In recent years, cognitive-behavioural therapy (CBT) has become the most widely delivered therapy for depression within the NHS.  CBT interventions are recommended by NICE for people with mild, moderate and severe depression.

By contrast, recent NICE guidelines recommend counselling only for people with persistent subthreshold depressive symptoms or mild to moderate depression who decline another first line form of treatment; and professionals are urged to discuss with the person the uncertainty of its effectiveness.  But is CBT really more effective for depression than counselling?

In one of the largest randomised controlled trials to date (King et al., 2000), patients who had up to 12 weeks of non-directive counselling did just as well as patients who had up to 12 weeks of individual CBT.  However, the results of this study have been widely challenged on the grounds that a proportion of patients either did not meet the criteria for any psychiatric diagnosis, or received a diagnosis of an anxiety state.

As a consequence of this, King and colleagues have recently re-analysed their data (King et al, 2013), focusing specifically on clients who had been diagnosed with an ICD-10 depressive disorder.

Methods

The re-analysis looked at the data in two ways:

1. First, for the 316 patients who had been randomised in the original trial, they examined whether having an ICD-10 diagnosis of depression influenced the results of the CBT versus counselling comparison.
2. Second, they directly compared the results from CBT and from counselling for those 130 patients with a primary or secondary diagnosis of ICD-10 depressive episode.

The outcome measures were the Beck’s Depression Inventory, the Social Adjustment Scale, and the Brief Symptom Inventory; at four and 12 months from baseline.

Results

In their first analysis, the authors found that the interaction between treatment type and ICD-10 diagnosis was not significant on any of the measures.  In other words, whether or not patients had an ICD-10 diagnosis of depressive episode did not affect how well they did in counselling, as compared to CBT.

In their second analysis, King and colleagues found that the 58 depressed patients who participated in CBT did not have significantly better outcomes than the 49 patients who participated in counselling:

• For instance, on the Beck’s Depression Inventory, the CBT patients dropped from a mean score of 29 at baseline, to 15 at four months, and 12 at 12 months
• Almost identically, the counselling patients started with a mean score of 31 at baseline, and dropped to 14 at four months and then 12 at 12 months.

Conclusions

The authors recommend that:

National clinical guidelines take our findings into consideration in recommending effective alternatives to CBT.

Sum up

As one of the largest comparative trials yet conducted of CBT versus counselling for depression, this study provides strong evidence that both approaches are about equal in effectiveness.

It is possible that the sample size in the present study was too small to detect a meaningful difference; but the striking similarities in outcomes across the measures support the authors’ claim that ‘it is very unlikely that the therapies in this trial differed in clinical effectiveness’.

It is also possible that other forms of CBT would prove superior to non-directive counselling; but outcomes from the Improving Access to Psychological Therapies programme in England (e.g., Glover, Webb, & Evison, 2010) have replicated the present findings: indicating that CBT and counselling, as currently practiced in England, are about equivalent in effectiveness.

Nevertheless, the British Association for Counselling and Psychotherapy have recently commissioned a trial to directly compare CBT with Counselling for Depression for 550 patients: the PRaCTICED study (Barkham, 2013).  Hopefully, this trial will give a definitive indication of how these two interventions compare.

Links

M. King, L. Marston and P. Bower Comparison of non-directive counselling and cognitive behaviour therapy for patients presenting in general practice with an ICD-10 depressive episode: a randomized control trial. Psychological Medicine, Available on CJO 2013 doi:10.1017/S0033291713002377 [PubMed abstract]

King, M., Sibbald, B., Ward, E., Bower, P., Lloyd, M., Gabbay, M., & Byford, S. (2000). Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technology Assessment, 4(19), 1-83.

Depression: the treatment and management of depression in adults (update). NICE clinical guideline, CG90, Oct 2009.

Glover, G., Webb, M., & Evison, F. (2010). Improving Access to Psychological Therapies: A review of the progress made by sites in the first rollout year (PDF). Stockton on Tees: North East Public Health Observatory.

Barkham, M. Counselling for Depression vs CBT. Article on Therapy Today.Net about the PRaCTICED study, last accessed 18 Dec 2013.