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Family Practice 2011; 28:489–504 Ó The Author 2011. Published by Oxford University Press. All rights reserved.

doi:10.1093/fampra/cmr017 For permissions, please e-mail:

Advance Access published on 9 May 2011

Effectiveness of cognitive behavioural therapy in

primary health care: a review

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Ragnhild Sørensen Høifødta,*, Christine Strømb, Nils Kolstrupb,
Martin Eisemanna and Knut Waterlooa
Department of Psychology and bDepartment of Community Medicine, Faculty of Health Sciences, University of Tromsø,
9037 Tromsø, Norway.
*Correspondence to Ragnhild Sørensen Høifødt, Department of Psychology, Faculty of Health Sciences, University of Tromsø,
9037 Tromsø, Norway; E-mail:
Received 9 November 2010; Revised 25 February 2011; Accepted 9 March 2011.

Background. Depression and anxiety are highly prevalent disorders causing substantial impair-
ment in daily life. Cognitive behavioural therapy (CBT) delivered face-to-face or as self-help has
shown to be an effective treatment for these disorders. Such treatments may be suitable for
delivery in primary health care.
Aim. The aim of the article was to review research on the effectiveness of CBT for depression and
anxiety disorders delivered in primary care by primary care therapists.
Methods. A literature search of quantitative studies of the effectiveness of CBT delivered in pri-
mary care was conducted on multiple electronic databases. A total of 17 studies were included in
the review.
Results. Eight studies of supported Internet- or computer-based CBT, six of which were random-
ized controlled trials (RCTs), indicate that this treatment is effective for mild to moderate depres-
sion and anxiety. Five studies suggest that this treatment may be more effective than usual care
for mild to moderate but not for more severe symptoms. Results of four RCTs of brief therapies
using written self-help material suggest that while such interventions are effective, no particular
approach outperformed any other, including usual care. Five RCTs of CBT delivered face-to-face
show that this treatment can be effective when delivered by therapists highly educated in the
mental health field. However, many primary care therapists may find such interventions too time
Conclusions. CBT delivered in primary care, especially including computer- or Internet-based
self-help programs, is potentially more effective than usual care and could be delivered effec-
tively by primary care therapists.
Keywords. Anxiety, cognitive therapy, computer-assisted therapy, depression, family practice,
primary health care.

Introduction According to Beck’s cognitive theory, negative or

fearful/catastrophic thoughts and biased information
Depression and anxiety disorders are highly prevalent processing typically characterize depressed and anxious
disorders with a projected lifetime risk of up to 31% for individuals.9,10 Cognitive behavioural therapy (CBT)
any mood disorder and 36% for any anxiety disorder.1 attempts to change dysfunctional patterns of thinking
Epidemiological studies show 12-month prevalence for and non-adaptive behaviours in order to prevent devel-
depression of up to 7% for men and 11% for women opment and maintenance of symptoms of depression or
and between 7% and 9% for men and 15% and 18% anxiety. Most research on the effectiveness of CBT has
for women for anxiety disorders.2–4 Depression and anxi- been done in specialized mental health services. These
ety cause substantial impairment in multiple functional studies show that CBT is as effective as pharmacother-
domains in daily life, reduction in quality of life and in- apy in treating mild to moderate depression and a variety
creased medical service utilization.3,5–7 In fact, the World of anxiety disorders, with treatment gains that are
Health Organization describes depression as a leading maintained at long-term follow-up and reduced rates of
cause of disability and social and economic burden, af- long-term relapse for depression.11–14 Despite the exten-
fecting 121 million people worldwide.8 sive support for CBT, this treatment remains difficult

490 Family Practice—an international journal

to access, due to insufficient numbers of trained thera- anxiety disorders delivered in a primary care setting
pists both in primary care and in specialist mental health by primary care therapists.
Research also indicates that cognitive bibliotherapy, Selection of studies
using written texts, computer/Internet-based programs We included studies where CBT was delivered or

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or audio/video-recorded material, has a moderate to supported by primary care therapists, e.g. practice
large effect in reducing symptoms of depression and nurses, GPs, social workers or other therapists without
anxiety.15–19 In some cases, self-help shows equal extensive specialized training in delivering structured
efficacy as face-to-face treatment of relatively short psychological therapy. Twenty studies where CBT was
duration. Self-help can be purely self-administered or delivered by highly trained or specialist therapists
can be used as part of a minimal contact therapy, were excluded.38–57 Consensus on what constitutes
which includes the active involvement of a therapist, a specialist therapist was reached by referring to the
though to a lesser extent than in traditional therapy. original studies and through discussion in the group of
Studies show that minimal contact therapies may be authors. Where no characteristics of the therapists
sufficient for several anxiety and depressive disorders were given in the original articles, authors were
but that some form of therapist support may be contacted to obtain such information. We included
essential for enhancing the treatment effects.18,20–22 one study where a self-help clinic was set up as part
Psychological problems may account for as much as of a pragmatic evaluation project since this clinic was
30% of consultations in primary care when subthresh- considered closely to resemble regular primary care
old disorders are included, and the majority of these pa- services.58
tients will receive most or all of their mental health care Studies where treatment combined CBT-based
in primary care. 3,23–25 Findings suggest that patients self-help with support from the primary care clinic
generally prefer psychological therapy to medication, were included. Therapist support was defined as any
and if possible, they prefer to consult their GP for treat- therapeutic involvement beyond screening procedures
ment.26–28 Seeking help from a GP has the advantages and could include face-to-face, telephone or e-mail
of being more accessible, affordable and less stigmatiz- contact. Studies of purely behavioural interventions
ing than specialized mental health services.29 were excluded from the review.
The treatment of depression and anxiety in general One study describing a prevention intervention for
practice is often limited to empathic listening, infor- depression was included since all participants had
mal supportive therapy, prescription of medication symptoms corresponding to subthreshold depression.59
and provision of medical certificates or referrals.30 Two evaluations of interventions for postnatal depres-
Several investigations confirm that only 21–65% of sion were excluded because the procedure of treatment
the patients who are treated for depression and anxiety through home visits deviated from the procedures in
in primary care receive guideline-concordant treat- other included studies.60,61 Four studies described com-
ment.23,31–35 Guidelines recommend psychosocial in- plex interventions comprising both CBT and medica-
terventions in the treatment of subthreshold and mild tion.62–65 One of these studies was excluded because
to moderate depression and do not recommend using the CBT component was minimal, and the main focus
antidepressants routinely to treat these conditions.36,37 was on medication adherence and effect.64 The three
The structured and time-limited nature of CBT makes other studies62,63,65 were included because CBT was
this treatment suitable for primary care settings. Espe- considered a central part of the interventions. These
cially, using self-help resources to engage patients be- complex interventions also included medication, collab-
tween sessions could be a viable option as a mean to orative care and choice of treatment and thus do not al-
improve the delivery of psychological interventions in low conclusions regarding the relative contribution of
primary health care. each treatment. However, analyses of process of care
The aim of the present article was to review the showing differences between groups in received treat-
research on the effectiveness of CBT for depressive ment give some indication on which components might
and anxiety disorders delivered in primary health care. have contributed to the intervention outcomes.
The review is selective, in that it focuses on studies We included only quantitative studies that used
where CBT was delivered in primary care by primary symptom measures as the primary end point.
care therapists without extensive specialized training
in the delivery of structured psychological therapy. Selection of participants
The selected studies included both adolescent and
adult participants. Since only eight of these studies
Methods included participants on the basis of a depression and/
or anxiety diagnosis according to Diagnostic and Sta-
We undertook a selective review of trials studying the tistical Manual of Mental Disorders or International
effectiveness of CBT interventions for depression and Classification of Diseases criteria, we also included
Effectiveness of CBT in primary health care 491
TABLE 1 Search terms used in the literature search health training, and in Proudfoot et al.,68 patients in
the intervention group received treatment as usual
AND AND which did not include any counselling or referral to
specialized services, which were interventions included
Cognitiv* behavior* therap* general pract* depression in treatment as usual. Thus, both studies can be con-
Cognitiv* behaviour* therap* GP anxiety

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sidered conservative tests of the interventions. There
Cognitiv* therap* Primary care
CBT Family doctor*/ were, however, major practical difficulties in conduct-
physician*/pract* ing the trial in Hickie et al.,69 and due to poor recruit-
ment of practices and patients and high attrition rates,
the sample size was too small to adequately test the
studies where participants were included on the basis hypothesis. The results must, therefore, be considered
of elevated scores on self-report scales. One study as a preliminary indication of the possible effective-
including patients with symptoms of somatization was ness of this mode of treatment.
excluded because the focus on unexplained somatic Promising results were also found in another RCT
symptoms was considered to differ from the more including patients with anxiety disorders.62 Here,
affective focus in the other included studies.66,67 a complex intervention which included supported
computer-based CBT and/or pharmacotherapy sup-
Search strategy ported by medication management, yielded robust ef-
A search was conducted on Medline (PubMed) fects on all outcome measures compared to usual
databases, PsycINFO, ISI Web of Knowledge and care. Thirty-four per cent of patients in the interven-
Google until 10 August 2010 for English language tion group chose only CBT, 9% chose medication only
papers. Table 1 shows the search terms that were used. and 57% received both treatments. The intervention
We also scrutinized references cited in identified effects may, therefore, be mediated either by higher
meta-analysis, systematic reviews and single studies to quality medication treatment or by higher rates of
find further studies. quality CBT in the intervention group, as assessed by
Data extraction. One of the authors (RSH) ex- number and consistency of CBT elements in the psy-
tracted data from the included studies, and two of the chotherapy sessions. Results show that participants in
other authors (KW and ME) checked these data. Dis- the intervention group who received at least one CBT
crepancies were resolved by referring to the original session (n = 261; average 7.63 sessions) experienced
studies. Data were extracted on symptoms/disorder, a significant decrease in symptoms of depression and
sample size, follow-up, dropout, type of intervention, anxiety that were not moderated by the administration
intervention provider, comparison treatment and of medications.82 Even though the relative contribu-
outcomes. tions of the CBT and medication components cannot
be clearly determined, these results indicate that the
CBT component contributed to the positive outcomes
Results of the intervention as a whole.
Two RCTs compared CCBT with treatment as usual
Internet- or computer-based CBT. The effectiveness of for moderately to severely depressed patients.70,71 In
computer- or Internet-based self-help programs has both studies, depressive symptoms improved equally
received increased attention during the last decade. significant over time in groups receiving treatment as
We identified eight studies of the effectiveness of usual and groups receiving online-/computer-based
supported computer-based CBT (CCBT) delivered in CBT in addition to usual treatment. In the study by
primary care. Six of these studies were randomized De Graaf et al.,70 the low adherence (see Table 2)
controlled trials (RCTs). may have masked potential intervention effects. On
A randomized trial by Proudfoot et al.68 and the other hand, poor adherence in this study and lack
a cluster randomized trial by Hickie et al.69 found of intervention effects in both studies may likely be
evidence of the advantage of including CCBT in explained by the severity of depressive symptoms.
addition to treatment as usual. The groups receiving Three studies compared different interventions
computer- or Internet-based CBT improved more without including control groups.58,59,72 In the study
over time on symptom measures than groups receiving by Van Voorhees et al.,59 depressed adolescents
usual care alone (see Table 2 ). The study by Proud- receiving an online prevention intervention combined
foot et al.68 included patients with all levels of initial either with a motivational interview or with a brief
depression, mixed anxiety and depression, as well as advice experienced equally significant decreases in de-
specific anxiety disorders, while Hickie et al.69 targeted pressive symptoms. A possible explanation for the
depressive symptoms and psychological distress. In the lack of differences between the interventions could be
latter study, all patients, including the control group, that the abbreviated motivational interview in this
received enhanced GP care from GPs with mental study was too short to have the expected persuasive
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TABLE 2 Summary of studies used in the review

Study Target disorder/symptoms Comparison conditions Intervention duration, Use of medication and N (%) Measurements Outcome
content and level of specialized mental
therapist support health care

Computerized or Internet-based CBT

De Graaf et al.70 Depressiona RCT: CCBT (Colour your life): Antidepressants: 303 Pre All groups improved
1. Unsupported online CCBT 9  30-minute sessions. Group 1: 14% 288 2 months significantly on measures of
(n = 100), Group 2: 27% 285 3 months depression, dysfunctional
Group 3: 25% 275 6 months attitudes, general health and
2. TAU TAU: more than 4 work and social adjustment
(n = 103), consultations with GP (ES = 0.6–0.9). No significant
or medication improvement on a general
symptom measure.
3. CCBT + TAU CCBT + TAU: Significantly more
(n = 100). combination of both. improvement on work and
Adherence to social adjustment with CCBT
Specialized care:

Family Practice—an international journal

intervention: + TAU. No difference
Group 1: 24% (36) CCBT between groups on clinically
Group 2: 36% (30) TAU significant change (29–36% at
Group 3: 24% (12) CCBT + TAU 6 months).
Hickie et al.69 Depressive symptoms and Cluster randomized trial: 8 weeks: Medication: 83 Pre Symptoms of psychological
psychological distressa 0% in both groups Post distress resolved after
1. Enhanced GP care Enhanced GP care: GPs with 6 months treatment for most patients.
(n = 54). mental health training who are 56 12 months More patients in the GP
trained in focused care + CBT group
psychological treatment experienced a resolution of
strategies, including CBT. symptoms compared to the
2. Enhanced GP care Online CBT (MoodGYM): Specialized care: GP care group. This pattern
+ online CBT (n = 29). five modules. Not specified Lost to follow-up was sustained at 6- and 12-
(28) Group 1 month follow-up. A moderate
(41) Group 2 and clinically meaningful
difference between the
conditions at post-treatment
(ES = 0.4), and a small,
but clinically meaningful
difference at 6-month follow-
up (ES = 0.3). Significant
reduction of disability in the
GP care group and a trend
towards reduction in the GP
care + CBT group.
No significant difference
between conditions.
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TABLE 2 Continued

Study Target disorder/symptoms Comparison conditions Intervention duration, Use of medication and N (%) Measurements Outcome
content and level of specialized mental
therapist support health care

Marks et al.58 Anxiety and depressive Open pragmatic evaluation: FearFighter (CCBT); Cope Medication: 210 Suitable All patients: 80% of patients
disorders (including OCD7)b and BTSteps (Booklet + IVR Completers: 60% 168 Pre rated themselves as better to
system): 108 Post some degree, 10% as
1. FearFighter (phobia/panic; Advised to use program at unchanged and 9% as worse to
n = 43). least six times in 12 weeks + some degree.Significant
six brief contacts with nurse improvement per system:
therapists (phone or face-to- FearFighter users on the Fear
face). Questionnaire (ES = 0.6–1.4),
2. Cope (depression/ Balance (CCBT): Advised to Non-completers: 60% Dropout from Cope users on depression
anxiety; n = 55). use program at least three intervention: measures (ES = 0.7–1.2),
times in 4 weeks + three brief (37) FearFighter Balance users on depression
3. Balance (GAD/depression; contacts with nurse therapists. Current treatment from GP or (29) Cope and anxiety measures (ES =

Effectiveness of CBT in primary health care

n = 56). mental health professional: (41) Balance 0.6) and BTSteps users on
4. BTSteps Mean therapist 45% (44) BTSteps a measure of obsessions and
(OCD; n = 16). time: 64 compulsions (ES = 0.9–1.4).
minutes. Improvement on work and
social adjustment was
significant for FearFighter,
Cope and Balance (ES = 0.4–
Proudfoot et al.68 Anxiety and/or RCT: 8 weeks: 8  50-minute Group 1/2 (%) 274 Allocation Depression scores decreased
depressionb CCBT sessions (Beating the Medication: 42/45 248 Pre in both groups over time. No
Blues) with homework + 185 Post significant interaction
15% severe 1. CCBT ± technical support from nurse 164 1 month between treatment and time
depression. antidepressants and practical/social help and for any measure, but summary
(n = 146). medication from GP. measures analysis show
2. TAU by GP No psychological intervention Counselling/ 163 3 months significantly lower depression
(n = 128). or counselling. psychotherapy and work and social
(n = 167): 7/22 adjustment scores for the
CCBT group. Significant
Other mental health 177 6 months decrease of negative
professionals attributions and increase of
(n = 167): 4/9 positive attributions in the
CCBT group. The effect of the
intervention on anxiety
measures approached
significance. Treatment effects
are equally significant for
patients using or not using
medication. Improvements
were sustained at 6-month
follow- up.

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TABLE 2 Continued

Study Target disorder/symptoms Comparison conditions Intervention duration, Use of medication and N (%) Measurements Outcome
content and level of specialized mental
therapist support health care

Roy-Byrne et al.62 Panic disorder, RCT: 10–12 weeks: eight modules Group 1/2 (%) 1004 Pre All outcomes (somatization,
generalized (CALM Tools for Living) Medication of 876 6 months anxiety, depression, anxiety
anxiety, social tailored to the four anxiety appropriate 813 12 months sensitivity and functional
anxiety and PTSDb disorders, completed during dose: 804 18 months status) were significantly
6–8 visits + monthly follow-up Pre: 29/31 better for the intervention
calls after treatment. 6 months: 46/42 group at 6, 12 and 18 months
1. Intervention Medication management for 12 months: 42/36 (ES: –0.3, –0.3 and –0.2).
including CCBT, those using antidepressants. 18 months: 41/38 Outcomes for physical health
medication or were similar in both groups.
both (n = 503). A significantly larger
proportion of patients in the
2. Usual care Average seven CBT sessions intervention group responded

Family Practice—an international journal

(n = 501). and two medication visits. and remitted at 6, 12 and 18
Therapists: 11 social workers/ months (response: 6 months:
nurses and 3 psychologists 57 versus 37%; 12 months: 64
with some/no mental health versus 45%; 18 months: 65
experience, no formal CBT Any medication: versus 51%; remission: 6
training. 6 half days of training Pre: 64/62 months: 43 versus 27%; 12
in the CALM program. 6 months: 70/68 months: 51 versus 33% and 18
12 months: 66/64 months: 51 versus 37%). NNT:
18 months: 61/61 5.3 at 12 months for response
and 5.5 for remission.
Any counselling:
Pre: 46/47
6 months: 88/51
12 months: 58/46
18 months: 39/42

Salkovskis et al.71 Major depressive disorderb RCT: Six to nine modules Medication: 100% 96 Pre Both groups improved
1. Self-help computer consisting of in both groups 4 weeks significantly over time on all
program + TAU (n = 50). three- to six-page depression measures. No
2. TAU (n = 46) booklets. GP is Specialized care: not 12 weeks (Post) group differences. High
informed of patient specified 77 26 weeks satisfaction with treatment in
progress and provides both groups.
standard treatment.
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TABLE 2 Continued

Study Target disorder/symptoms Comparison conditions Intervention duration, Use of medication and N (%) Measurements Outcome
content and level of specialized mental
therapist support health care

Shandley et al.72 Panic disorderb Natural groups design: Internet CBT (Panic Online): Medication: 96 Pre Significant improvement from
six modules over 12 weeks. PO–GP: 59% 69 12 weeks pre to post on panic
78% with agoraphobia. 1. Internet CBT + GP support PO–GP: Support and PO–P: 44% 55 6 months parameters, negative affect,
(PO–GP; n = 53). feedback from CBT trained panic cognition and quality
(20–40 hours) GPs. Regular of life (QoL). Significant
visits encouraged. difference between groups on
2. Internet CBT + e-mail PO–P: e-mail support and two domains of QoL from
support from psychologist feedback from psychologist, post-treatment to follow-up:
(PO–P; n = 43). at least weekly. Stabilized over minimum 2 Dropout from PO–P increased and PO–GP
weeks before start of trial 1 intervention decreased.PO–P versus PO–
(pre-post): GP at 6 months: panic free-
Specialized care: no other (38) PO–GP status (52% versus 47%); high

Effectiveness of CBT in primary health care

panic treatment during the (16) PO–P end-state functioning (48%
trial versus 32%). No group
differences, except significant
increase in high end-state
functioning in PO–P group
and not in PO–GP group from
post-treatment to follow-up.
Significantly higher attrition
from treatment in the GP
group. No significant
difference in overall attrition
(47% versus 37%).
Van Voorhees et al.59 Persistent subthreshold RCT: Internet CBT/IPT (CATCH- Medication and specialized 83 Pre Significant decline in
depressiona: IT): 14 modules. MI or BA care: 6 weeks depressive symptoms and
with GPs trained in the 80 12 weeks number of clinically depressed
approach. in both groups from pre to 6
Patients’ age: 14–21 years. 1. Motivational interview (MI; Both groups engaged in the 0% in both groups. weeks, sustained at 12 weeks.
5–10 minutes) + Internet CBT Internet site (MI 91%, BA Significant decline in self-
(n = 43). 78%). harm thoughts and
hopelessness for both groups
2. Brief advice (BA; 1–2 MI group: three additional Under active treatment the from pre to 6 weeks and 6–12
minutes) + Internet CBT motivational phone calls from last year was an exclusion Dropout from weeks. MI group: Significantly
(n = 40). trained social worker. criterion. intervention: lower prevalence of
(5) MI hopelessness and cumulative
(3) BA prevalence of depressive
episodes at 12 weeks, and
significant reduction from pre
to 12 weeks in percentage
reporting any self-harm
thoughts or hopelessness.

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TABLE 2 Continued

Study Target disorder/symptoms Comparison conditions Intervention duration, Use of medication and N (%) Measurements Outcome
content and level of specialized mental
therapist support health care

Written self-help material

Mead et al.73 Anxiety and depressiona RCT: CBT self-help manual + up to Medication (Group 1/2): 114 Pre No significant difference in
1. Guided self-help 4  15- to 30-minute sessions Pre: 65/68% 103 3 months effect between groups on
(n = 57). with assistant psychologist. Post: 53/57% measures of anxiety and
2. Wait list (12) Dropout from depression symptoms at 3
(n = 57). intervention. months. The effect of the
Specialized care: currently on intervention on social
wait list. functioning approached
Richards et al.74 Mild to moderate anxiety RCT: 3 months: No significant difference in 139 Allocated Significant improvement over
and/or depressiona medication cost between 106 Pre time (1 and 3 months) on
groups. measures of general symptoms

Family Practice—an international journal

and QoL, but no difference
1. Guided self-help (n = 75). CBT self-help manual + up to Referred to specialized care or 67 1 month between groups. Patients in
three sessions with practice counselling (n = 87): the self-help group were twice
2. TAU by GP (n = 64). nurse. Group 1: 11% 41 3 months as likely to achieve reliable
Group 2: 35% Dropout in and clinical change at 1 month
intervention compared to the TAU group.
period: This difference disappeared at
(73) self-help 3 months.
(67) TAU
Sorby et al.75 Panic disorder and RCT: 8 weeks: Group 1/2: 64 Allocated Significant improvement over
generalized anxiety disorderb Benzodiazepines 60 Pre time in both groups on
1. Self-help booklet Anxiety management 33/32% 2 weeks measures of anxiety and
+ TAU (n = 30). booklet (CBT) + four Antidepressants 20/11% 4 weeks depression. Significantly faster
consultations with GP. No change in dosage 49 8 weeks improvement in two first
2. TAU (n = 19). GP explains booklet + during first 2 weeks of trial. weeks for self-help group on
adopts usual therapeutic measures of anxiety but not
strategies (monitor, depression.
guide and encourage).
Specialized care: not specified Dropout from
(0) self-help
(21) TAU
Van Boeijen et al. Panic disorder and RCT: 12 weeks: Medication: 154 Randomization All three groups improved
generalized anxiety 1. Self-help with support 1: CBT self-help manual + 5  Group 3: 50% 143 Pre equally significant from pre- to
disorderb from GP (n = 53). 20-minute sessions with GP. post-treatment, 6 and 12
2. CBT in specialized 2. 12  45-minute sessions Specialized care: 131 Post months follow-up on measures
health care (n = 63). with experienced CBT Group 1: 0% 113 6 months of anxiety, worry, panic,
therapists. Group 2: 100% 102 12 months avoidance, depression,
3. Simple GP-delivered 3. Any number of sessions Group 3: 33% referred Dropout from general health and disability.
CBT (n = 26). with GP. Could include intervention:
referral for other psychiatric (11) Group 1
treatment or medication. (14) Group 2
(8) Group 3
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TABLE 2 Continued

Study Target disorder/symptoms Comparison conditions Intervention duration, Use of medication and N (%) Measurements Outcome
content and level of specialized mental
therapist support health care

Face-to-face CBT
Asarnow et al.65 Adolescent depressiona RCT: 6 months: Medication: baseline: 418 Pre Significantly lower mean
Asarnow et al.77 42% major depression and 1. Quality CBT intervention: 13  50- Group 1: 14% 344 6 months depression scores, higher
25% moderate to severe improvement intervention: minute sessions with care Group 2: 18% 327 12 months mental health-related QoL
depression medication, CBT or both or managers (master’s/PhD’s in 322 18 months and lower rates of severe
brief follow-up including CBT mental health or nursing) depression in the intervention
components (n = 211). trained through the project in 6 months: group versus the usual care
manualized CBT for Group 1: 13% Dropout in group (31% versus 42%) at 6
depression. 32% of patients Group 2: 16% intervention months but not significant at
received CBT. 19% had 12 or period: 18 months. Significantly faster
more sessions. (16) Usual care recovery in intervention group
2. Usual care Usual care: enhanced with (19) Intervention at 6 months but not significant

Effectiveness of CBT in primary health care

(n = 207). education materials on Any psychotherapy/ at 18 months. Significant
depression evaluation and counselling: indirect effects at 12 and 18
treatment and 1–2 hours Group 1: 32% months: Effect of 6 month
training. Group 2: 21% depression on 12-month
depression and of 12-month
depression on 18-month
depression. Same pattern for
mental health-related QoL
and rates of severe depression.
Fifty per cent decline in
patients reporting suicide
attempts and deliberate self-
harm in both groups at 6
months but no differences
between groups on these
measures or suicidal ideation.
Kerfoot et al.78 Adolescent depressiona Natural groups design: 8 weeks: Medication and specialized 52 Pre Both groups had similar levels
1. Patients of social workers Eight sessions with social care: not specified. 46 17 weeks of depression and global
receiving CBT training (n = workers trained in brief CBT adjustment at post-treatment
29). through one whole day and and follow-up. At post-
2. Routine care: patients of four half-day workshops. 33 weeks treatment, 77% of the CBT
social workers on wait list for Adherence to group and 80% of the routine
CBT training (n = 23). (45) intervention: 4 care group had residual
or more sessions symptoms or disorder.
79 a
King et al. Depression Natural groups design: 6 months: Medication: 272 Pre No significant difference
1. Patients of GPs receiving Any number of consultations Group 1: 37% 3 months between groups on measures
CBT training (n = 137). with GP trained in CBT Group 2: 36% of depression, state and trait
2. TAU: Patients of GPs on through four half-day 246 6 months anxiety and QoL, except a
wait list for CBT training workshops. slightly significant greater
(n = 135). Referred to proportion of patients in the
specialized care: intervention group with role
Group 1: 33% limitations due to emotional
Group 2: 18% problems in social function,
mental health and energy and
vitality at 6-month

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TABLE 2 Continued

Study Target disorder/symptoms Comparison conditions Intervention duration, Use of medication and N (%) Measurements Outcome
content and level of specialized mental
therapist support health care

König et al.80 Anxiety disordersa Cluster randomized trial: 6 months: Medication: 389 Pre Slight improvement in
1. Intervention (n = 201). Any number of treatment Not specified 335 Post (6 months) symptoms of anxiety,
2. Usual care (n = 188). sessions with physicians 327 9 months depression and QoL in
trained in basic CBT Mental health service use both groups but no significant
techniques. Physicians were (Group 1/2): differences between the
also offered a flexible Dropout: groups.
psychiatric consultation– Intervention period: 31/33% (14) Intervention
liaison service including (13) Usual care
assessment of specific patients, Follow-up period: 33/33%
advice and CBT training.
Roy-Byrne et al.63 Panic disorderb RCT: 12 weeks: Group 1/2 (%) 232 Pre Proportion of subjects with no
Craske et al.81 1. Collaborative care (CC): CBT with up to six sessions Medication of appropriate 179 Post panic attacks and minimal

Family Practice—an international journal

CBT + expert medication with behavioural health dosage: anticipatory anxiety and
recommendations (n = 119). specialist (master level or Pre: 26/30 phobic avoidance was
doctoral level academic 3 months: 44/40 176 6 months significantly greater in
degree with no/minimal CBT 6 months: 42/39 165 9 months intervention group at all
experience) + introduction 9 months: 41/39 179 12 months follow-up points (ES = 0.2–
video and patient workbook 12 months: 41/39 Adherence to 0.3).
+ six phone calls of 15–30 intervention: Remission at 12 months
minutes in the next 9 months. Any medication: (12) 0 sessions was 29% in intervention group
2. Treatment as usual from Expert medication advice Pre: 45/48 and 16% in TAU. Robust
PCP (n = 113). from psychiatrist and 3 months: 62/56 (20) 1–3 sessions intervention effects on anxiety
medication management by 6 months: 59/55 (68) 4–6 sessions sensitivity (ES = 0.4–0.5),
PCP. 9 months: 56/53 functional status (ES = 0.3),
12 months: 54/52 mental health-related QoL
(ES = 0.1–0.3) and depressive
Any counselling: Pre: 25/23 symptoms (ES = 0.3). Physical
3 months: 70/34 health did not change in
6 months: 39/32 any of the groups.
9 months: 24/33 Number of attended sessions
12 months: 18/34 predicted decreased anxiety
sensitivity at 3 and 12 months.
Number of
follow-up calls predicted
decreased anxiety sensitivity,
phobic avoidance and
depression at 12 months. Dose
response tendency
for rates of response
and remission both for
CBT and medication.

TAU, treatment as usual; ES, effect size; OCD, obsessive compulsive disorder; IVR, interactive voice response; GAD, generalized anxiety disorder; PTSD, posttraumatic stress disorder; NNT, num-
ber needed to treat; IPT, interpersonal psychotherapy; PCP, primary care physician.
Diagnosis according to Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria.
Inclusion based on elevated scores on self-report scales.
Effectiveness of CBT in primary health care 499

power. Also, participants received financial incentives More positive results come from two studies of pa-
to participate, which may have enhanced investment tients with panic and generalized anxiety disor-
and adherence to the treatment. Thus, a generally high ders.75,76 Van Boeijen et al.76 concluded that the use
level of motivation may have masked group differen- of GP supported self-help in primary care can be con-
ces. This bias also challenges the generalizability of the sidered a feasible and effective treatment for patients

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results to settings where financial incentives are absent. with these disorders. This treatment seems to be com-
A study by Shandley et al.72 found that an Internet- parable to face-to-face CBT in secondary care. Sorby
based intervention for panic disorder supported by et al.75 found that treatment as usual both with and
GPs with some CBT training resulted in clinically sig- without the addition of an anxiety management self-
nificant improvements (see Table 2) and was equally help booklet resulted in significant improvement on
effective as the same intervention supported by a more measures of depression and anxiety. However, the
specialized mental health provider (e-mail support self-help group improved significantly faster on several
from a psychologist). A methodological problem was anxiety measures during the first weeks of treatment.
that the GP group initially had a higher degree of co- In this study, GPs adopted their usual therapeutic
morbidity and a higher proportion of participants on strategies and were not specifically trained to deliver
medication, which can suggest more severe illness in the anxiety management treatment. This suggests that
this group. GPs may be able to administer a self-help package ef-
An open pragmatic study evaluated four CCBT fectively without special training.
packages for panic/phobia, depression/anxiety, gener-
alized anxiety/depression and obsessive–compulsive Face-to-face CBT
disorder.58 Completers of each system improved sig- Five RCTs evaluated the effect of face-to-face CBT de-
nificantly on measures specific to their problems and livered in primary care. In three studies, primary care
clinically meaningful effect sizes of >0.8 were ob- clinicians were randomized to receive an educational
tained. These effect sizes were broadly comparable to package on CBT or to a wait list for this training.78–80
the figures for computer-aided care and face-to-face Analyses found no significant differences in patient
CBT in other studies.83,84 However, even though com- outcomes between groups receiving CBT from trained
pleters and non-completers were indistinguishable when clinicians and those receiving routine care. In fact, in
starting treatment, the amount of improvement should the study by Kerfoot et al.,78 the majority of patients in
be regarded with some caution because of the high rates both groups had residual depressive symptoms post-
of refusal (20%) and non-completion (29%). Users of treatment (see Table 2). In this sample of adolescents,
a shorter and more basic program for generalized anxi- problems were often chronic and severe and included
ety/depression with less therapist support did not attain high rates of behavioural and social problems. How-
clinically meaningful effect sizes. ever, only half of the sample had major depression.
The intervention may therefore be more effective in
Written self-help material a more typical sample of depressed adolescents.
Self-help books share many similarities with com- Two studies suggest positive effects of face-to-face
puter-based CBT but are more static and have fewer CBT components included in complex interven-
opportunities for interactivity and tailoring of compo- tions.63,65,77,85 In one study of patients with panic disor-
nents and feedback. We identified four RCTs using der, behaviour health specialists were trained to deliver
written self-help material with clinician support in pri- CBT and to coordinate care, including pharmacother-
mary care. Results from these studies are mixed. Two apy.63,81,85 The intervention had robust positive effects
studies including heterogeneous groups of patients on several outcome measures, and improvement was
with symptoms of anxiety and/or depression found no significantly greater in the intervention group compared
or limited beneficial effects of guided self-help com- to the group receiving usual care (see Table 2). In this
pared to a waiting list condition or usual treat- study, the content and quality of the CBT were evalu-
ment.73,74 A significant proportion of patients in the ated and reported. Still, the exact contribution of CBT
Mead et al.73 study reported reading at least half of cannot be determined since many patients also used
the manual and undertaking therapeutic activities, medication and received medication management.
and 88% of the patients attended at least one session, However, the following results suggest that improved
while 54% attended all four sessions. This suggests outcomes in the intervention group may be at least
that the lack of effect cannot be accounted for by partly attributed to the CBT component. Firstly, the
problems with adherence. The study by Richards proportion of patients receiving quality CBT was signif-
et al.74 could only detect large-scale main effects due icantly larger in the intervention group than in the
to poor recruitment rates and a high level of dropout. usual care group. The differences in quality of pharma-
The high rates of refusal and attrition also introduce cotherapy were not significant. Secondly, results indi-
potential bias to the sample and point to feasibility is- cate a dose–response tendency where number of
sues for the intervention. attended CBT sessions and follow-up calls were related
500 Family Practice—an international journal

to better outcomes. Thirdly, patients receiving both CBT component to the overall effect could not be
CBT and medication (n = 62) improved significantly clearly interpreted. In treating depressive symptoms
more on anxiety and depression measures than the in the moderate to severe range, two relatively large
group using only medication (n = 49).85 high-quality randomized trials suggest that this treat-
Asarnow et al.65 trained care managers to deliver ment may not be more effective than usual care.70,71

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CBT for adolescent depression as part of a quality im- Also, this is in line with previous research on self-help
provement intervention that also included expert and computer-guided interventions.15,18,20 With sup-
leader teams, patient and clinician choice regarding ported Internet- or computer-guided CBT being
treatment modality and support to primary care clini- equally or potentially more effective than usual treat-
cians with patient evaluation, education and medica- ment for mild to moderate symptoms, primary care
tion. After the intervention phase, patients reported providers may consider offering such treatment as
significantly fewer symptoms compared to patients re- an alternative to pharmacological treatment or as
ceiving usual care (see Table 2). The intervention also a supplement to augment treatment with medications.
had positive indirect long-term effects.77 This suggests Studies showing that patients generally prefer psycho-
that the initial benefit of the intervention may have logical therapy to medication emphasizes the rele-
produced a shift towards a healthier path, for example vance of a more psychologically orientated treatment
by lowering the risk for chronic or recurrent depres- option in primary care.26–28 Studies suggest that espe-
sion. Neither here it can be clearly determined if the cially for depression and panic disorder, CBT may
intervention effects are due to the CBT part of the in- have an enduring effect that extends beyond the end
tervention. However, the main difference in received of treatment.86–89 While relapse rates are high for pa-
treatment between the groups was an increase in psy- tients withdrawn from pharmacotherapy, CBT seems
chotherapy in the intervention group. The groups did to be as effective in preventing relapses in the long term
not differ on rates of medication or combined treat- as keeping patients on medication.86,88,89 Although such
ment. This suggests that the CBT component of the in- results remain to be replicated with briefer self-help
tervention has contributed to the improved outcomes treatments, the potential for positive long-term effects
in the intervention group. Fidelity to the CBT model of CBT would further support the use of such treat-
was encouraged through regular consultations with ments as a valuable alternative to the present usual
the therapists but was not required or reported, which treatment.
is a limitation of the study. Some studies suggest that guided CBT-based self-
help may be as effective as similar interventions deliv-
ered by more specialized mental health providers or as
Discussion face-to-face CBT in specialized mental health care.72,76
However, the interventions of these two studies dif-
The main objective of this review was to provide an fered widely, and one of the studies used a natural
overview of the available evidence on the effective- groups design without randomization. No firm conclu-
ness of CBT for depressive and anxiety disorders de- sions can, therefore, be made on the present basis.
livered in primary care by primary care therapists. It Results of four RCTs of brief therapies using written
is impossible to draw an overall conclusion since the self-help material suggest that although such interven-
17 included studies differed on several methodological tions are effective for depression and anxiety disorders,
aspects, including content of the intervention, treat- no particular approach outperformed any other, includ-
ment provider, comparison groups, outcomes and pa- ing usual care. All the reviewed interventions using
tient populations. The level of support and the degree written CBT material were less extensive than most
to which the support was related to the use of self-help therapies and included only between three and five ses-
programs also varied. sions, and in two of the studies,73,76 the consultations
Consistent with results from prior academic clinical were of short duration. Such interventions may poten-
trials, this review suggests that clinician-supported In- tially be a beneficial amendment to treatment as usual
ternet- or computer-based CBT delivered in primary for some anxiety disorders but may be insufficient for
care is effective for mild to moderate depression and patients with mixed depression and anxiety. This is con-
anxiety. A tentative conclusion indicated by some sistent with results from the study of CCBT by Marks
studies is that this treatment may be more effective in et al.58 where a shorter treatment program for mixed
treating mild to moderate symptoms of depression depression and anxiety was less effective than more ex-
and anxiety than treatment as usual.62,68,69 However, tensive programs. This is also in line with current guide-
although all three studies were RCTs and two can be lines for the treatment of depression where six to eight
considered conservative tests of the interventions, one sessions are recommended for persistent subthreshold
study did not recruit enough participants to ade- depression or mild to moderate depression.37
quately test the hypothesis69 and another tested a com- Training primary care therapists to deliver face-to-
plex intervention,62 and thus, the contribution of the face CBT for depression or anxiety does not seem to
Effectiveness of CBT in primary health care 501

have advantages compared to treatment as usual.78–80 psychological therapies for depression and anxiety, in-
None of the reviewed studies evaluated to which ex- cluding face-to-face CBT and counselling.90–93
tent the clinicians applied their new skills when treat- A weakness in many studies of face-to-face CBT is
ing patients, and hence, the quality of the CBT the lack of evaluation of therapists’ fidelity to the
intervention remains uncertain. This limits the conclu- structure and content of the intervention. Uncertainty

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sions that can be drawn because poor results may be of the actual content of the intervention makes it diffi-
caused either by true lack of effect or by feasibility is- cult to draw clear conclusions concerning treatment
sues hampering the delivery of the intervention. Low effect. A related issue, when evaluating self-help inter-
feasibility was suggested in the study by van Boeijen ventions, is the evaluation of participants’ adherence
et al.,76 where GP-delivered CBT was considered too to the self-help program. This is measured and re-
time consuming, and GPs often preferred treatment ported in most studies on computer- or Internet-based
with antidepressants or referral to secondary care. CBT, whereas in studies using written self-help mate-
Problems with recruitment and dropout of therapists rial, only one out of four reported such information.
were also encountered in the studies by Kerfoot Future research should aim to determine which du-
et al.,78 King et al.79 and König et al.80 This indicates ration of treatment, treatment components and
that most primary care therapists may find this process amount of therapist contact is needed to obtain posi-
too time consuming. tive outcomes for different disorders. Another impor-
Two studies suggest that face-to-face CBT in pri- tant issue for investigation is to study the effectiveness
mary care may be effective when delivered properly of treatment delivered by therapists with limited train-
by highly educated therapists with a master or PhD ing compared with more extensively trained therapists.
degree in the mental health field who are motivated Other important issues for further research refer to for
to find time to both acquire the skills and knowledge whom these interventions are effective and acceptable
of the approach and to apply these skills in the clinical and how to prevent dropout and enhance adherence.
setting under close supervision. This must, however,
be interpreted with caution since the studies included
complex interventions and the contribution of the Conclusions
CBT components cannot be clearly determined.
In summary, this review shows that CBT-based self-
Methodological issues and future directions help with clinician support delivered in everyday pri-
The majority of the reported studies are randomized mary care setting represents an effective treatment for
controlled studies, which by the virtue of their design depression and anxiety disorders. Such interventions
attempt to reduce potential biases. Most compared seem to be effective both when supported by GPs,
CBT to treatment as usual or no treatment. Still, sev- nurses, social workers or individuals with academic de-
eral studies compared different treatment protocols grees in the mental health or health behaviour field.
without including control groups. Future studies Some studies suggest that for mild to moderate symp-
should include such appropriate comparative ele- toms computer- or Internet-based CBT is more effec-
ments as medication or usual care. This is necessary tive than treatment as usual. However, for more
to determine how much of the patients’ improvement severe depressive symptoms, computer- or Internet-
is due to the passage of time, any therapist contact or based self-help in addition to usual care does not out-
to the intervention of interest and if this treatment is perform the effect of usual care alone. More research
more effective than the present treatment. Usual is needed to further confirm this conclusion. However,
treatment cannot be clearly defined since researchers especially for patients preferring psychologically ori-
have not attempted to constrain or interfere with pri- entated treatment, primary care providers may con-
mary care therapists’ usual choice of treatment in or- sider offering this kind of treatment as an alternative
der to replicate natural conditions. However, usual to pharmacological treatment.
treatment generally includes medication, some level Brief supported CBT-based self-help treatments using
of supportive therapy and/or referral to mental health written material did not outperform treatment as usual
specialists. Treatment varies between countries due in this review. Whether supported self-help treatments
to differences in guidelines and different ways of of longer duration would be more effective than usual
organizing primary health care. It also varies between care cannot be answered by the studies reviewed.
individual GPs depending on competence, prefer- Training of primary care therapists in delivering
ences and characteristics of the patient–physician face-to-face CBT does not seem to enhance treatment
relationship. effects relative to usual treatment in primary care.
Most studies reported rates of dropout from the in- Such interventions may not be feasible for the
terventions varying between 0% and 88%, with the majority of therapists because of the time and
vast majority being in the 15–30% range. Dropout engagement needed to learn the approach and to
rates in this range are comparable to those of other apply new skills in the clinical work.
502 Family Practice—an international journal
Declaration Spek V, Cuijpers P, Nykicek I et al. Internet-based cognitive
behaviour therapy for symptoms of depression and anxiety:
a meta-analysis. Psychol Med 2007; 37: 319–28.
Funding: Research Council of Norway (196423/V50). 22
Marrs RW. A meta-analysis of bibliotherapy studies. Am J
Ethical approval: none. Community Psychol 1995; 23: 843–70.
Conflict of interest: none. Wang PS, Berglund P, Kessler RC. Recent core of common mental

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disorders in the United States: prevalence and conformance
with evidence-based recommendations. J Gen Intern Med
2000; 15: 284–92.
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