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Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies

  • P. Cuijpers (a1) (a2), T. Donker (a1) (a2), A. van Straten (a1) (a2), J. Li (a3) and G. Andersson (a4) (a5)...



Although guided self-help for depression and anxiety disorders has been examined in many studies, it is not clear whether it is equally effective as face-to-face treatments.


We conducted a meta-analysis of randomized controlled trials in which the effects of guided self-help on depression and anxiety were compared directly with face-to-face psychotherapies for depression and anxiety disorders. A systematic search in bibliographical databases (PubMed, PsycINFO, EMBASE, Cochrane) resulted in 21 studies with 810 participants.


The overall effect size indicating the difference between guided self-help and face-to-face psychotherapy at post-test was d=−0.02, in favour of guided self-help. At follow-up (up to 1 year) no significant difference was found either. No significant difference was found between the drop-out rates in the two treatments formats.


It seems safe to conclude that guided self-help and face-to-face treatments can have comparable effects. It is time to start thinking about implementation in routine care.


Corresponding author

*Address for correspondence: P. Cuijpers, Ph.D., Professor of Clinical Psychology, Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands. (Email:


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Andersson, G, Carlbring, P, Grimlund, A (2008). Predicting treatment outcome in Internet versus face to face treatment of panic disorder. Computers in Human Behavior 24, 17901801.
Baker, BL, Cohen, DC, Saunders, JT (1973). Self-directed desensitization for acrophobia. Behaviour Research and Therapy 11, 7989.
Beck, AT, Rush, AJ, Shaw, BF, Emery, G (1979). Cognitive Therapy of Depression. Guilford Press: New York.
Borenstein, M, Hedges, LV, Higgins, JPT, Rothstein, HR (2009). Introduction to Meta-Analysis. Wiley: Chichester, UK.
Brown, RA, Lewinsohn, PM (1984). A psychoeducational approach to the treatment of depression: comparison of group, individual and minimal contact procedures. Journal of Consulting and Clinical Psychology 52, 774783.
Carlbring, P, Nilsson-Ihrfelt, E, Waara, J, Kollenstam, C, Buhrman, M, Kaldo, V, Söderberg, M, Ekselius, L, Andersson, G (2005). Treatment of panic disorder: live therapy vs. self-help via Internet. Behaviour Research and Therapy 43, 13211333.
Chambless, DL, Hollon, SD (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology 66, 718.
Côté, S, Bouchard, S (2008). Virtual reality exposure for phobias: a critical review. Journal of Cyber Therapy and Rehabilitation 1, 7591.
Craske, MG, Rose, RD, Lang, A, Welch, SS, Campbell-Sills, L, Sullivan, G, Sherbourne, C, Bystritsky, A, Stein, MB, Roy-Byrne, PP (2009). Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings. Depression and Anxiety 26, 235242.
Cuijpers, P (1997). Bibliotherapy in unipolar depression. Journal of Behavior Therapy and Experimental Psychiatry 28, 139147.
Cuijpers, P, Schuurmans, J (2007). Self-help interventions for anxiety disorders: an overview. Current Psychiatry Reports 9, 284290.
Cuijpers, P, van Straten, A, Warmerdam, L, Andersson, G (2008). Psychological treatment of depression: a meta-analytic database of randomized studies. BMC Psychiatry 8, 36.
Donner, L, Guerney, BG (1969). Automated group desensitization for test anxiety. Behaviour Research and Therapy 7, 113.
Duval, S, Tweedie, R (2000). Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455463.
Floyd, M, Scogin, F, McKendree-Smith, NL, Floyd, DL, Rokke, PD (2004). Cognitive therapy for depression: a comparison of individual psychotherapy and bibliotherapy for depressed older adults. Behavior Modification 28, 297318.
Gellatly, J, Bower, P, Hennessy, S, Richards, D, Gilbody, S, Lovell, K (2007). What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychological Medicine 37, 12171228.
Ghosh, A, Marks, IM, Carr, A (1988). Therapist contact and outcome of self-exposure treatment for phobias. British Journal of Psychiatry 152, 234238.
Gould, RA, Clum, GA, Shapiro, D (1993). The use of bibliotherapy in the treatment of panic: a preliminary investigation. Behavior Therapy 24, 241252.
Gregory, R, Canning, S, Lee, T, Wise, J (2004). Cognitive bibliotherapy for depression: a meta-analysis. Professional Psychology, Research and Practice 35, 275280.
Hecker, JE, Losee, MC, Fritzler, BK, Fink, CM (1996). Self-directed versus therapist-directed cognitive behavioral treatment for panic disorder. Journal of Anxiety Disorders 10, 253265.
Hecker, JE, Losee, MC, Roberson-Nay, R, Maki, K (2004). Mastery of Your Anxiety and Panic and brief therapist contact in the treatment of panic disorder. Journal of Anxiety Disorders 18, 111126.
Higgins, JP, Thompson, SG, Deeks, JJ, Altman, DG (2003). Measuring inconsistency in meta-analyses. British Medical Journal 327, 557560.
Higgins, JPT, Green, S (2008). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008] ( The Cochrane Collaboration, 2008.
Hirai, M, Clum, GA (2006). A meta-analytic study of self-help interventions for anxiety problems. Behavior Therapy 37, 99111.
Hogan, RA, Kirchner, JH (1968). Implosive, eclectic verbal and bibliotherapy in the treatment of fears of snakes. Behaviour Research and Therapy 6, 167171.
Kahn, M, Baker, B (1968). Desensitization with minimal therapist contact. Journal of Abnormal Psychology 73, 198200.
Kay-Lambkin, FJ, Baker, AL, Lewin, TJ, Carr, VJ (2009). Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy. Addiction 104, 378388.
Kiropoulos, LA, Klein, B, Austin, DW, Gilson, K, Pier, C, Mitchell, J, Ciechomski, L (2008). Is Internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT? Journal of Anxiety Disorders 22, 12731284.
Knaevelsrud, C, Maercker, A (2007). Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry 7, 13.
Lau, J, Elliott, MA, Jimenez-Silva, J, Kupelnick, B, Mosteller, F, Chalmers, TC (1992). Cumulative meta-analysis of therapeutic trials for myocardial infarction. New England Journal of Medicine 327, 248254.
Lidren, DM, Watkins, PL, Gould, RA, Clum, GA, Asterino, M, Tulloch, HL (1994). A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of Consulting and Clinical Psychology 62, 865869.
Lipsey, MW (1990). Design Sensitivity; Statistical Power for Experimental Research. Sage: Newbury Park.
Marks, IM, Kenwright, M, McDonough, M, Whittaker, M, Mataix-Cols, D (2004). Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomised controlled trial in phobia/panic disorder. Psychological Medicine 34, 918.
Marrs, RW (1995). A meta-analysis of bibliotherapy studies. American Journal of Community Psychology 23, 843870.
Marshall, WL, Presse, L, Andrews, WR (1976). A self-administered program for public speaking anxiety. Behaviour Research and Therapy 14, 3339.
Mataix-Cols, D, Cameron, R, Gega, L, Kenwright, M, Marks, IM (2006). Effect of referral source on outcome with cognitive-behavior therapy self-help. Comprehensive Psychiatry 47, 241245.
Menchola, M, Arkowitz, HS, Burke, BL (2007). Efficacy of self-administered treatments for depression and anxiety. Professional Psychology, Research and Practice 38, 421429.
Piaggio, G, Elbourne, DR, Altman, DG, Pocock, SJ, Evans, SJ (2006). Reporting of noninferiority and equivalence randomized trials: an extension of the CONSORT statement. Journal of the American Medical Association 295, 11521160.
Rosen, GM, Glasgow, RE, Barrera, Jr. M (1976). A controlled study to assess the clinical efficacy of totally self-administered systematic desensitization. Journal of Consulting and Clinical Psychology 44, 208217.
Schmidt, MM, Miller, WR (1983). Amount of therapist contact and outcome in a multidimensional depression treatment program. Acta Psychiatrica Scandinavica 67, 319332.
Selmi, PM, Klein, MH, Greist, JH, Sorrell, S, Erdman, HP (1990). Computer-administered cognitive-behavioral therapy for depression. American Journal of Psychiatry 147, 5156.
Shadish, WR, Sweeney, RB (1991). Mediators and moderators in meta-analysis: there's a reason we don't let dodo birds tell us which psychotherapies should have prizes. Journal of Consulting and Clinical Psychology 59, 883893.
Sharp, DM, Power, KG, Swanson, V (2000). Reducing therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care: global measures of outcome in a randomised controlled trial. British Journal of General Practice 50, 963968.
Spek, V, Cuijpers, P, Nyklíček, I, Riper, H, Keyzer, J, Pop, V (2007). Internet-based cognitive behavior therapy for mood and anxiety disorders: a meta-analysis. Psychological Medicine 37, 319328.
Spielmans, GI, Pasek, LF, McFall, JP (2007). What are the active ingredients in cognitive and behavioral psychotherapy for anxious and depressed children? A meta-analytic review. Clinical Psychology Review 27, 642654.
Tillfors, M, Carlbring, P, Furmark, T, Lewenhaupt, S, Spak, M, Eriksson, A, Westling, BE, Andersson, G (2008). Treating university students with social phobia and public speaking fears: Internet delivered self-help with or without live group exposure sessions. Depression and Anxiety 25, 708717.
Vestre, ND, Judge, TJ (1989). Evaluation of self-administered rational emotive therapy programs for interpersonal anxiety. Journal of Rational-Emotive and Cognitive-Behavior Therapy 7, 141154.
Watkins, PL, Clum, GA (Eds.) (2008). Handbook of Self-help Therapies. Routledge: New York.
Wollersheim, JP, Wilson, GL (1991). Group treatment of unipolar depression: a comparison of coping, supportive, bibliotherapy, and delayed treatment groups. Professional Psychology, Research and Practice 22, 496502.


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