Self-help, with and without a guide

Almost everything in this course so far has been a kind of self-help, and so is this lesson. That makes this the lesson where the evidence is closest to what you're doing right now: working through structured material, mostly on your own. So it's worth reading carefully, including the parts that say less than you'd hope and the parts that say more.

What NICE means by self-help

Lesson 1 showed you that NICE's step 2 for generalised anxiety disorder offers "individual non-facilitated self-help, individual guided self-help and psychoeducational groups". Those words have precise meanings in the guideline.¹

Non-facilitated self-help, under CG113 1.2.13, should "include written or electronic materials of a suitable reading age (or alternative media)"; "be based on the treatment principles of cognitive behavioural therapy (CBT)"; "include instructions for the person to work systematically through the materials over a period of at least 6 weeks"; and "usually involve minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes."¹

Guided self-help, under 1.2.14, should "be supported by a trained practitioner, who facilitates the self-help programme and reviews progress and outcome", and "usually consist of 5 to 7 weekly or fortnightly face-to-face or telephone sessions, each lasting 20 to 30 minutes."¹

NG222 defines guided self-help for depression in nearly the same terms: CBT-based and related materials, with "Support from a trained practitioner who facilitates the self-help intervention, encourages completion and reviews progress and outcomes", usually "6 to 8 structured regular sessions".²

Against a control, and against a therapist: anxiety

Now the evidence, with what each comparison group got. A Cochrane review is a systematic review done to the Cochrane Collaboration's published methods, and it grades how certain its evidence is.

For anxiety disorders, the Cochrane review of self-help by Mayo-Wilson and Montgomery included 101 studies with 8,403 participants, 92 of them pooled. This course read its abstract.³ Its main comparisons:

"For the primary outcome of symptoms of anxiety, moderate-quality evidence showed medium effects compared with no intervention (standardised mean difference (SMD) 0.67, 95% confidence interval (CI) 0.55 to 0.80; 72 studies, 4537 participants), and low-quality evidence of small effects favoured face-to-face therapy (SMD -0.23, 95% CI -0.36 to -0.09; 24 studies, 1360 participants)."³

A standardised mean difference is the same kind of number as the g from lesson 2. And on response, counting how many people improved enough: "The intervention was associated with greater response than was seen with no treatment (risk ratio (RR) 2.34, 95% CI 1.81 to 3.03; 21 studies, 1547 participants) and was not significantly inferior to face-to-face therapy in these studies (RR 0.78, 95 % CI 0.56 to 1.09; 10 studies, 575 participants), but the latter comparison included versions of therapies that were not as comprehensive as those provided in routine clinical practice."³

So on symptoms, a small deficit against face-to-face therapy; on response, no significant one. And the qualifier belongs to the face-to-face comparison: if the therapies tested were less thorough than routine ones, a real therapist might have done better than these trials show. That reading of the qualifier is this course's.⁷

Two more things from the same abstract. "Moderate-quality" and "low-quality" are its grades of how confident the authors are that the true effect is near the pooled figure; reviewers mark the evidence down for bias in the trials, results that disagree, and wide intervals, and it's a grade on the evidence, not on the treatment. Sleep lesson 6 taught the recommendation grades built on top of it. And: "Inconsistency and risk of bias reduced our confidence in the overall results."³

Lesson 2's question applies at once. The review's "no intervention" includes attention and relaxation controls, so the 0.67 is a mix: against a pure waiting list alone it might well have come out larger, and against the attention controls alone smaller. That reading is this course's, from lesson 2's ordering.⁷

Three more meta-analyses of self-help for anxiety come out close by.⁴ Every one was read at abstract level.

So, for anxiety, self-help beats its controls clearly, and against a therapist the reviews range from a small deficit to none. That summary is this course's, from the four abstracts.⁷

And for depression

Lesson 2 gave the depression figures, with their comparisons: unguided self-help CBT at 0.45 (from the review of CBT for depression that lesson 2 cited) against control conditions the abstract doesn't separate, and self-guided internet CBT at 0.27 against usual care, waiting lists or attention controls, with a number needed to treat of 8.⁵ The authors of that second review conclude plainly: "Self-guided iCBT is effective in treating depressive symptoms", and that it "can be considered as an evidence-based first-step approach in treating symptoms of depression", while adding that "Several limitations of the iCBT should be addressed before it can be disseminated into routine care."⁵ iCBT is internet-delivered CBT.

This course didn't read a depression review comparing self-help with a therapist head to head, and doesn't guess.

Two halves of one conclusion

One abstract seems to say two things, and working out how is the first worked case.

Mayo-Wilson and Montgomery conclude: "Self-help may be useful for people who are not able or are not willing to use other services for people with anxiety disorders; for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior." And, in the same abstract: "Self-help has been recommended as the first step in the treatment of some anxiety disorders, but the short-term and long-term effectiveness of media-delivered interventions has not been established."³

And one thing the evidence doesn't say. "Evidence regarding harm was lacking," the same review reports, and the Cochrane review of therapist-supported internet CBT for anxiety (Olthuis and colleagues) says "Adverse events were rarely reported."³⁴ Not measuring harm isn't finding none, so "self-help has no risks" is more than anyone here can claim.

What a guide adds

For depression, the largest evidence on guidance is a 2021 network meta-analysis by Karyotaki and colleagues that pooled individual people's data rather than whole studies: 39 trials, 8,107 people analysed. Pooling individual data is what lets the authors split results by each person's severity at the start, which is the finding that matters here.⁵

First the half a reader doing it alone would want: "Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term." Then the comparison between them: "Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization."⁵

And by severity: "Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9." The PHQ-9 is a nine-item depression questionnaire, a higher score means more symptoms, "baseline" means at the start, and "subthreshold" means below the level for a diagnosis. So for depression, the guide mattered more as symptoms rose, at the end of treatment.⁵

Why would a guide help? The sources go only so far. NG222's definition says the practitioner "encourages completion and reviews progress and outcomes".² And a meta-analysis of apps found that "Studies that delivered a cognitive behavior therapy (CBT)-based app and offered professional guidance and reminders to engage produced larger effects on multiple outcomes."⁶ Both point at keeping people going. Whether that's the whole of it, nothing this course read says; that reading is this course's.⁷

The Cochrane review of therapist-supported internet CBT has one more fact worth keeping. Of its 38 trials, "Studies were conducted in Sweden (18 trials), Australia (14 trials), Switzerland (3 trials), the Netherlands (2 trials), and the USA (1 trial)".⁴ Thirty-two of thirty-eight in two countries, which bounds what the result says about anyone else's health system.

Turning it on yourself

Now the second worked case, which is about you. Take it a step at a time.

How close is the match? The trials tested structured CBT programmes, usually over weeks, often online, sometimes with a guide. This course is none of those: it's education about the evidence, with no CBT exercises and no schedule. So the evidence above is indirect for it.

What was the comparison? For self-guided internet CBT in depression, usual care, waiting lists or attention controls; for anxiety, controls ranging from waiting lists to placebo. Every figure is "better than" something, and lesson 2 showed that the something matters.

How certain? Moderate at best for anxiety against controls, low against a therapist, very low on guided against unguided.

For whom? For depression, the more symptoms, the more a guide seemed to add at the end of treatment. Lesson 1's note from NG222 says the same from the other direction: in more severe depression, options "with more therapist contact should be carefully considered first".²

What's licensed? Very little about this course's effect on your mood, which nobody has measured. Something about structured self-help: it helped on average, against its controls, and for anxiety the effects were medium to large. And something about you: if your symptoms are more than mild, or self-help isn't helping, the guided version and a doctor are what the evidence points to.⁷

Four things people get wrong

"A self-help book and guided self-help are the same thing." The word "self-help" covers both, so it's easy to assume. NICE defines guided self-help by a trained practitioner and several sessions.

"Self-help is for mild problems only, so if it didn't work, I'm severe." Averages describe groups; some people in every treated group improved little. Not being helped isn't a test of severity. It's a reason to see a doctor.

"Face-to-face is always better." Against a therapist, the anxiety reviews range from a small deficit to none, and Mayo-Wilson and Montgomery say self-help "may be useful for people who are not able or are not willing to use other services". But the same sentence goes on: "for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior."³

"An app is as good as seeing a therapist." The mirror image, and just as easy to believe after the last paragraph. On symptoms, three of the four anxiety reviews found a deficit against a therapist (on response, Mayo-Wilson and Montgomery found self-help not significantly inferior), and the one that didn't had nine comparisons and an interval running below zero.⁴

Practice

Connections

Back. Lesson 1's stepped care, where self-help is step 2, and lesson 2's question: what did the comparison group get? Every figure here has its answer beside it.

Forward. Lesson 4 is worry, where the single techniques people are handed have much less behind them than the packages this lesson read.

Go deeper

• Mayo-Wilson and Montgomery, 2013, the Cochrane review, free at PubMed Central. This course read the abstract. Its conclusions paragraph is worth reading whole.
• NICE CG113, recommendations 1.2.11 to 1.2.20, the specification of step-2 and step-3 treatment.

Sources

1. National Institute for Health and Care Excellence, CG113, 2011, updated 2020, recommendations 1.2.12 to 1.2.15. Read. Supports: the step-2 options and the specifications of non-facilitated and guided self-help.
2. National Institute for Health and Care Excellence, NG222, 2022, Table 1's guided self-help row and Table 2's note. Read. Supports: the depression definition of guided self-help and the note on more severe depression.
3. E. Mayo-Wilson and P. Montgomery, "Media-delivered cognitive behavioural therapy and behavioural therapy (self-help) for anxiety disorders in adults", Cochrane Database of Systematic Reviews 2013, CD005330, doi 10.1002/14651858.CD005330.pub4. Read: the abstract. Supports: the study counts, both symptom comparisons and the response comparisons with their quality, the qualifiers, the clinician-support sentence, both conclusions, the call for pragmatic trials, harm not measured, and availability to consumers.
4. Four further reviews, each read at abstract level: T. Haug and colleagues, Clinical Psychology Review 32(5), 2012; C. Lewis and colleagues, British Journal of Psychiatry 200(1), 2012; D. Pauley and colleagues, Psychological Medicine 53(2), 2023; and J. V. Olthuis and colleagues, "Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults", Cochrane Database of Systematic Reviews 2016, CD011565. Supports: the table, the guidance findings for anxiety, the countries, and adverse events.
5. E. Karyotaki and colleagues, "Internet-Based Cognitive Behavioral Therapy for Depression", JAMA Psychiatry 78(4), 2021; and "Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms", JAMA Psychiatry 74(4), 2017. Read: the abstracts. Supports: both against controls over the short and long term, guided against unguided by severity, g = 0.27 and its comparisons, and the 2017 conclusions and caveat.
6. J. Linardon and colleagues, "The efficacy of app-supported smartphone interventions for mental health problems", World Psychiatry 18(3), 2019. Read: the abstract. Supports: guidance and reminders going with larger effects.
7. This course's own constructions, labelled where they appear. The impression of typical apps and books, the reading of the face-to-face qualifier and of the mixed control, the one-line summary of the four anxiety reviews, the reading of how the Cochrane conclusion's halves fit, the reading of why a guide helps, and the step-by-step case for a reader doing it alone are this course's.