How Effective is Cognitive Behavioral Therapy

Running head: HEALTHCARE
How Effective is Cognitive Behavioural Therapy in Treating Mental Health Patients with
Depression
Name of the Student
Name of the University
Author Note

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Introduction
Cognitive Behavioural Therapy (CBT) is defined as a talking therapy that works by
changing the way of one’s thought process (Robertson, 2019). It is commonly used for the
treatment of the mental health complications like anxiety and depression (National Health
Services (NHS, 2019). The following evidence-based practice research is aimed towards
elucidating the effectiveness of CBT for treating mental health patients suffering from
depression. The research will undertake a qualitative research approach by conducting
systematic review of literature. The paper will initiate with a detailed search strategy that was
used for the selecting the articles from the online databases. This will be followed by the
critical discussions of the selected set of articles followed by a summative overview of the
entire paper. The conduction of this research is important as systematic review of literature
over CBT is important for the establishment of the evidence-based practice (EBP) guidelines
in the mental health nursing. EBP deals with conscientious usage of latest yet relevant
evidences in making decisions about patient’s care (Ruzafa-Martínez et al., 2019). It is
defined as a problem solving approach in clinical practice. The main steps of generation of
EBP include conduction of systematic research through critical appraisal of relevant
evidences in order to answer an alarming clinical question. The information evolved through
critical review of literature is aligned with the clinical expertise of the healthcare
professionals and the patients’ preferences in order to design the customised interventions
(Melnyk et al., 2017). There are different EBP practice models that are helpful in the field of
mental health nursing like Stetler model, Iowa model, Rossworm and Larrabee model,
D.Censo model of EBP. Stetler model is popular in nursing research (Dang and Dearholt,
2018). It emphasizes practitioner oriented EBP and give importance to both external and
internal evidences. The phases of Stetler model include preparation (phase 1), Validation
(phase 2), Comparitive evaluation or Decision making (phase 3), Translation/application

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(phase 4), Evaluation (phase 5) (Nilsen, 2015). The steps of the Iowa Model in the EBP
include selection of the clinical question, formation of the team, retrieving of evidences,
grading of the evidences, development of the EBP standards, implementation of EBP and
evaluation of the nursing outcomes (White and Spruce, 2015). CBT is regarded as gold
standard for the psychological treatment. However, recently, few researchers have argued
plurality in the psychotherapeutic interventions while questioning the status of the CBT as the
gold standard for the treatment of depression (David, Cristea and Hofmann, 2018). Thus
conducting EBP research will in clearing the doubts towards efficacy of the EBP model in
depression management.
Search
Search terms
A well constructed search strategy is defined as the core of the systematic review
(Mendes et al., 2019). One of the important aspect of search strategy is proper selection of the
search terms. Search terms are popularly known as key words that are selected based on the
scope of the research questions. The proper use of the keywords helps to broaden the
probability of finding relevant research hits from the electronic databases (Ferrari, 2015). The
main search terms that are used in this research are included in the table below:
Keyword
s
Keywords Boolean
Operato
r
Synonym
of Keyword
Boolean
Operato
r
Synonym
of
Keyword
Boolean
Operato
r
Synonym
of
Keyword

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Keyword
1
depression OR depressive
disorder
OR depressiv
e
symptom
s
major
depressiv
e disorder
Boolean
Operator
AND
Keyword
2
Cognitive
Behaviour
al Therapy
OR CBT OR Cognitive
Behaviou
r Therapy
OR
Boolean
Operator
AND
Keyword
3
efficacy OR effectivenes
s
OR impact OR Outcome
Table 1: The keywords that are used for search
Boolean operators are used in order to combine the keywords. Grewal, Kataria and
Dhawan (2016) stated that Boolean Operators (AND and OR) are modifiers that helps to
obtain different combination of keywords and thus increasing the probability of getting
relevant hits.
Databases
The two electronic databases that were used for the search of the articles are CINAHL
and PubMed. CINAHL indexes several nursing journals that assist the researches to search
articles by the use of the search terms. CINAHL is user-friendly interphase for the search of
the literary articles. Since the focus of CINAHL database is primarily on the nursing journals,

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it is selected as the prime database of choice (Scala, Price and Day, 2016). PubMed is the
second database that was selected for the search of the nursing articles. PubMed contain
access to several peer reviewed journal articles. According to Vassar et al., (2017), systematic
review must aimed towards reviewing significant number of articles from different journals
in order to reduce the probability of selection bias. Thus, selecting PubMed as one of the
databases for searching journal articles helped to gain access of diverse papers from different
international journals and thereby minimizing the selection bias.
Inclusion and Exclusion Criteria
The initial search of the articles by the use of the keyword combinations highlighted
in the Table 1 helped in the identification of 1912 articles from CINAHL. This was followed
by refining of the search articles. The refining the number of the articles obtained from the
literature search is done by the use of the inclusion and exclusion criteria. Aveyard and Sharp
(2013) argued that proper use of the inclusion and exclusion criteria. The inclusion and
exclusion criteria that are used for refining of the search are highlighted in the table below:
Factors Inclusion Criteria Exclusion Criteria
Year of publication 2009 to 2019 (last 10 years) Articles published before 2009
Language English Other than English
Population People suffering from depression People suffering from other
mental health complications
where depression is not a
significant concerns
Type of articles Primary articles and secondary
articles
Grey literatures and dissertation
Table 2: Inclusion and Exclusion Criteria

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Articles that were published within the last 10 years are included in the research.
Parahoo (2014) stated that for the generation of the EBP critical analysis of the articles that
are published within the last 10 years is important. This helps to achieve a detailed overview
of the previous work one over the selected clinical questions. Both the secondary and primary
articles were selected for the review. DiCenso, Guyatt and Ciliska (2014) stated that
secondary articles like systematic review of literatures or review of the randomised control
trail (RCT) belongs to level 1 of the hierarchy of evidences. Thus selection of systematic
review of RCTs will help to increase the overall strength of this EBP research. People having
depression as principal mental health complications or as one of the prime co-morbidity are
selected as the main population of choice during the selection of the articles in order to align
with the main scope of research. English was selected as the main language of choice under
the inclusion criteria as it s the official language of UK and used internationally for research.
Selection of English as the foremost language of research will help to increase the overall
acceptance of the research (Kendig et al., 2017).
The application of inclusion and exclusion criteria as filters in the database research in
CINAHL helped in the identification of 291 articles. The similar set of inclusion and
exclusion criteria were used for the finding the research articles from the PubMed database.
The keywords that are used in order to refine the search for are: cognitive behavioral therapy
AND depression OR Mental Illness AND efficacy. Different set of keywords are used for
CINAHL and PubMed in order to refine the search. Using keywords for CINHAL for
PubMed yielded 14745.
The total articles retrieved from the PubMed search was 293. Both the articles
retrieved from PubMed and CINAHL were examined in order to eradicate the redundant
articles. Screen shot of the search from CINAHL and PubMed is highlighted in the Appendix.

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A detailed process of the search used for the identification of the final set of articles are
highlighted in the PRISMA chart below:

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PRISMA 2009 Flow Diagram
Records identified through
PubMed (n = 293)
Records excluded = 250
(n = )
Records after duplicates removed (290)
Records identified through
CINHAL (n = 291)
Articles assessed abstract (n = 40)
Studies screened full-text (n = 15)
Final set of articles
included in review (n =
5)
Articles excluded, (do
not meet inclusion)
(n = 10)
Articles excluded, (do
not meet inclusion)
(n = 25 )
Records screened based on title (290)
(n = )

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Discussion
Ruwaard et al. (2009) conducted randomized controlled trial (RCT) with a long term
follow-up in order to ascertain the efficacy of therapist guided web-based CBT for the
treatment of mild to moderate depression. The RCT study structure can be considered as one
of the strength of the study as it helps to reduce the chances of getting biased results. The
study was conducted over 54 individuals suffering from chronic to moderate depression with
18-month follow- Average sample size can be considered as limitation of the study as it
reduce the chances of generalization of the data (Wolf et al., 2013). The analysis of the
results showed that participants during the in the treatment group recovered significantly in
comparison to the wait-list control condition thus showing the importance of the intention to
treat. On an average, the recovery rate was stable until 18 months of follow up. The overall
results demonstrated the efficacy of the web-CBT for the treatment of the mild to moderate
depression along with giving importance to the therapist-associated guidance in
psychological interventions (Ruwaard et al., 2009). Cuijpers et al. (2013) conducted meta-
analysis of the RCT that falls under level 1 of hierarchy in order to elucidate the effects of
CBT for the treatment of adult depression. The aim of study by Cuijpers et al. (2013) was
slightly different from Ruwaard et al. (2009) as it tested that efficacy of manual CBT rather
than web-based CBT. Total of 115 studies were selected for the review focusing on adult
patient with depression. Review of the articles showed that CBT is effective for the treatment
of adult depression however, its positive effects might have been over-estimated till now. The
meta-analysis also helped din understanding that CBT is the most studied psychotherapy for
the treatment of depression and holds supreme weightage for the generation of the evidence-
based practice guidelines. The study also failed to highlight any evidences showing that CBT
is more effective in comparison to the other psychotherapies that are used for the treatment of

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depression. The study though helped in understanding the efficacy of the CBT over the
treatment of depression among the adults, the study failed to highlight the underlying
pathophysiology behind depression’s prognosis upon CBT implementation. The study scores
high on publication bias (Cuijpers et al., 2013). Cuijpers et al. (2013) conducted study over
the adults and Ruwaard et al. (2009) failed to mention any specific age group over which the
study has been conducted. Thus aligning the findings of both the studies might be difficult
because Maughan, Collishaw and Stringaris (2013) stated that the developmental trajectories
of depression differ depending upon age group of the individuals.
De Graaf et al. (2009) conducted RCT in order to study the clinical effectiveness of
the online computerized based CBT for the treatment of depression. The scope of the study is
similar to that of Ruwaard et al. (2009) as it conducted the study in order to identify the
efficacy of computer-based CBT. However, De Graaf et al. (2009) also compared the efficacy
of the CBT while no treatment is received under the primary care treatment. 303 people who
are suffering from depression were randomly allocated to one of the three groups. The
follow-up period for the study was 6-month. Three interventions that are studied in this study
include colour your life; treatment as usual (TAU) by the general practitioner; Colour your
life and TAU. Here Colour Your Life is an online multimedia yet interactive computerised
CBT programme. The analysis of the result showed that there are no significant differences in
the outcome between the three interventions under the intention to treat analysis and per
protocol analysis. At last the author concluded that unsupported computerised CCBT failed to
outperform the usual care and the combination of both the therapy failed to fetch any
additional effects. The reduction in the depressive symptoms among the people who are
suffering from the moderate to severe depression was found to be moderate in all the three
interventions. The online CBT did not prove to be beneficial for all the individuals suffering
from depression (De Graaf et al., 2009). Two strengths that can be easily identified from the

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study include large sample size and the study design. The results elucidated by De Graaf et al.
(2009) prove to be different from Cuijpers et al. (2013) and Ruwaard et al. (2009) as they
failed to highlight any signficiant benefits of the CBT over depression management in the
absence of any other primary care. However, it is not clear whether Cuijpers et al. (2013) and
Ruwaard et al. (2009) only implemented CBT in the absence of any other therapy.
Beltman, Voshaar and Speckens (2010) conducted the meta-analysis of the RCT in
order to elucidate effectiveness of the CBT for the management of depression among the
people who are suffering from somatic diseases. Though the scope of the study focuses on the
mental illness, somatic disease was also selected for review as Hegeman et al. (2015) are of
the opinion that chronic somatic disease like pain or trauma leads to the development of poor
mental health condition leading to depression. The analysis of the results helped to
understand that CBT therapy helps in significant reduction in the depressive symptoms
among the people who are suffering from the mental illness arising from any somatic disease.
The depressive status of the people who qualified the DSM V criteria for the depression were
only selected for the study. The results of Ruwaard et al. (2009) and Beltman, Voshaar and
Speckens (2010) are same and thus helping to understand the importance of the CBT for the
treatment of depression among the adults with mental illness. Beattie et al. (2009) conducted
their study over the primary care patients in order to analyse their expectations and overall
experiences over the online CBT for the depression management. The qualitative study used
semi-structured interview in order to record the data both before and after the application of
the therapy. Parallel to this an RCT was conducted for examining the effectiveness and cost-
effectiveness of CBT with depression. The understanding the perspective of the patients hold
prime importance under the EBP guideline formation and thus the study of Beattie et al.
(2009) was included in the review. The results indicated that home-based computerised CBT
is popular among the patients due to its convenience among the service users. Development

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of the virtual relationships with the therapists ability to communicate effectively through the
online medium are few of the important aspects behind the popularity of the computerised
CBT (CCBT) and its cost effectiveness. However, the study also showed that under the
absence of the visual cues and the immediate response from the therapists in the online
therapy, unlike the face to face interaction, the CCBT can fail to extract significant results
among the patients with severe negative thoughts (Beattie et al., 2009). The authors also
highlighted in their study that if online CBT is required to be implemented through NHS, it is
important to understand the preferences of the patient about the mode of delivery of the
therapy while ensuring the referral practices are targeted appropriately. The study having two
different study wing can be considered as one of the prime strength of the study helping to
access more than one outcome (Beattie et al., 2009). The study used 10 sessions of CBT over
the individuals residing in southwest England however, the sample size is only 24 thus
indication the poor sample. Ginsburg and Smith (2016) stated that sample size below 100 in
the RCT help to fetch unbiased results and thus hampering the process of generating
generalised results that can be applied to population on whole.
Conclusion
The above systematic review was conducted through the search of the literary articles
from the electronic databases. The two main electronic databases that were used for the
conduction of the study include CINAHL and PubMed. The search of the articles with the
help of the keywords that matches with the scope of the study helped in the identification of
five articles (primary and secondary) that are published within the last 10 years. The analysis
of the 5 papers for the conduction of the systematic review helped in the identification several
new aspects associated with the application of the CBT for the effective management of
depression among the people who are suffering from the mental health complications. The

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analysis of the 5 different papers helped to reveal that application of the CCBT is effective
for the reduction of the severity of depression among the people suffering from the
depression. The review also helped in identifying that the CCBT is effective over overcoming
depression among the patients who have developed mental illness or depression arising out of
certain somatic cell complications. However, further analysis in the domain of the depression
management for somatic disease through CBT must be undertaken in order to strongly
establish the validity and efficacy of the CBT under the evidence-based practice guidelines.
The review failed to highlight any significant evidence for the management of the depression
with the help of the manual CBT only without the application of any other primary
interventions.
Implications
The main implications of this research under the nursing practice is, the study assisted
in the generation of the evidence-practice guidelines. The study helped the nurse to identify
that CCBT is effective over CBT (manually) in order to promote depression management
among the adults who are suffering from the mental illness developed due to certain
emotional consequences. The evidences that added to my knowledge base is, efficacy of the
CCBT is effective only when the service user of the CBT is successful in generating virtual
relationship with the therapists online and is effective in exchanging their thoughts through
online medium. Raney et al. (2017) are of the opinion that under virtual therapy planning it is
important for the healthcare service providers to make the service users or the mental patients
accustomed with the concept of the online therapy in order to improve the overall outcome of
the study. The further information that must be extracted from the study include difference in
the efficacy of the CCBT over the older adults and teenagers as this will further helped to
customise the therapy planning. Scott et al. (2018) stated that the process of prognosis of the

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depression differs depending on age of the individuals. The process of searching of evidence
informs that nursing practice must be customised depending on the preference of the patients
who are using the CBT. The main gaps in the evidence is, the 5 out of 4 papers failed to
highlight that whether additional medications were given apart from CBT in order to treat
depression. Presence of the additional therapies for depression management might increase
the probability of getting biased results (Smith et al., 2015; Huguet et al., 2016).

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Appendix
Appendix 1: Table of Search
Database
Searched
Date Searched Search strategy
used (keywords)
Limits
(Inclusion
and
Exclusion
Criteria)
No. Of Results Notes
PubMed 31st December
2019
cognitive
behavioral therapy
AND depression
OR Mental Illness
AND efficacy
Published
within
last 10
years,
Available
full-text
with
abstract
and
published
in
English
293 NA
CINAHL 31st December
2019
cognitive
behavioral therapy
AND depression or
depressive disorder
or depressive
symptoms or major
depressive disorder
Published
within
last 10
years,
Available
full-text
with
291 NA

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AND efficacy or
effectiveness or
impact or benefits
or outcomes
abstract
and
published
in
English

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Table 2: CINAHL Search

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Appendix 3: PubMed Search
PubMed Search with CINAHL keywords