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Behavior Therapy 40 (2009) 302 – 314
A Nonrandomized Effectiveness Comparison of Broad-Spectrum
Group CBT to Individual CBT for Depressed Outpatients in a
Community Mental Health Setting
Mark A. Craigie, Paula Nathan
Centre for Clinical Interventions, Perth, Western Australia
Controlled trials have established the efficacy of cognitive-
behavior therapy (CBT) for depression. However, the
relative effectiveness of individual versus group treatment
formats in real-world settings is less well established. The
current study evaluated the effectiveness of group CBT
(n = 157) compared to individual CBT (n = 77) for depressed
outpatients in a naturalistic setting. Symptom improvements
for depression, anxiety, and quality of life were compared
between treatment formats in intent-to-treat and completer
analyses. Effect sizes and rates of recovery were examined.
Results showed that both individual and group CBT were
effective, even in the presence of high levels of comorbidity.
Whereas individual CBT was associated with larger effect
sizes and significantly higher rates of recovery, group CBT
compared favorably to outcomes established by past
research. A broad-spectrum group CBT program may be a
viable treatment option when depression symptoms are
less severe and when this format of treatment delivery is
desirable.
TREATMENT EFFICACY STUDIES ( Elkin et al., 1989;
Hollon et al., 1992) and research reviews have led
to the general conclusion that diagnosis-specific
cognitive-behavior therapy (CBT) is an efficacious
treatment for major depression and a range of
Our special thanks go to all the patients and therapists that have
contributed to the data on which this study is based. Thanks also to
the anonymous reviewers for their helpful feedback and to Dr
Hunna Watson for her valuable comments during final manuscript
preparation.
Address correspondence to Dr. Mark Craigie, Centre for Clinical
Interventions, 223 James St Northbridge, Perth, Western Australia,
6003; e-mail: markcraigie@bigpond.com.au.
0005-7894/08/0302–0314$1.00/0
© 2008 Association for Behavioral and Cognitive Therapies. Published by
Elsevier Ltd. All rights reserved.
www.elsevier.com/locate/bt
affective disorders (Butler, Chapman, Forman &
Beck, 2006; Westen & Morrison, 2001). However,
generalizing results of efficacy trials of empirically
supported therapies (ESTs) to real-world mental
health settings can be problematic. Differences in
patient, therapist, and treatment characteristics that
can exist between efficacy trials and regular clinical
practice raise doubts as to whether treatment effects
can be readily transported into more clinically
representative settings (Roth & Fonagy, 1996).
Effectiveness research aims to address this pro-
blem by determining if efficacy effects can be re-
produced in conditions resembling routine clinical
practice and for patients more typically en-
countered in such settings (Russell & Orlinsky,
1996). Routine clinical practice in this paradigm
typically involves a nonuniversity setting, natural
recruitment, less rigorous application of exclusion/
inclusion criteria, and more heterogeneous and
comorbid samples. Treatment protocols are less
rigidly applied, and therapists do not receive inten-
sive supervision and training for the purposes of the
study (Shadish et al., 1997; Westbrook & Kirk,
2005). As Westbrook and Kirk have noted, effec-
tiveness research often requires a trade-off between
high internal validity at one end of the research
spectrum (e.g., treatment integrity checks, randomi-
zation and control) and clinical representativeness at
the other end of the spectrum (e.g., nonrandomiza-
tion, no integrity checks, limited supervision).
Fortunately, a growing body of clinically repre-
sentative studies have demonstrated the transport-
ability of CBT effects (Kellett, Clark, & Matthews,
2007; Merrill, Tolbert, & Wade, 2003; Persons,
Roberts, Zalecki, & Brechwald, 2006; Shadish et al.,
1997; Westbrook & Kirk, 2005). Westbrook and
Kirk (2005) compared their individual CBT out-
 effectiveness of group cbt for depressed outpatients
comes for a depressed outpatient sample (N = 127)
to those of a prominent efficacy trial (Elkin et al.,
1989). Although their uncontrolled effect size
(Cohen’s [1988] d = 1.5) for the Beck Depression
Inventory (BDI; Beck et al., 1961) was somewhat less
than that of the Elkin et al. (1989) study (d = 2.0), the
recovery rate for the BDI (score b 13.5) was not
significantly different (42% and 50%, respectively).
When Westbrook and Kirk examined outcomes for
patients with pretreatment depression scores in
the moderate range (pretreatment BDI ≥ 20), they
still observed a favorable effect size (d = 2.1) and
recovery rate (39%). These findings were compar-
able to the findings of other effectiveness studies
conducted under similar conditions (Merrill et al.,
2003; Persons et al., 2006).
Persons et al. (2006) and others (e.g., Addis,
Wade, & Hatgis, 1999) have argued that the frequent
occurrence of comorbid Axis I disorders in patients
presenting to routine practice can be a barrier to
therapists using ESTs. Comorbidity introduces com-
plexities for therapists by requiring them to order and
tailor treatment elements from a number of disorder-
specific protocols to each problem and maintaining
factor (Persons et al., 2006). Barlow, Allen, and
Choate (2004) have proposed that a more unified
protocol that targets common maintaining factors
across disorders may be a parsimonious approach
that can address this problem. Their proposal is
underpinned by clinical and theoretical research that
suggests that common maintenance processes under-
lie a range of affective disorders (e.g., Borkovec,
Abel, & Newman, 1995; Brown, Chorpita, &
Barlow, 1998; Clark & Watson, 1991).
In line with this view, Nathan and colleagues (2004)
developed a time-limited and structured broad-
spectrum group CBT program for patients with
depressive and/or anxiety disorders based on the
combination of numerous EST elements (e.g.,
Gloaguen, Cottraux, Cucherat, & Blackburn,
1998; Telch et al., 1993; Wade, Treat, & Stuart,
1998). Recently, McEvoy and Nathan (2007) have
shown that this protocol was effective for a large
(N = 138) outpatient sample with mixed anxiety
and depressive disorders. A controlled study by
Norton and Hope (2005) of their broad-spectrum
group CBT for anxiety disorders has also produced
positive findings.
Although only limited evidence exists to the effi-
cacy of broad-spectrum group CBT, meta-analytic
reviews suggest group CBT is an efficacious treat-
ment for unipolar depression (McDermut, Miller, &
Brown, 2001; DeRubeis & Crits-Cristoph, 1998)
and is not significantly inferior to individual treat-
ment (Oei & Dingle, 2008; McDermut et al., 2001;
Robinson, Berman, & Neimeyer, 1990). Group CBT
303
has also been shown to be effective in clinically re-
presentative settings (Bright, Baker, & Neimeyer,
1999; Kellett et al., 2007; Petersen & Halstead,
1998), is a format that lends itself to standardization,
and can be delivered to large numbers of patients in a
time- and resource-efficient manner (Oei & Dingle,
2008). However, methodological differences and
frequent small sample sizes make it difficult to draw
strong conclusions about differences in outcome bet-
ween formats (Tucker & Oei, 2007). For example,
would individual and group CBT in a routine clinical
setting that services patients with frequent Axis I
comorbidity and depressive symptoms in the mod-
erate to severe range demonstrate similar outcomes,
or would the inherent flexibility afforded by
individual CBT produce superior results? Given the
purported practical benefits of group CBT (Oei &
Dingle, 2008; Tucker & Oei, 2007), further research
in a large representative community-based sample
seems warranted and would improve the chances of
detecting any clinically meaningful differences in
outcome that may exist. In addition, it would be
useful to know how well group CBT fares in a
naturalistic context when depressive symptoms are
more severe, as research has shown higher pretreat-
ment depression is predictive of less favorable out-
comes (Merrill et al., 2003).
To address these aims, the current study compared
the effectiveness of the Nathan et al. (2004) broad-
spectrum group CBT protocol to individual CBT for
a large sample of outpatients with a primary diag-
nosis of depression in a community mental health
setting. The study design involved a nonrandomized
and naturalistic allocation of participants to each
treatment format. Group CBT involved a time-
limited one-size-fits-all approach, whereas indivi-
dual CBT was more tailored and open-ended.
Differences in treatment effectiveness were exam-
ined by comparing the rate of mean symptom
improvement for each treatment modality and the
impact of higher pretreatment depression severity
on depression symptom improvement and rate of
recovery measured against standardized criteria.
The results were examined for the whole sample
and for subsamples with pretreatment scores above
both moderate and severe cutoff thresholds. Al-
though there are obvious threats to internal validity,
as Speer (1994) has noted, this approach can offer
meaningful clinical data for decision making in
routine clinical practice.
It was hypothesized that both therapy formats
would be associated with significant symptom re-
duction. Given the expected high level of comor-
bidity usually present in outpatient samples, we
predicted that the more flexible individual CBT
would be associated with more symptom improve-
304 craigie & nathan
ment and better depression symptom outcomes
than group CBT.
Method
participants
The sample comprised 356 patients with a primary
diagnosis of major depressive disorder according to
criteria of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR; American Psychia-
tric Assocition [APA], 2000). These patients were
referred for either individual or group therapy at
the Centre for Clinical Interventions (CCI)1 , a pub-
licly funded outpatient mental health clinic. From
this total pool, 234 patients completed treatment.
Treatment completion was defined as attendance of
at least five treatment sessions, a valid set of pre-
and posttreatment depression data, and treatment
completed at a mutually agreeable time between
patient and therapist. Of the total pool, 39 (34%)
who began individual CBT failed to satisfy treatment
completion criteria. Of these patients, 3 satisfied all
criteria, apart from the requirement of providing a
complete set of depression data. For group CBT, 83
(35%) patients who started treatment failed to
satisfy treatment completion criteria. Of this sub-
sample, 15 satisfied all criteria, apart from the re-
quirement of providing a complete set of depression
data. Patients referred typically had a wide range of
mood and anxiety disorder problems and were
required to be between 18 and 65 years of age.
measures
Mini International Neuropsychiatric Interview
(MINI Plus Version 5.0; Sheehan et al., 2001) is a
structured interview for establishing Axis I diag-
noses and is based on DSM-IV (APA, 1994) criteria.
Past research has shown that the MINI Plus has
good interrater and test-retest reliability and high
convergence with other diagnostic interviews
(Lecrubier et al., 1997).
Beck Depression Inventory-II (BDI-II; Beck,
Steer, & Brown, 1996) is a 21-item self-report ins-
1
CCI is a community-based and government-funded adult
outpatient clinic located in Perth, Australia. It is exclusively staffed
by clinical psychologists who employ evidence-based psychosocial
interventions for DSM-IV Axis I disorders. All patients attending
programs are referred by mental health professionals in the private
and public sector operating externally to the clinic. The clinic was
established to take outpatient referrals for adults suffering from an
anxiety or unipolar depressive disorder from across the metropo-
litan area. Referring professionals were generally well aware that
the clinic does not take referrals for individuals with primary
problems relating to organically based cognitive impairments,
psychosis, or substance abuse/dependence. Such individuals are
typically referred to clinics and hospitals that specialize in treating
such problems.
trument that assesses severity of depressive symp-
toms and is commonly used in treatment evaluation
studies. Beck et al. have demonstrated that the
BDI-II has good test-retest reliability (r = .93) and
internal consistency (coefficient alpha = .92) and is
highly correlated with the earlier BDI-IA (r = .93).
Higher BDI-II scores represent more severe depres-
sion (0 to 13 = normal-minimal; 14 to 18 = mild-
moderate; 19 to 29 = moderate-severe; 30 to 63 =
extremely severe). The BDI has commonly been
used in efficacy and effectiveness studies for CBT
and thus provides a useful comparison to the out-
comes of these other studies.
Beck Anxiety Inventory (BAI; Beck, Epstein,
Brown, & Steer, 1988) is a 21-item self-report mea-
sure of the intensity of general anxiety symptoms. It
has sound test-retest reliabity (.83; de Beurs, Wilson,
Chambless, Goldstein, & Feske, 1997). The BAI is a
common measure used in treatment outcome re-
search and was chosen due to the significant asso-
ciation of outpatient depression with anxiety (Kessler
et al., 1996; Kessler, Chiu, Demler, Merikangas, &
Walters, 2005).
Quality of Life Enjoyment and Satisfaction
Questionnaire (Q-LES-Q; Endicott, Harrison, &
Blumenthal, 1993) is a self-report measure of the
degree of enjoyment and satisfaction an individual
experiences in various areas of daily living (e.g.,
physical, mood, relationships, work, overall life
satisfaction). This study employed the 15-item over-
all satisfaction and enjoyment summary subscale of
the Q-LES-Q. Scores on this scale are reported as
percentages. The Q-LES-Q has been shown to have
sound psychometric properties when compared to
similar measures and adequate internal consis-
tency (.74; Endicott et al., 1993). This measure
was included to assess outcome beyond diagnosis-
specific symptomatology. As Gladis, Gosch, Dishuk,
and Crits-Christoph (1999) have argued, if treat-
ments are to be more thoroughly evaluated, mental
health outcomes need to be assessed more broadly.
assessment procedure
Patients taking part in this study were referred
according to the normal day-to-day clinic referral
process through standard external referral channels
(e.g., psychiatrists and medical doctors from private
and public mental health agencies) during the years
2001 to 2006. Referrals were generally not accepted
from agencies for patients who are known to have a
diagnosed psychotic disorder, substance abuse/
dependence problems, or organically based mental
disability. No attempt was made to solicit referrals
for the specific purpose of this study. In accordance
with standard clinic intake assessment procedure,
clinical psychologists, clinical psychologist regis-
 effectiveness of group cbt for depressed outpatients
trars, and clinical psychology placement students
conducted interviews using the MINI Plus diagnostic
interview to determine Axis I diagnoses. Patients
completed the BDI-II, BAI, Q-LES-Q, and a battery
of other measures as part of a standard intake
assessment protocol. For those participants taking
medication, their medication was prescribed by
general practitioners or psychiatrists external to the
clinic and prior to intake. General inclusion criteria
for admission to CCI treatment programs were the
presence of a primary mood or anxiety disorder. As
previously mentioned, to be included in this study,
patients were required to have completed at least five
treatment sessions of individual or group-based CBT
treatment for depression. This level of treatment
dose was considered to represent at least half of the
major treatment components and therefore a mean-
ingful, although conservative treatment dose. Exclu-
sion criteria for treatment at CCI were the presence
of psychotic features, an eating disorder, or sub-
stance use judged by the assessing clinician as likely
to interfere with treatment engagement.
treatment protocol
The group CBT treatment was a broad-spectrum
structured program for depression and anxiety that
consisted of 10 weekly 2-hour group sessions, with
a 1-month follow-up session (Nathan et al., 2004).
The program was based on Beck’s (1979) manual
for depression and Barlow and Craske’s (1994)
manual for anxiety. Past research has demonstrated
the efficacy and effectiveness of these programs in
clinical samples (e.g., Gloaguen et al., 1998;
Shapiro et al., 1994; Telch et al., 1993; Wade et
al., 1998). The program manual provided detailed
therapist notes, agenda and activities for each
session, and standard handout and worksheet
materials for patients. For each session, clinicians
were instructed to follow the agenda and activities
outlined in the treatment manual. Weekly goal
setting, regular use of calming techniques, and
homework tasks involving the application of each
treatment component were core features of each
session. The group program involved the following
week-by-week session plan: (1) psychoeducation
about depression and anxiety (including goal
setting); (2) behavioral activation, graded exposure,
and weekly goal setting; (3) calming techniques,
graded exposure, and introduction to the cognitive
model and thought diaries (identifying thoughts
and feelings); (4) introduction to thought disputa-
tion and balanced thinking; (5) introduction to
unhelpful thinking styles and more thought dis-
putation; (6) review of past CBT techniques, review
of goals, and action planning using CBT techni-
ques; (7) coping with emotional triggers using
305
thought diaries and active coping responses using
problem solving; (8) thought diary practice and
review and development of flashcards; (9) thought
diary practice and self-management plan; (10)
progress review, dealing with setbacks, and refining
self-management plans.
Individual CBT described in Nathan et al.
(2001a) and Nathan et al. (2001b) also employed
treatment elements based on Beck’s (1979) manual
for depression and Barlow and Craske’s (1994)
manual for anxiety. However, whereas the indivi-
dual therapist manuals contain very similar treat-
ment components to the group therapist manual
(Nathan et al., 2004), clinicians implemented
individual CBT in a more flexible manner based
on a detailed cognitive-behavioral case formulation
developed for each patient. As such, the selection,
ordering, and implementation of treatment compo-
nents and the number of treatment sessions could
vary according to each patient’s treatment plan and
progress.
The clinic where the interventions took place
aims to provide evidence-based CBT for affective
disorders. As such, therapists were instructed to
adhere as closely as practically possible to CBT
protocols described in therapist manuals. Regular
weekly clinical supervision aimed to embody a CBT
perspective.
therapists
All therapists involved in the study had at least
master-s-level clinical psychology training in CBT
and clinical assessment and were qualified clinical
psychologists, clinical psychologist registrars, or
clinical psychology master-level students. Nine
therapists employed in a full-time capacity com-
prised the primary therapists for the group CBT
programs that were conducted for this study. The
number of groups conducted per therapist ranged
from 1 to 14. All but 9 of the 50 groups were led by
a primary therapist and a co-therapist. The level of
experience of the primary therapist ranged from 1
year as a clinical psychologist registrar to more than
20 years of experience as a clinical psychologist.
About 25% of the groups were conducted by a
primary therapist with at least 1 year of experience
as a clinical psychologist registrar, the remainder of
the groups were conducted by a primary therapist
with 2 or more years work experience as a clinical
psychologist. Ten clinical psychologists/registrars
conducted individual therapy. Nine of these thera-
pists also took part in group treatment and treated
67% of the patients starting individual treatment.
The remaining patients were treated by master-level
clinical psychology students who were on place-
ment. All therapists conducting treatment received
306 craigie & nathan
weekly routine clinical supervision provided by a
senior clinical psychologist or the clinic director
who has over 20 years experience in CBT. Thera-
pists working at the clinic are required to maintain
an individual therapy caseload and regularly con-
duct group CBT according to clinic program sche-
duling considerations. Therapists predominantly
report CBT as their dominant intervention para-
digm and regularly participate in or conduct CBT-
based professional development workshops for
mental health professionals.
design
This study involved a nonrandomized pre-post
design, with no long-term follow-up assessment.
Therapists were responsible for collecting pre- and
posttreatment symptom data.2 For the purposes of
this study, no attempt was made to allocate specific
therapists to specific patients or to particular treat-
ment formats. Allocation of patients to treatment
formats and therapists followed a naturalistic app-
roach based on clinical considerations, referrer re-
commendations (group or individual CBT), work-
loads, and group treatment schedules. Patients
referred to group CBT who were unwilling to take
part in a group program were offered individual
treatment. Group CBT generally commenced each
month, and consisted of between 5 to 12 patients of
mixed diagnoses meeting general inclusion criteria.
Over the duration of this study no study-specific
treatment monitoring, extra supervision, or training
was provided to ensure treatment protocol adherence.
Results
sample characteristics and
pretreatment group differences
Table 1 presents the basic demographic and diag-
nostic characteristics for the intent-to-treat and
completer samples. When comparing demographic
and diagnostic characteristics for individual and
group CBT samples, independent-sample t-tests and
χ2 analysis revealed no significant differences in
education level, gender, medication usage, marital
status, type of primary depression diagnosis, fre-
quency of additional Axis I diagnoses, or frequency of
secondary anxiety disorders for intent-to-treat or
completer samples (all psN .05). Mean age was signi-
ficantly higher for group CBT compared to individual
CBT in the intent-to-treat sample, t(354) = 2.76,
pb .01, although the difference following Cohen’s
2 treatment for the intent-to-treat sample and treat-
Although therapists are aware in a general sense that a primary
aim of data collection at CCI was treatment research and
evaluation, they were not informed of the aims, hypotheses, and
design of this particular study.
(1988) recommendations was small, Cohen’s d = .31
(d = .2 is small; d = .5 medium; d = .8 large). There
was no age difference in the completer sample.
Moreover, there was no significant difference bet-
ween group and individual CBT in the rate of
previous inpatient psychiatric admissions in the
completer sample (all ps N .05). In the intent-to-treat
sample, a significantly higher rate of patients starting
group CBT reported having accessed previous
psychological treatment compared to individual
CBT, χ2(1) = 6.55, p b .05. The rate of patients re-
porting a previous inpatient psychiatric admission
was also higher in patients receiving group CBT
compared to those receiving individual CBT in the
intent-to-treat sample, χ2(1) = 8.78, p b .01. Simi-
larly, for patients completing treatment, a signifi-
cantly higher rate of patients receiving group CBT
reported having accessed previous psychological
treatment compared to individual CBT, χ2(1) =
6.92, p b .01. In regard to pretreatment symptom
measures (see Table 2), there were no significant dif-
ferences between individual and group CBT samples
on the BDI-II, BAI, and Q-LES-Q measures for
intent-to-treat or completer samples (all p’s N .05),
with all effect size magnitudes falling in the small
range (all d’s b .3).
attendance and treatment completion
Chi-square analysis revealed that there was no sig-
nificant difference between treatment modes in fre-
quency of patients failing to complete treatment,
χ2(1) = 0.13 p N .05. There were no significant diffe-
rences between treatment completers and noncom-
pleters in terms of age, gender, level of education,
marital status, medication use, number of Axis I
diagnoses, and pre-treatment symptom scores (all
ps N .05). A total of 50 CBT groups were conducted
over the course of the study. The mean number of
patients with unipolar depression starting in each
group was 4.75 (SD = 1.95). In terms of attendance,
individual CBT noncompleters attended a mean
number of 3.85 (SD = 3.12) sessions, whereas group
CBT noncompleters attended a mean number of
4.17 (SD = 3.90) sessions. The mean difference bet-
ween sessions attended was not significant (p N .05).
Patients completing individual CBT had significantly
more treatment sessions (M = 10.64, SD = 5.13) than
those completing group CBT (M = 8.69, SD = 2.08),
t(232) = 4.11, p b .001, d = .54 (medium).
intent-to-treat symptom improvement
Table 2 presents the mean scores at pre- and post-
ment completer sample categorized by treatment
mode. The mean pretreatment BDI-II depression
scores for both intent-to-treat and completer samples
 effectiveness of group cbt for depressed outpatients 307

Table 1
Percentages and Means for Demographic and Diagnostic Characteristics of Intent-to-Treat and Treatment Completer Samples According to
CBT Format
Variable Whole Sample Intent-to-Treat Completers
(N = 356)
Individual Group Individual Group
(n = 116) (n = 240) (n = 77) (n = 157)
Primary diagnosis
Major depression, single episode 32 26 35 23 32
Major depression, recurrent 45 51 42 52 46
Major depression, melancholia 3 4 3 3 3
Dysthymia 20 19 20 22 18
Axis I co-morbidity 1 56 54 57 47 55
Anxiety disorder diagnosis 2 49 47 50 39 47
Panic disorder 5 6 5 8 4
Panic disorder with agoraphobia 8 6 8 4 8
Generalized anxiety disorder 18 18 18 14 16
Social phobia 17 16 17 13 17
Obsessive compulsive disorder 1 0 2 0 1
Post traumatic stress disorder 1 0 1 0 2
Taking medication 74 69 76 72 78
Previous psychological treatment 83 75 86 72 87
Previous inpatient admission 3 28 18 33 20 30
Gender – female 65 60 67 62 68
Mean age in years 36.4 (11.7) 34.0 (11.5) 37.6 (11.7) 35.2 (12.1) 38.3 (12.0)
Marital status:
Single (never married) 44 43 44 43 42
Married/cohabitating 18 23 15 17 16
De facto 17 17 17 14 17
Divorced/separated/widowed 21 17 24 13 25
Highest education achieved 4
Less than high school 24 19 25 23 23
High school/technical/trade 45 52 42 48 38
College/tertiary completed 31 28 33 27 35
Note. Mean standard deviations in parentheses. Percentages rounded to nearest whole number.
1
Percentage of patients with one or more additional diagnoses beyond their primary diagnosis.
2
Percentage of patients with a secondary anxiety disorder diagnosis additional to primary diagnosis.
3
Has reported a previous psychiatric inpatient admission.
4
Percentages based on a total of 321 patients of the total sample providing education data.

were in the severe range. A series of 2 (Group) × 2
(Time) repeated measures analyses of variance
(ANOVAs) were performed to examine mean symp-
tom improvements (pre- to posttreatment) and the
relationship to treatment format (group versus indi-
vidual) on each symptom measure.
Consistent with previous effectiveness studies
(e.g., Persons et al., 2006; Westbrook & Kirk,
2005), uncontrolled effect sizes were calculated
according to Cohen’s (1988) formula [d = (pretreat-
ment mean – posttreatment mean)/pretreatment
SD]. This analysis revealed a significant main effect
of time on the BDI-II [F(1, 349) = 303.52, p b .001,
partial η2 = .46], BAI [F(1, 350) = 127.15, p b .001,
partial η2 = .27], and the Q-LES-Q [F(1, 345) =
110.13, p b .001, partial η2 = .24]. The Treatment
Format × Time interaction was significant for the
BDI-II [F(1, 349) = 5.96, p b .001 partial η2 = .02]
and BAI [F(1, 350) = 9.84, p b .01, partial η2 = .03],
but not the Q-LES-Q [F(1, 345) = 0.17, p N .05,
partial η2 = .00]. These interaction effects show that
the mean level of improvement from pre- to post-
treatment on the BDI-II and BAI, but not the
Q-LES-Q, was significantly greater for the indivi-
dual CBT sample than the group CBT sample. At
posttreatment, the differences between individual
and group CBT mean scores on the BDI-II, BAI, and
Q-LES-Q were small, d = 0.35, 0.24, and 0.08,
respectively.
As the previous analysis approach cannot un-
equivocally comment on the nature and magnitude
of within-group symptom improvements, a within-
group repeated-measures ANOVA was conducted
separately for each treatment format on each symp-
tom measure. As Table 2 shows, this analysis re-
vealed significant within-group symptom improve-
ment on all measures for individual and group CBT.
The uncontrolled BDI-II effect sizes were large for
both treatment formats, and mostly in the medium
range for the other measures, although only a small
effect was observed on the BAI for the sample
receiving group CBT.
308 craigie & nathan

Table 2 159.16, p b .001, partial η2 = .41], and the Q-LES-Q

Unrestricted Intent-to-Treat (N = 356) and Completer (N = 234) Pre- [F(1, 209) = 150.56, p b .001, partial η2 = .42]. The
to-Posttreatment Mean Scores and Within-Group F-Ratios and
Effect Sizes for each Outcome Measure and for each CBT Format Treatment Format × Time interaction was significant
for the BDI-II [F(1, 232) = 13.86, p b .001, partial
Measure Pre-Treatment Post-Treatment F Effect
M (SD) M (SD) Size
η2 = .06] and BAI [F(1, 229) = 16.93, p b .001, partial
Cohen’s η2 = .07], but not the Q-LES-Q [F(1, 209) = 2.74,
d p N .05, partial η2 = .01]. These interaction effects
Intent-to-Treat show that for individual CBT, the mean level of
BDI-II improvement on the BDI-II and BAI, but not the
Individual 30.0 (10.4) 16.3 (12.0) 129.79⁎⁎⁎ 1.30 Q-LES-Q, was significantly greater than group CBT.
Group 31.3 (11.2) 20.9 (13.6) 187.21⁎⁎⁎ 0.93 At posttreatment, the differences between individual
BAI
Individual 21.1 (12.2) 12.9 (11.2) 64.96⁎⁎⁎ 0.67
and group treatment mean scores on the BDI-II, BAI,
Group 20.2 (11.3) 15.6 (11.4) 56.00⁎⁎⁎ 0.41 and Q-LES-Q were d = 0.52, 0.45, 0.48, respectively.
Q-LES-Q To ascertain the significance and magnitude of
Individual 43.2 (14.7) 52.3 (19.1) 42.27⁎⁎⁎ −0.62 within-group symptom improvements for each
Group 42.3 (14.1) 50.8 (17.0) 79.70⁎⁎⁎ −0.60 treatment format separately, a within-group
Completers
repeated-measures ANOVA was performed sepa-
BDI-II rately for each treatment format on each symptom
Individual 30.8 (10.3) 11.7 (9.9) 192.23⁎⁎⁎ 1.90 measure. As Table 2 shows, this analysis revealed
Group 30.7 (11.1) 17.7 (12.4) 200.75⁎⁎⁎ 1.20 significant within-group symptom improvement
BAI on all measures for both individual and group
Individual 20.7 (12.0) 9.2 (8.3) 86.27⁎⁎⁎ 0.96
Group 19.6 (11.0) 13.7 (10.7) 61.57⁎⁎⁎ 0.54
CBT. Uncontrolled effect sizes for the BDI-II and Q-
Q-LES-Q LES-Q were large for both treatment formats,
Individual 46.4 (13.5) 62.7 (14.7) 62.45⁎⁎⁎ −1.20 whereas for the BAI, a large effect was observed
Group 42.9 (13.8) 55.3 (15.8) 101.19⁎⁎⁎ −0.90 for individual CBT and a medium effect for group
Note. Intent-to-treat – individual n = 116, group n = 240; completers – CBT.
individual n = 77, group n = 157.
depression severity and symptom
improvement
To examine the impact of pretreatment depression
completer symptom improvement symptom severity on symptom improvement for
Like the intent-to-treat sample, mean pretreatment each treatment format, statistical analyses were re-
BDI-II scores for completers were in the severe run for the completer sample, but with subsamples
range for both individual and group CBT. To exa- selected from the dataset that were restricted
mine the nature of symptom improvements and according to severity of pretreatment BDI-II scores.
the influence of treatment format (group versus As Table 3 shows, the analysis was conducted
individual) and time (pre- to posttreatment), a 2 × 2 according to three severity threshold cutoffs: pa-
repeated-measures ANOVA was conducted on each tients with pretreatment BDI-II scores in the clinical
symptom measure. This analysis revealed significant range (N13.5) established by Ogles, Lambert, and
main effects of time on the BDI-II [F(1, 232)= Sawyer (1995) as 2 SD above the nonclinical mean,
388.82, p b .001, partial η2 = .63], BAI [F(1, 229)= at least 20 (in or above the moderate severity

Table 3
Completer Pre-to-Posttreatment BDI-II Mean Scores and Within-group F-Ratios and Effect Sizes According to Pre-treatment Cut-off and
CBT Format
Pretreatment Cut-off/CBT Pretreatment Posttreatment F Effect Size
Format M (SD) M (SD) Cohen’s d
BDI-IIpre N13.5
Individual (n = 74, 96%)⁎ 31.6 (9.7) 12.0 (10.0) 200.74⁎⁎⁎ 2.02
Group (n = 148, 94%) 31.9 (10.1) 18.3 (12.4) 206.48⁎⁎⁎ 1.35
BDI-IIpre ≥ 20
Individual (n = 66, 86%) 33.4 (8.7) 12.4 (10.2) 207.21⁎⁎⁎ 2.41
Group (n = 134, 85%) 33.5 (9.2) 19.1 (12.5) 209.25⁎⁎⁎ 1.57
BDI-IIpre ≥ 30
Individual (n = 40, 52%) 38.7 (6.8) 14.7 (11.5) 132.12⁎⁎⁎ 3.53
Group (n = 81, 52%) 39.5 (6.6) 23.1 (12.7) 145.70⁎⁎⁎ 2.48
Note. ⁎ Percentages shown are (n/N), where N is the relevant CBT format completer sample total N (i.e., individual N = 77, group N = 157).
 effectiveness of group cbt for depressed outpatients
range), and at least 30 (in or above the very severe
range). These latter selection thresholds were based
on BDI/BDI-II properties and previous effective-
ness benchmark analyses (Persons et al., 2006;
Westbrook & Kirk, 2005) that have examined
outcomes for different BDI depression severity
thresholds and offer a meaningful reference point
by which to compare symptom improvements.3
Independent-sample t-tests revealed no significant
mean group differences between treatment formats
for pretreatment BDI-II scores at each severity
threshold level (all p’s N .05, d’s b .15).
A 2 × 2 (Treatment Format × Time) repeated-
measures ANOVA performed on BDI-II scores for
each successive severity threshold subsample (i.e.,
BDI-II N 13.5, ≥ 20, ≥ 30) revealed significant time
main effects [F(1, 220) = 401.71, p b .001, partial
η2 = .65; F(1, 198) = 409.22, p b .001, partial η2 =
.67; F(1, 119) = 277.28, p b .001, partial η2 = .70],
respectively. The Treatment Format × Time inter-
action terms were also significant for each sub-
sample (i.e., BDI-IIpre N13.5, ≥20, ≥30), [F(1, 220) =
13.34, p b .001, partial η2 = .07; F(1, 198) = 14.11,
p b .001, partial η2 = .07; F(1, 119) = 9.85, p b .001,
partial η2 = .08], respectively. For each severity
threshold subsample, the average level of depres-
sion symptom improvement from pre- to posttreat-
ment was significantly greater for those patients
receiving individual CBT than those patients re-
ceiving group CBT.
In terms of within-group improvement for each
treatment format, Table 3 shows that all BDI-II
mean improvements were significant and large for
individual and group CBT and increased in
magnitude for each successive severity threshold
subsample. At posttreatment, the magnitude of
BDI-II mean score differences between individual
and group CBT for each successive severity thresh-
old were significant (all t-scores N 3.5, p’s b .01) and
in the medium effect size range (d = 0.54, 0.57,
0.69), respectively. As Table 3 shows, posttreatment
means for individual CBT were in the mild range for
each severity threshold cutoff group. In contrast,
for group CBT, posttreatment mean scores were in
the mild-moderate range for the first two severity
threshold cutoff groups, and in the moderate range
for the BDI-II ≥30 severity threshold cutoff group.
3
It is acknowledged that there are some differences between the
BDI and the later version BDI-II used in this study (4 items have been
changed, as well as some rewording of items). However, they have
the same number of items, and by and large are very similar
instruments, in terms of type of items, scoring format, range (0 – 63),
and are highly correlated (r = .93, Beck et al., 1996).
309
depression severity and recovery
To assess the relationship between pretreatment
depression severity and recovery from depressive
symptoms, recovery rates on the BDI-II were calc-
ulated for each pretreatment severity cutoff thresh-
old for individual and group CBT. Jacobson and
Truax’s (1991) guidelines were adopted for this
analysis, in which recovery (clinically significant
improvement) required a reliable improvement on
the BDI-II and a posttreatment score within the
bounds of the normal population at posttreatment. In
the current study, a reliable change (Reliable Change
Index N 1.96) for the BDI-II required changes of at
least 7.54 and 8.12 points for individual and group
CBT completer samples, respectively. For simplicity
and comparison purposes (see footnote 3), following
an earlier benchmarking analysis of effectiveness
outcomes using the BDI (Westbrook & Kirk, 2005),
a conservative change of at least 9 points was set for
a reliable change. The cutoff for recovery was de-
fined as a score within two SDs of the nondistressed
mean for the BDI (b13.5) as established by Ogles et
al. (1995). This cutoff score has been employed in a
number of effectiveness and benchmarking depres-
sion treatment studies that used the BDI (e.g.,
Merrill et al., 2003; Westbrook & Kirk, 2005).
Moreover, the more conservative cutoff defined as a
score within one SD of the nondistressed mean (≤ 9)
used by Ogles et al. (1995) and Persons et al. (2006)
was also employed. Following recommendations
and procedures described by Speer (1992), correc-
tions were made to pretreatment BDI-II scores to
account for regression to the mean.
Table 4 presents the reliable change and recovery
percentages for each pretreatment severity threshold
cutoff and treatment format. Chi-square analysis of
patients completing treatment revealed that for the
b13.5 cutoff criterion, individual CBT was asso-
ciated with significantly higher rates of recovery for
all subsamples [N13.5: χ2(1) = 13.07, p b .001; ≥20:
χ2(1) = 11.61, p b .01; ≥30: χ2(1) = 10.32, p b .01],
which was generally maintained for the restricted
intent-to-treat subsamples [N13.5: χ2 (1) = 7.10,
p b .01; ≥20: χ2(1) = 4.20, p b .05; ≥30: χ2(1) =
2.42, p N .05]. Likewise for the more stringent ≤9
cutoff criterion, completers receiving individual CBT
had significantly higher recovery rates compared to
group CBT for all subsamples [ N13.5: χ2(1) = 11.84,
p b .01; ≥20: χ2(1) = 9.05, p b .01; ≥30: χ2(1) =
10.05, p b .01], which was maintained for the intent-
to-treat sub-samples [ N13.5: χ2(1) = 7.46, p b .01;
≥ 20: χ 2 (1) = 5.48, p b .05; ≥ 30: χ 2 (1) = 6.40,
p b .05]. As can be seen in Table 4, when pretreat-
ment BDI-II scores were restricted to ≥30, the rate of
recovery for completers of group CBT was half that
of individual CBT at the b13.5 cutoff and less than
310 craigie & nathan
Table 4
Reliable Change and Recovery Percentages for Completers (and Intent-to-Treat) for Individual and Group CBT Samples
BDI-II cut-off/CBT Format Reliably No Reliable
Improved Change
BDI-IIpre N13.5
Individual (n = 74, 108) 85 (63) 15 (37)
Group (n = 148, 224) 64 (50) 33 (48)
BDI-IIpre ≥ 20
Individual (n = 66, 94) 86 (66) 14 (34)
Group (n = 134, 199) 66 (53) 32 (45)
BDI-IIpre ≥ 30
Individual (n = 40, 59) 83 (61) 17 (39)
Group (n = 81, 133) 67 (49) 32 (50)
Note. Percentages are rounded to the nearest whole number. Intent-to-treat percentages in parentheses, and n refers to the number of
patients in the restricted completer and intent-to-treat samples in question. Reliable change was at least a 9 point change. For example, for
the ≥ 20 sub-sample, the Recovered – 1 criterion required a reliable improvement and a post-treatment score below 13.5. The Recovered – 2
criterion required a reliable improvement and a post-treatment score equal to or below 9.
half that of individual CBT at the more stringent ≤9
cutoff.
post-hoc analyses
Recovery rates for BDI-II scores were also exam-
ined for patients completing treatment who had
pretreatment BDI-II scores in the clinical range, but
less than very severe (N13.5 and b 30). Individual
CBT (n = 34) and group CBT (n = 67) patients meet-
ing this criterion had mean pretreatment BDI-II
scores of 23.21 (SD = 4.25) and 22.72 (SD = 4.23),
respectively, and mean posttreatment scores of 8.68
(SD = 6.62) and 12.91 (SD = 9.15), respectively.
Uncontrolled pre- to posttreatment effect sizes for
individual and group CBT were both in the large
range (d = 3.4 and d = 2.3, respectively). For the
b13.5 cutoff criterion, 76% of patients completing
individual CBT (55% of intent-to-treat) and 55%
of patients completing group CBT had recovered
(46% of intent-to-treat). For the more stringent
recovery cutoff (≤9), 65% of patients receiving
individual CBT had recovered (47% of intent-to-
treat), and 45% receiving group CBT had recovered
(36% of intent-to-treat). The rate of recovery for
completers was significantly lower for group CBT
compared to individual CBT for the b13.5 cutoff,
χ2(1) = 4.34, p b .05, but not for the ≤ 9 cutoff,
χ2(1) = 3.59, p N .05.
Given the previous results and past research
findings that show higher depression symptoms
at pretreatment are predictive of less favorable
symptom outcomes (Merrill et al., 2003; Peterson
& Halstead, 1998), Pearson bivariate correlations
were calculated between pre- and posttreatment
BDI-II scores for the group CBT and individual
CBT samples separately. This analysis showed a
small positive correlation between pre-treatment
and post-treatment scores for the individual CBT
sample, r(76) = .28, p b .01, and a large positive cor-
Reliably Recovered – 1 Recovered – 2
Deteriorated BDI-IIpost b13.5 BDI-IIpost ≤9
0 (0) 68 (47) 53 (37)
3 (2) 41 (32) 29 (23)
0 (0) 67 (48) 50 (36)
2 (2) 41 (33) 28 (23)
0 (0) 60 (41) 42 (29)
1 (1) 30 (23) 16 (14)
relation, r(156) = .54, p b .001 for the group CBT
sample. A Fisher’s z-test (using r-to-z transforma-
tion) between independent correlations showed that
the correlation for group CBT was significantly
greater than that for individual CBT, z = 2.22, p b .05.
Discussion
Consistent with our prediction, individual and
group CBT were associated with large improve-
ments in depressive symptoms in both the intent-to-
treat and completer analyses. There were significant
secondary improvements in anxiety and quality of
life for both treatment modes in the intent-to-treat
and completer samples. Like past research (e.g.,
Kellett et al., 2007; Peterson & Halstead, 1998;
Westbrook & Kirk, 2005), results suggest that CBT
for depression in both individual and group format
can be successfully transported into a routine
clinical setting.
Methodological limitations are unavoidable with
naturalistic designs. Hence, we use caution when
attributing improvement to the treatment pro-
tocols tested. However, consistent with earlier
proposals of the advantages of individual therapy
(e.g., Morrison, 2001; Tucker & Oei, 2007),
individual CBT was more effective and was asso-
ciated with superior symptom outcomes than group
CBT, and this superiority held in each severity
threshold subsample. Analysis showed that higher
pretreatment BDI-II scores were more strongly
associated with higher posttreatment BDI-II scores
for group CBT relative to individual CBT. Overall,
the results for depression symptoms suggest that the
superiority of individual CBT was clinically mean-
ingful and in the medium effect-size range.
It is conceivable that numerous uncontrolled
patient, treatment, and method factors might have
played a role in contributing to the superiority of
 effectiveness of group cbt for depressed outpatients
individual CBT over group CBT (e.g., a patient
treatment preference bias). However, another
possible explanation previously put forward by
Oei and Dingle (2008) and others (e.g., Morrison,
2001; Persons, 1989) proposes that patients who
are more severely depressed or socially anxious may
generally find it harder to engage in group
treatment, and therapists in a group setting may
have less opportunity to address specific patient
needs. As past effectiveness research has shown, a
greater number of treatment sessions is associated
with more favorable outcomes (e.g., Merrill et al.,
2003). It follows that the generally greater treat-
ment time and flexibility likely to be afforded by
individual treatment may allow more effective
targeting of anxiety and depression maintaining
factors than group treatment. The high rate of
comorbidity in the sample and shorter mean
treatment duration of group CBT are consistent
with this notion.
Although individual CBT was generally superior
to group CBT, both treatment approaches were
associated with equivalent improvements in the
broader and less pathology-related measure of qua-
lity of life. Given the need to demonstrate mental
health improvements more broadly (Gladis et al.,
1999), this finding seems important. Nevertheless,
the present findings cannot demonstrate that quality-
of-life improvements were independent of symptom
alleviation, and it is unclear why significant group
differences occurred for anxiety and depression
symptoms, but not quality of life. It may be that some
nonspecific factors (e.g., mutual support, normal-
ization, interpersonal learning) may be more promi-
nent in group treatment than individual treatment
(e.g., Morrison, 2001; Tucker & Oei, 2007). If so, it
follows that such factors may have the potential to
enhance perceived quality of life (at least in the short
term) and may be somewhat independent of standard
CBT elements that may also contribute to improved
quality of life (e.g., goal setting, behavioral activa-
tion, and problem solving). In this way, group specific
factors may in part compensate for any dilution of
treatment time or treatment impact that may occur in
a group-based approach. Further research is required
to examine if group specific psychosocial processes
contribute to enhanced quality of life for depressed
outpatients.
The results also need to be viewed in relation to
earlier depression effectiveness research. Uncont-
rolled BDI-II effect sizes and recovery rates attained
by completer samples for each treatment format
were comparable to outcomes achieved in earlier
CBT effectiveness studies (e.g., Merrill et al., 2003;
Persons et al., 2006; Westbrook & Kirk, 2005).
Although BDI version differences suggest caution
311
when comparing across studies, it is noteworthy that
the group CBT recovery rate (41%) was very similar
to Westbrook and Kirk’s individual treatment
completer recovery rate (42%), and the individual
CBT recovery rate (68%) easily exceeded their re-
sults. A majority of completers in both treatment
formats reliably improved, and very few deterio-
rated. In light of the high pretreatment depression
severity and high rate of Axis I comorbidity present
in the sample, these findings are encouraging. When
group CBT pretreatment BDI-II scores were re-
stricted to less than 30, the recovery rate for this
mode of treatment became even more favorable
(55%). These latter findings suggest that broad-
spectrum group CBT may be a viable alternative to
disorder-specific protocols for less severely depressed
patients and as a response to treatment supply/
demand problems that can vex mental health settings
(e.g., Addis et al., 1999; Division of Clinical
Psychology, 1997).
The favorable results need to be tempered in light
of the more modest intent-to-treat outcomes.
Attrition rates were substantial for both treatment
formats. Of those patients completing individual
CBT, about a third did not recover. Of those com-
pleting group CBT, more than half did not recover.
The reasons why a substantial percentage of pa-
tients failed to complete treatment cannot be ans-
wered from the current study design and dataset but
point to the need for innovations in treatment
retention. Further research will need to determine
how factors associated with CBT, the clinical con-
text, treatment format, and patient characteris-
tics contribute to attrition and modest recovery
rates. Axis I comorbidity and the association found
between pretreatment depression severity and
poorer outcome appear to be two areas for further
investigation.
Methodological limitations impact on the inter-
nal validity of the findings and therefore require
comment. First, nonrandom allocation of patients
to treatment formats, lack of control over treat-
ment length, and lack of formal treatment adher-
ence checks create uncertainty as to causal infe-
rences about treatment formats and their purported
effects. A sampling bias in the form of some patients
preferring individual therapy may have in some way
exaggerated or attenuated results for each treatment
format. Similarly, medication, medication changes,
and other systemic biases may have been influential.
A nonrandom allocation of therapists to group/
individual treatment may have also introduced a
therapist bias to specific treatment formats. Al-
though it is desirable from an internal validity sense
to remove the influence of as many potential con-
founding factors as possible, in the current context,
312 craigie & nathan
resource and practical limitations prohibited their
removal, and adjustments may even have been in-
compatible with the premise of this naturalistic in-
vestigation. Gaining an understanding of the nature
of outcomes for each treatment format in real-world
conditions was deemed the more important research
priority.
A number of other issues limit interpretation of
the findings. Clinic operating conditions and re-
source limitations precluded the collection of long-
term follow-up data to determine if improvements
were maintained.4 It will be important for future
research to determine if individual and group CBT
have a similar or different relationship to main-
tenance of gains in routine clinical settings. More-
over, self-report outcome measures of the type used
in this study are vulnerable to the influence of social
demand. Unfortunately, resources were not avail-
able to allow the use of a validated clinician-rated
measure that could be administered by independent
assessors blind to the study aims. Item differences
between the BDI and BDI-II3 also reduce the valid-
ity of making comparisons to earlier studies that
used the BDI and restricting samples according to
pretreatment BDI-II severity acts to inflate the
magnitude of effect sizes observed (i.e., via reduc-
tion in the variance between pretreatment scores).
Despite the aforementioned limitations, a pri-
mary aim of this type of research approach is to
establish the external validity of treatment under
more clinically representative conditions. The
characteristics of this study fulfill many of Shadish
et al.’s (1997) clinical relevance criteria. The setting
was a nonuniversity clinic, clinicians had regular
case-loads, patients were not solicited for the
purposes of the study, patients were referred
through regular clinical routes, and they presented
with a wide range of problems. No extra super-
vision was provided for the purposes of the study,
and no strict monitoring was performed to ensure
treatment adherence. Furthermore, allowing pa-
tients to have an input into the type of treatment
format they prefer enhances the external validity of
the findings by providing information about the
possible outcomes that might be achieved in settings
that have similar treatment allocation methods,
protocols, and patient populations.
In conclusion, the findings of this study support
the view that in a more clinically representative
setting, individual CBT is the superior treatment
4
For group CBT a substantial amount of 1-month short-term
follow-up data existed, with unreported analyses suggesting that
gains on all measures were maintained. However, a similar level of
data was not available for individual CBT. Given the discrepancy
between treatment formats in amount of follow-up data, a decision
was made not to report these data.
format for depression compared to group CBT,
especially when depression is more severe. Broad-
spectrum group CBT appears to be a suitable option
for less severely depressed patients. If these results
were replicated, perhaps this mode of treatment is
best considered as an acceptable intervention for
clinics that have limited access to individual CBT.
The naturalistic approach to treatment evaluation
employed in this study also provides clinically
meaningful information that may assist treatment
planning, service benchmarking, and hopefully
wider utilization of evidence-based protocols. As
such, future research should seek to replicate these
findings under similar and controlled conditions,
and to establish the comparative cost-effectiveness
of each format of treatment.
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R E C E I V E D : October 21, 2007
A C C E P T E D : August 11, 2008
Available online 31 October 2008