 10.46, d.f. = 6 (P = 0.11); I 2 = 43%
Test for overall effect Z = 2.56 (P = 0.01) 74 72 0 2 4
Favours experimental Favours control

(b)
Group CBT Individual CBT SMD SMD
Study or subgroup Mean s.d. Total Mean s.d. Total Weight IV, Random, 95% CI IV, Random, 95% CI
Brown & Lewinsohn (1984)26 6.47 5.51 25 12.31 9.39 13 32.3% 70.81 (71.51 to 70.11)
Shaffer et al (1981)20 7.82 6.05 47 5.59 7.33 19 37.1% 0.34 (70.19 to 0.88)
Zettle et al (1992)25 13.21 8.92 14 12.15 8.31 13 30.6% 0.12 (70.64 to 0.87)

Total (95% CI) 86 45 100.0% 70.10 (70.80 to 0.60)

Heterogeneity: t = 0.27; w2 = 6.83, d.f. = 2 (P = 0.03); I 2 = 71%
Test for overall effect Z = 0.27 (P = 0.78) 74 72 0 2 4
Favours experimental Favours control

(c) Group CBT Individual CBT SMD SMD

Study or subgroup Mean s.d. Total Mean s.d. Total Weight IV, Random, 95% CI IV, Random, 95% CI
Brown & Lewinsohn (1984)26 6.12 6.46 25 8.46 7.52 13 36.6% 70.34 (71.01 to 0.34)
Schmidt & Miller (1983)27 13.4 7.2 10 8.4 7.8 11 21.4% 0.64 (70.24 to 1.52)
Teri & Lewinsohn (1986)22 6.03 5.94 39 7.92 7.43 13 42.0% 70.20 (70.92 to 0.34)

Total (95% CI) 74 37 100.0% 70.11 (70.52 to 0.30)

Heterogeneity: w2 = 3.52, d.f. = 2 (P = 0.17); I 2 = 43%
Test for overall effect Z = 0.53 (P = 0.60) 74 72 0 2 4
Favours experimental Favours control

Fig. 3 Group cognitive–behavioural therapy (CBT) v. individual CBT (a) immediate post-treatment, (b) short-term follow-up, (c) medium-
to long-term follow-up. SMD, standardised mean difference.

188

Table 1 Results of studies not included in meta-analysis a
Group cognitive–behavioural therapy
Intervention type Mean (s.d.)
Group dialectical behavioural therapy
Lynch et al (2003)28,b 12.93 (9.38)
Feldman et al (2009)29 11.30 (5.31)
Group interpersonal therapy
Bolton et al (2003),30 Bass et al (2006)32 6.1 (6.3)
Bolton et al (2003),30 Bass et al (2006)32,c 6.1 (7.5)
Group self-monitoring
Rehm et al (1981)34 9.33 (6.1)
a. All results are for immediately post-treatment, except where indicated.
b. Medium- to long-term data (6 months) were available for Lynch et al as dichotomous data: 75% v. 31% remission (group dialectical behavioural therapy v. usual), w2 = 6.15, P = 0.01).
c. Medium- to long-term follow-up (6 months).
the benefits appear to be maintained, although the evidence is
less robust because of the small number of papers providing
follow-up data.
The studies comparing group CBT to individual CBT had a high
risk of bias and very small sample sizes. Notwithstanding these
limitations, these data suggest that individual CBT might be superior
to group CBT in the immediate period following treatment. There
was no evidence of difference at short- and medium- to long-term
follow-up, but again the available data are very limited.
Relevant cost-effectiveness data are lacking but there are
indications that group psychological therapies may be cost-
effective, at least in low- and middle-income countries. The lack
of data about cost-effectiveness of group therapy within any
high-income country is striking, given that increased cost-
effectiveness is a key justification for treating people in groups.
Strengths and limitations
This review focuses on studies of group CBT in the context
in which it is most likely to be delivered within the National
Health Service in the UK, that is in primary care and the
community. Many organisations provide group-based
psychological therapy, but systematic reviews of the evidence to
support this development have been lacking.
Our review has a number of limitations. The vast majority of
the identified studies allowed participants to take concomitant
antidepressant medication, which makes it difficult to isolate the
effect of the group psychological therapies alone on depression.36
However, this is in line with the most recent guidance from NICE,
which advocates a stepped-care model with a multifaceted
treatment approach including medication and psychological
therapies.1 There was considerable heterogeneity between the
effect sizes of different studies. This may reflect differences in
severity of depression at baseline. More recent studies tended to
be of better quality but, generally, the quality of studies was low
and sample sizes were very small. The lack of follow-up data is
a serious problem that makes it difficult to use this research
to inform evidence-based policy about how best to deliver
psychological therapy services. This is compounded by the lack
of data about cost-effectiveness.
In their recently updated guidance on the management of
depression, NICE identified five trials of group CBT v. waiting-list
control or treatment as usual.1 There was a significant effect of
group CBT in lowering depression scores at end-point
(SMD =70.60 (95% CI 70.84 to 70.35)) and at 6 months
follow-up (SMD =70.40 (95% CI 70.83 to 0.02)). The National
Institute for Health and Clinical Excellence concluded that there
was limited evidence about group CBT but it was an option for
Group psychological therapies for depression in the community
Usual care
n Mean (s.d.) n Mean difference (95% CI)
17 16.86 (12.93) 17 73.93 (711.92 to 3.66)
10 17.11 (6.23) 9 75.81 (711.04 to 70.58)
103 20.6 (9.0) 113 714.50 (716.56 to 712.44)
103 20.5 (10.1) 113 714.40 (716.76 to 712.04)c
12 14.27 (7.09) 16 74.94 (79.84 to 70.04)
people with persistent subthreshold depressive symptoms and
mild to moderate depression who declined low-intensity
psychosocial interventions. Our review updates the NICE review
by including a further nine trials not identified by NICE.
The National Institute for Health and Clinical Excellence
argued that group CBT was likely to be less cost-effective than
low-intensity interventions but more cost-effective than individual
CBT, and so was placed between them in the stepped-care model.
However, NICE did not identify any trials or provide any analysis
of the cost-effectiveness of group CBT v. either usual care or
individual CBT. The comparison between group and individual
CBT was not directly addressed by NICE but was addressed by
Cuijpers et al.37 Their review compared group psychological
therapies v. individually delivered therapies in a range of settings,
with the most recent included study being published in 2005. Our
results support the findings of that review, with evidence for
increased benefit from individually provided therapies compared
with group sessions immediately post-treatment but not over a
longer follow-up period.
Group-based psychological therapies are rapidly being rolled
out across England in response to the Improving Access to
Psychological Therapies initiative. Our systematic review has
highlighted that the evidence to support this development is
limited but auspicious. There will always be individuals who will
not like or respond to group therapy but for those that it does suit,
group therapy may be a reasonably cost-effective approach.
There are several good reasons to believe that delivering
psychological therapies in groups may be appropriate. Group
interventions allow people to support each other as well as to
re-invigorate natural social networks.38 Group therapy is a good
way of increasing access by making it possible to treat more
people from the same resource. This may also make group-based
therapy potentially more cost-effective, at least from the
perspective of a commissioner of services. However, it is
important to bear in mind that small differences in effectiveness,
as well as consideration of overall costs (of which direct treatment
provision is only one part) mean that group interventions may or
may not be more cost-effective than individual care at a health
service or societal level. This review highlights the need for
high-quality trials of group-based psychological therapy, including
economic analysis, in high-income countries such as the UK in
order to inform policy about provision of psychological therapies
in the community.
Funding
This study was funded by South West GP Trust.
189
Huntley et al
Alyson L. Huntley, PhD, Academic Unit of Primary Care; Ricardo Araya, MD,
Academic Unit of Psychiatry; Chris Salisbury, MD, Academic Unit of Primary Care,
School of Social and Community Medicine, University of Bristol, Bristol, UK
Correspondence: C. Salisbury, MD, Academic Unit of Primary Care, School
of Social and Community Medicine, University of Bristol, Canynge Hall,
39 Whatley Road, Bristol, UK. Email: c.salisbury@bristol.ac.uk
First received 21 Jan 2011, final revision 4 Aug 2011, accepted 26 Oct 2011
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 British Journal of Psychiatry (2012)
200, 184–190. doi: 10.1192/bjp.bp.111.092049

Fig. DS1 PRISMA 2009 flow diagram

Records identified through

database searching
Identification

(n = 13,303)

Records after duplicates removed

(n = 11,131)

Records screened by title for obvious irrelevance

Screening

Records screened Records excluded

(n = 185 remaining) (n = 10,946)

Records screened by abstract

Eligibility

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons (n = 95)
(n = 90)

30 papers included in
Included

review
(n = 23 studies)

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-
Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

For more information, visit www.prisma-statement.org.

 Table DS1 Characteristics of included studies
Depression
Reference Setting Participants Intervention group Comparison group Therapists measure

(a) Studies with the comparison of group CBT plus usual care v. usual care alone (n = 12)
Araya et al Primary care n = 240 major depression 3-month stepped-care programme n = 120 Usual care n = 120 Social workers and nurses HRSD
(2003),6 (2006)7 Chile 42.6 years (s.d. = 3.6) 7 weekly sessions, homework advised and Trained and supervised
100% female 2 booster sessions
88% completed
Epstein (1986)8 No details n = 26 BDI 411 Group CBT n = 9 No treatment n = 10 No details BDI
USA 39.42 years 8 consecutive weekly sessions of 1.5 h
Data supplement

No further details
Hamamci (2006)9 University n = 31 moderate depression (BDI 419) Group CBT n = 10 No treatment n = 11 Therapist with didactic and BDI
Turkey 19.52 years (s.d. = 2.09) 3 h sessions over 11 weeks, no homework experiential training in CBT
48% female
% completed unknown
Hamdan-Mansour et al University n = 84 moderate to severe depressive Group CBT based on the ‘Teaching Kids No additional healthcare Group leaders were master-level BDI
The British Journal of Psychiatry (2012)

(2009)10 Israel symptoms to Cope’ programme n = 44 n = 40 psychiatric/mental health nurses

Students (no ages given) 10 weekly sessions of 45 min who received training by expert
45% female No mention of homework nurse who designed programme
200, 184–190. doi: 10.1192/bjp.bp.111.092049

No further information
Hautzinger & Welz University n = 100 GP or self-referral Group CBT n = 65 Waiting list n = 35 No details GDS
(2004)11 Germany 80% had major depression 12 groups of 5–7 participants, 2 h weekly
60 years + over 3 months
No gender details
90% completed
Hegerl et al University n = 368 primary care patients with There were 5 arms of study Sertraline group n = 83 Group leader (no details) HRSD
(2010)12 Germany depression HRSD mean score 16 Group CBT n = 61
(range 13–20) 9 weekly group sessions of 50 min
46.4 years (s.d. = 14.6) Manual guided
59% completed No mention of homework
Nezu (1986)13 University n = 26 non-psychotic unipolar depression Group PST n = 11 Waiting list n = 6 Advanced clinical psychology BDI
USA (RDC) 8 weekly sessions 1.5–2 h plus homework graduate students with 4.5 years
No further details experience
77% completed Manuals used
Supervised
Ravindran et al University n = 97 primary dysthymia Group CBT and placebo drug n = 24 Placebo drug n = 24 Therapists with 15 years of HRSD
(1999)14 Canada 21–54 years Groups of 7–10 participants, 12 weekly, CBT therapy in the hospital setting
58% female 90 min sessions plus homework
97% completed
Wollersheim & Wilson University n = 32 570 MMPI Group CBT n = 8 Delayed treatment n = 8 No details BDI
(1991)15 USA 39.4 years 10 sessions
59% female Participants encouraged to practice
78% completed No further details
Wong (2008)16 University n = 337 Group CBT n = 167 Waiting list n = 170 Group CBT trainees BDI
Hong Kong BDI 49 10 weekly sessions, 3 h each 3 days training
42.72 years (s.d. = 8.7) 7–8 participants per group Manual used
78% female No further details Observed
96% completed

(continued)

1
2
Table DS1 Characteristics of included studies (continued)
Depression
Reference Setting Participants Intervention group Comparison group Therapists measure

Wong (2008)17 University n = 96 Group CBT n = 48 Waiting list n = 48 Experienced mental health workers BDI
Hong Kong BDI 49 10 weekly sessions 2.5 h Manual used
37.4 years (s.d. = 9.4) 8–9 participants per group Supervised
78% female No further details
96% completed
Yang et al (2009)18 University n = 65 out-patients with major Group CBT n = 38 ‘Monotherapy’ Author ‘who was trained’ ran BDI
Hong Kong depression Received for 2 month, 120 min weekly for 8 (antidepressants) the group therapy
Mean age 42 years weeks then encouraged to practise for the n = 27
64% female next 2 months
55% completed
(b) Studies with the comparison of group CBT v. individually delivered CBT (n = 5)
Banken (1993)19 University n = 28 CWD n = 19 Individual CWD n = 9 Advanced doctoral students in HRSD
USA BDI 513, HRDS 514 12 sessions of 1.5 h Details as per group sessions clinical psychology
44.7 years (s.d. = 11.89) No further details Supervised
75% female
61% completed
Shaffer et al (1981),20 University n = 44 sought treatment for depression Group CBT n = 10, Individual CBT n = 12 Clinical psychologists with extensive HRSD
Shapiro et al (1982)21 USA and anxiety and were screened 10 weekly sessions, 1.5 h Details as group except experience in both group and
21–40 years No further details sessions were 1 h individual CBT
66% female
80% completed
Teri & Lewinsohn (1986),22 University n = 66 major or minor depression CWD n = 47 Individual CBT n = 19 Advanced graduate students in BDI
Lewinsohn et al (1985)23 USA (SADS-RDC) 12 sessions over 8 weeks with 6 per group 12 sessions over 12 weeks clinical psychology 2 years’ experience
34.7 years (s.d. = 10.36) Homework was given 3-month training
60% female Used manual
No details on completion Supervised
Wierzbicki & Barlett University n = 18 depression (DSM-III) Group CBT n = 9 Individual CBT n = 9 Graduate students on an BDI
(1987)24 USA BDI 8–35 at recruitment Groups of 4 and 5, 60 min weekly Details as group CBT MA programme in psychology
No further details for 6 weeks
Zettle et al (1992)25 University n = 30 HRSD 514 Group CBT n = 14 Individual CBT n = 13 Therapist with previous training HRSD
USA 43 years 12 weekly sessions in 2 groups 12 weekly sessions in cognitive therapy
‘Mostly female’ No further details Homework
90% completed
(c) Studies with both comparisons in a three-arm study design (n = 2)
Brown & Lewinsohn University n = 63 unipolar depression CWD n = 25 Waiting list n = 11 Advanced doctoral students BDI
(1984)26 USA 36.5 years 12 sessions of 2 h, twice weekly for 4 weeks, Individual CWD in clinical psychology
70% female followed by weekly for next 4 weeks n = 13 details as group except Trained
(75 were randomised but only 63 Homework and meetings with instructors sessions were 450 min Manual used
actually had depression) at 1 and 6 months Supervised
Schmidt & Miller University n = 56 BDI of 510 Group CBT n = 11 Waiting list n = 10 Paraprofessional therapists with BDI
(1983)27 USA 42 years 8 weekly sessions of 90 min Individual CBT n = 12 experience in clinical interviewing
84% female plus homework Details as group 16 h of training over 8 weeks
96% completed was given
Manual used

(continued)
 Table DS1 Characteristics of included studies (continued)
Depression
Reference Setting Participants Intervention group Comparison group Therapists measure

(d) Studies describing other group psychological therapies (n = 4)

Lynch et al (2003)28
Feldman et al (2009)29
Bolton et al (2003),30
Verdeli et al (2003),31
Bass et al (2006),32
Siskin et al (2008)33
Rehm et al (1981)34
University n = 34 Group DBT and telephone coaching n = 17 Standard medication n = 17 Clinical psychology doctoral BDI
USA DDES and HRSD 418 2 h weekly for 28 weeks plus standard for 28 weeks students, MA therapist, clinical
66 years (s.d. = 5.0) medication plus homework psychology interns and licensed
85% female PhD clinical psychologist
85% completed
Hospital n = 24 treatment-resistant major Group DBT n = 12 Waiting-list control n = 12 Co-led by two clinical psychologists HRSD
USA depressive disorder 16 weekly sessions of 1.5 h plus homework who had had specific intensive DBT
41.8 years training
75% female
79% completed
Rural n = 248 screened with HSC and met IPT n = 116 Waiting list n = 132 Groups were led by a local person HSC
Uganda DSM-IV criteria for depression Each group (8–10) met for 90 min weekly of the same gender as the group
Mean age 47 years for 16 weeks 2 weeks of intensive training from
50% female No description of homework 2 of the authors
97% completed
University n = 56 Group self-monitoring therapy n = 12 Waiting list n = 16 Advanced graduate students in HRSD
USA Participants met 5/8 RDC for depression 7 weeks clinical psychology with previous
39.2 years No further details experience
No further details Trained
93% completed Manual used

HRSD, Hamilton Rating Scale for Depression; CBT, cognitive–behavioural therapy; BDI, Beck Depression Index; GP, general practitioner; GDS, Geriatric Depression Scale; RDC, Research Diagnostic Criteria; PST, problem-solving therapy; MMPI, Minnesota Multiphasic
Personality Inventor; DSM, Diagnostic and Statistical Manual of Mental Disorders; CWD, Coping with depression; SADS-RDC, Schedule for Affective Disorders and Schizophrenia – Research Diagnostic Criteria, DDES, Detection of Depression in the Elderly Scale; DBT,
dialectical behavioural therapy; IPT, Interpersonal therapy; HSC, Hopkins Symptom Checklist.