ReviewTreatment-as-usual (TAU) is anything but usual: A meta-analysis of CBT versus TAU for anxiety and depression
Introduction
Depression and anxiety are common mental disorders and the primary cause of disability worldwide (Whiteford et al., 2013). There is a 21.4% lifetime prevalence in adults for a mood disorder and 33.7% for an anxiety disorder (Kessler et al., 2012). In attempts to identify effective treatments, researchers have investigated the benefits of psychotherapy, with cognitive behavior therapy (CBT) most widely studied. Meta-analyses have shown CBT, including computerized CBT, to be effective for individuals with depression and anxiety compared to wait-list (WL), treatment-as-usual (TAU) or a control group (Hedges g=0.88) (Andrews et al., 2010, Butler et al., 2006). Reflectively, the National Institute of Health Care Excellence (NICE) guidelines in the UK recommend CBT either in a self-help, computerized, individualized or group format depending on stage of illness and illness severity (NICE, 2009, NICE, 2011).
In order for a particular therapy or treatment approach to have demonstrated efficacy, it must have been investigated in a randomized controlled trial (RCT). Commonly, the aim of an RCT is to identify the superiority of a new intervention and the use of a control group is used to provide evidence of this (Le Henanff et al., 2006). Yet, what constitutes an adequate control group continues to be debated. Early researchers argued that the nonspecific factors of the control group must be accounted for, and as a result recommended the use of a psychological placebo (Rosenthal and Frank, 1956). However, implementing well-designed psychological placebos has been fraught with complications (Baskin et al., 2003, Parloff, 1986), and so researchers conducting RCTs have frequently used “treatment-as-usual”, wait-list, or no treatment as alternative control conditions.
There have been no systematic reviews or meta-analyses that have examined the impact of the TAU control condition on the reported treatment effects, highlighting a gap in the literature. However, the existing meta-analyses suggest the specific type of control group matters. Recently, Honyashiki et al. (2014) examined the difference between treatment effects in CBT when comparing two different types of control groups: no treatment (NT) and psychological placebo (PP) for adults with an acute depressive disorder. The results showed that CBT was superior to NT (OR 2.24, 1.32–3.88), and CBT was nominally, but not significantly, superior to PP (OR 1.30, 0.53–2.94), with NT inferior to PP (OR 1.73, 0.67–4.84). Clearly the choice of a control group, and whether or not the control group involves some form of psychological therapy, influences the outcomes of the comparative effectiveness of CBT. However, this meta-analysis did not include studies with a TAU comparison group despite TAU being more commonly used as a control condition. It is important to examine the effect of a TAU control condition because in addition to it being commonly employed as a control group, TAU is what is already being delivered clinically; therefore the results of a study should be informative of any necessitated changes to clinical practice (or not).
Previous reviews have focused on examining either comparisons between a range of psychological treatments versus TAU (Flückiger et al., 2014, Wampold et al., 2011), or CBT versus a range of control groups to explore how the choice of control group influences the estimate of effects. Wampold et al. (2011) meta-analysis of 14 studies examined the efficacy of a range of evidenced-based treatments (EBTs) for depression and anxiety compared to TAU. The EBT condition aggregated the results from RCTs of CBT as well as mindfulness-based cognitive therapy, eye movement desensitization and reprocessing, interpersonal psychotherapy and behavioral activation. They showed that although there was a significant effect when comparing EBTs to all TAU conditions (combined), there was no significant difference between the EBTs compared with TAUs that were only psychotherapeutic interventions. This review highlighted the way in which the term “treatment-as-usual” is used to describe a heterogeneous set of interventions, and that greater clarification and consideration of what the TAU condition entails is needed before drawing conclusions from past RCTs about the efficacy of EBTs. The limitation of this review was that it focused on the comparison between TAU with a broad set of evidence-based psychological interventions for depression and anxiety. There have been no previous systematic reviews that have focused solely on studies comparing a psychological therapy from one modality (e.g., cognitive behavioral therapy) with TAU. A systematic review is now needed with a consistent “treatment group” but varying TAU conditions to explore how varying TAU conditions may result in different treatment effects. CBT provides an ideal example because it has been widely studied in both depression and anxiety disorders, and compared to a range of TAU conditions.
In a Cochrane Review, Gava et al. (2007) demonstrated that patients with obsessive compulsive disorder (OCD) receiving any variant of CBT exhibited significantly fewer symptoms post-treatment than those receiving TAU (SMD −1.24, 95% CI −1.61 to −0.87, I² test for heterogeneity 33.4%). However, the efficacy of CBT versus TAU in the treatment of depression and other anxiety disorders remains less clear because previous reviews have focused on comparing CBT versus a range of control groups to explore how the choice of control group influences the estimate of effects. For example, in a meta-analysis focused on anxiety and depression, Tolin (2010) examined the effects of CBT versus other psychological therapies and revealed that CBT performed better than psychodynamic therapy but not interpersonal and supportive therapies. In another recent meta-analytic review, Cuijpers et al. (2014) compared the effects of CBT for generalized anxiety disorder (GAD) to control groups that included TAU, but did not investigate the effect of CBT versus TAU in isolation, nor whether the type of TAU influenced the findings. Andrews et al. (2010) demonstrated that the size of the effect of CBT is larger when compared with WL than with TAU, i.e. when participants were prevented from receiving treatment within the waiting period CBT appears as more potent versus when participants received treatment as part of usual care, CBT appeared less efficacious. Therefore, it is important to consider CBT versus TAU further.
Precisely what is meant by the term TAU when used to refer to as a control group remains elusive. The term “TAU” varies widely and depends on the knowledge, expertise and resources of the health care professionals delivering it. Accordingly, studies that compare a treatment intervention with a TAU control group are difficult to interpret. The term TAU/care-as-usual/standard care is often used interchangeably. For the purposes of this study, we will use TAU to refer to all of these terms. The Consolidated Standards of Reporting Trials (CONSORT) statement provides guidelines to improve the quality of reporting of RCT׳s (Schulz et al., 2010). As part of these guidelines it is recommended that authors should describe each intervention, including control interventions; and if the control group is to receive TAU it is important to describe thoroughly what that constitutes, so that the description can allow a clinician wanting to use the condition to know exactly how to administer the condition that was evaluated in the trial (Glasziou et al., 2008). As such, the purposes of this article are (1) to determine the relative efficacy of CBT treatments for anxiety and depression versus a “TAU” control condition, (2) to determine how the term “TAU” is being used, and (3) explore whether the type of TAU condition influences the estimate of effects of CBT.
Section snippets
Inclusion criteria
- (i)
Types of studies. We included all trials using random allocation to an intervention and TAU control group that met the inclusion criteria for type of participant, intervention and outcome, and were published in English in a peer reviewed journal. Randomized control trials with multiple arms were also included as long as the inclusion criteria were met.
- (ii)
Types of participants. Males and females aged 18 and above with the presence of a depressive or anxiety disorder of any severity were included.
Study selection
This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Standards (Moher et al., 2009). A systematic search of Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO was conducted on the 3rd of March 2014. Please refer to Appendix A Cochrane Central Register of Controlled Trials (CENTRAL), Appendix B CINAHL search for Depression, Appendix C PsycInfo
Summary of main findings
This study aimed to determine the efficacy of CBT treatments for anxiety and depression that use a TAU control condition. The results suggest that CBT was more efficacious than TAU in the treatment of depression, anxiety and mixed anxiety and depression. The impact of CBT on clinical outcome was similar for studies that aimed to treat anxiety or depression; however, the effect was smaller in studies of transdiagnostic therapies, when the intervention aimed to treat both disorders as their
Conclusion
It is essential that future researchers describe the TAU condition clearly enough to allow for replication and interpretation of results. We recommend four key details to be reported that can be simply thought of as “who, what, how many, and any treatment additions?” The present meta-analysis provides evidence that CBT was more efficacious than TAU in the treatment of depression, anxiety, and mixed anxiety and depression. Yet, our results show that the term “TAU” is not a homogenous comparison
Funding source
Departmental funds were used for this research.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
We thank Dr. Louise Mewton and two anonymous reviewers for their suggestions on the earlier versions of the manuscript.
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2023, Journal of Affective DisordersCitation Excerpt :To make informed decisions about implementation, this must clearly be factored in. There has been a longstanding discussion about insufficient reporting of TAU comparators in the field of psychiatry (Burns and Priebe, 1996; Watts et al., 2015), but it is evident that the level of details provided can still be improved. Indeed, there is a need for methodological guidelines standards of design and reporting of control conditions in the mental health field in general (Faltinsen et al., 2022).
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References marked with an asterisk indicate studies included in the meta-analysis. The in-text citations to studies selected for meta-analysis are not preceded by asterisks.