The effects of blinding on the outcomes of psychotherapy and pharmacotherapy for adult depression: A meta-analysis

Health Economic Evaluation of an Online-Based Motivational Program to Reduce Problematic Media Use and Promote Treatment Motivation for Internet Use Disorder-Results of the OMPRIS Study

Internet Use Disorders (IUD) have a relevant effect on national economies. In the randomized, controlled, multicenter, prospective, and single-blinded OMPRIS study (pre-registration number DRKS00019925; Innovation Fund of the Joint Federal Committee of Germany, grant number 01VSF18043), a four-week online program to reduce media addiction symptoms, was evaluated for cost-effectiveness. The intervention group (IG) was compared to a waiting control group (WCG) from German statutory health insurance (SHI) and a societal perspective. Resource use, namely indirect and direct (non) medical costs, was assessed by a standardized questionnaire at baseline and after the intervention. Additionally, intervention costs were calculated. Determining the Reliable Change Index (RCI) based on the primary outcome, assessed by the "Scale for the Assessment of Internet and Computer Game Addiction" (AICA-S), individuals with and without reliable change (RC) were distinguished. The incremental cost-effectiveness ratio was calculated using the difference-in-difference approach. There were 169 (IG n = 81, WCG n = 88) persons included in the analysis. The mean age was 31.9 (SD 12.1) years. A total of 75.1% were male, and 1.8% diverse. A total of 65% (IG) and 27% (WCG) had an RC. The cost per person with RC was about EUR 860 (SHI) and EUR 1110 (society). The intervention leads to an improvement of media addiction symptoms at moderate additional costs.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Psychological treatment of depression: A systematic overview of a 'Meta-Analytic Research Domain'

BACKGROUND

Over the past 16 years, we have developed a 'Meta-analytic Research Domain' (MARD) of all randomized trials of psychological treatments of depression. A MARD is a living systematic review of a research field, that cannot be otherwise covered by one (network) meta-analysis and includes multiple PICOs. In this paper we give an overview of the findings of this MARD.

METHODS

A narrative review of the results of the 118 meta-analyses on psychotherapies for depression that were published within our MARD.

RESULTS

Most research has been conducted on cognitive-behavioral therapy (CBT), but several other psychotherapies are also effective, with few differences between therapies. They can be effectively delivered in individual, group, telephone and guided self-help format and are effective in many different target groups and across different age groups, although the effects are significantly smaller in children and adolescents. Psychotherapies have comparable effects as pharmacotherapy at the short term but are probably more effective at the longer term. Combined treatment is more effective than either psychotherapy or pharmacotherapy alone at the short, but also at the longer term.

LIMITATIONS

We did not summarize all published meta-analyses (protocols, methodological studies) and have not compared our results to those found in other meta-analyses on comparable subjects.

CONCLUSION

Psychotherapies can contribute considerably to a reduction of the disease burden of depression. MARDs are an important next step in the aggregation of knowledge from randomized controlled trials in psychological treatments of depression as well as in other healthcare sectors.

Clinical Practice Guideline: The Diagnosis and Treatment of Unipolar Depression—National Disease Management Guideline

BACKGROUND

Depression is one of the most common mental disorders worldwide. The German National Disease Management Guideline on Unipolar Depression (NDGM), (Nationale Versorgungsleitlinie, NVL), updated in 2022, contains recommendations on the diagnosis and treatment of acute and chronic depressive disorders.

METHODS

The update was based on the findings of a systematic review of the evidence (2013-2022) and was issued by a multidisciplinary panel after a formalized consensus process.

RESULTS

The structure of the guideline was fundamentally revised and is now based on the phases of depression and/or its treatment, as well as on the severity of the disease. There is newly added material with recommendations on Internet- and mobile-device based treatments, esketamine, repetitive magnetic stimulation, psychosocial therapies, rehabilitation, social participation, and complex forms of care. The guideline also emphasizes better coordination of all services in the care of patients with depression. This article covers the most important changes and additions among the 156 recommendations in the guideline. More information and accompanying materials are available at www.leitlinien.de/depression.

CONCLUSION

There are effective treatments for depression and a variety of supportive measures that can be applied with great benefit by primary care physicians, psychiatrists, psychotherapists, and complementary care providers. The updated guideline aims to further improve the early detection, definitive diagnosis, treatment, and interdisciplinary care of people with depression.

Premature dropout from psychotherapy: Prevalence, perceived reasons and consequences as rated by clinicians

Background

Why clients discontinue their psychotherapies has attracted more attention recently as it is a major problem for many healthcare services. Studies suggest that dropout rates may be affected by the mode of therapy, low-quality therapeutic alliance, low SES, and by conditions such personality disorders or substance abuse. The aims of the study were to investigate what happens in therapies which end in a dropout, and to estimate how common dropout is as reported by practicing clinicians.

Method

An online questionnaire was developed and completed by 116 therapists working in clinical settings. They were recruited via social media (Facebook and different online psychotherapy groups) in Sweden and worked with Cognitive Behavioural Therapy (CBT), Psychodynamic Therapy (PDT), Interpersonal Psychotherapy (IPT) and Integrative Psychotherapy (IP).

Results

Psychotherapists rated the frequency of premature dropout in psychotherapy to be on average 8.89% (MD = 5, SD = 8.34, Range = 0-50%). The most common reasons for a dropout, as stated by the therapists, were that clients were not satisfied with the type of intervention offered, or that clients did not benefit from the treatment as they had expected. The most common feeling following a dropout was self-doubt.

Conclusion

In conclusion, premature dropout is common in clinical practice and has negative emotional consequences for therapists. Premature dropout may lead to feelings of self-doubt and powerlessness among therapists. The therapeutic alliance was mostly rated as good in dropout therapies. Further research is needed to validate the findings with data on the prevalence and subjective reasons behind a dropout from point of view of clients.

Care pathways for people with major depressive disorder: a European Brain Council Value of Treatment study

Background

Despite well-established guidelines for managing major depressive disorder, its extensive disability burden persists. This Value of Treatment mission from the European Brain Council aimed to elucidate the nature and extent of “gaps” between best-practice and current-practice care, specifically to:Identify current treatment gaps along the care pathway and determine the extent of these gaps in comparison with the stepped-care model and Recommend policies intending to better meet patient needs (i.e., minimize treatment gaps).

Methods

After agreement upon a set of relevant treatment gaps, data pertaining to each gap were gathered and synthesized from several sources across six European countries. Subsequently, a modified Delphi approach was undertaken to attain consensus among an expert panel on proposed recommendations for minimizing treatment gaps.

Results

Four recommendations were made to increase the depression diagnosis rate (from ~50% episodes), aiming to both increase the number of patients seeking help, and the likelihood of a practitioner to correctly detect depression. These should reduce time to treatment (from ~1 to ~8 years after illness onset) and increase rates of treatment; nine further recommendations aimed to increase rates of treatment (from ~25 to ~50% of patients currently treated), mainly focused on targeting the best treatment to each patient. To improve follow-up after treatment initiation (from ~30 to ~65% followed up within 3 months), seven recommendations focused on increasing continuity of care. For those not responding, 10 recommendations focused on ensuring access to more specialist care (currently at rates of ~5–25% of patients).

Conclusions

The treatment gaps in depression care are substantial and concerning, from the proportion of people not entering care pathways to those stagnating in primary care with impairing and persistent illness. A wide range of recommendations can be made to enhance care throughout the pathway.

The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses

Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta-analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta-analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta-analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment-as-usual (TAU), or psychotherapies vs. pharmacotherapies head-to-head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta-analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta-analytic evaluation of the effect sizes reported by the largest meta-analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: -0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19-0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.

The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis

OBJECTIVE

Meta-analyses of psychotherapies usually report effects sizes, while clinicians and patients need to know the proportion of patients who benefit from therapy. We conducted a meta-analysis of therapies for depression reporting the rates of response (50% symptom reduction), remission (HAM-D <7), clinical significant deterioration for psychotherapy, and control conditions (CAU, waitlist, and pill placebo), as well as the relative risk of these outcomes and the numbers-needed-to-be-treated (NNTs).

METHODS

We searched bibliographic databases and included 228 randomized trials comparing psychotherapy for depression against control conditions (75 with low risk of bias). Only therapies with at least 10 trials were included. We extracted outcomes from the studies, and for those studies not reporting the outcomes, we used a validated method to estimate the rates.

RESULTS

The overall response rate in psychotherapies at 2 (±1) months after baseline was 41% (95% CI: 38~43), 17% (15~20) for usual care (CAU), and 16% (95% CI: 14~18) for waitlist. No significant differences between types of therapy were found. The NNT for therapy versus CAU was 5.3 and versus waitlist 3.9. About one third of patients remitted after therapy compared with 7%-13% in control conditions. The rates of deterioration were 5% versus 12%-13%, respectively. Most sensitivity analyses supported the general findings.

CONCLUSION

Psychotherapies for depression may be effective compared with control conditions, but more than half of patients receiving therapy do not respond and only one third remitted. More effective treatments and treatment strategies such as sequencing and combining treatments are clearly needed.

Prevalência de depressão e fatores associados em idosos atendidos na Atenção Primária à Saúde em região metropolitana do Distrito Federal

Objetivo: verificar a prevalência de depressão e as variáveis sociodemográficas e clínicas associadas a esse transtorno nos idosos atendidos na Atenção Primária à Saúde (APS) em região metropolitana do Distrito Federal.Métodos: estudo transversal realizado entre janeiro e agosto de 2018, com idosos atendidos na Unidade Básica de Saúde da Granja do Torto, em Brasília, DF. Foi aplicado instrumento versando sobre variáveis sociodemográficas, comportamentais e clínicas. Para a avaliação dos sintomas depressivos, foi utilizada a Escala de Depressão Geriátrica, versão reduzida (EDG-15). Na análise dos dados, foi realizada a estatística descritiva e a aplicação do teste qui-quadrado para associação das variáveis categóricas, com nível de significância de 5% (p≤ 0,05).Resultados: a amostra constituiu-se de 70 idosos. Foi encontrada prevalência de 41,4% de sintomas depressivos nos idosos estudados, 35,7% com indicativo de depressão leve e 5,7% de depressão grave. No grupo com sintomas depressivos, houve predomínio do sexo feminino, idade entre 70 a 79 anos, casados, católicos, analfabetos, aposentados, de baixa renda e com duas ou mais pessoas com grau de parentesco vivendo na mesma residência. Foi identificado, no grupo com depressão, associação significativa com escolaridade (p=0,05), nível de instrução (p=0,04), renda mensal (p=0,006), condições clínicas como osteoporose (p=0,02) e artrite/artrose (p=0,03), quedas (p=0,03) e uso de antidepressivos (p=0,02), sendo, nessa classe, escitalopram o mais utilizado (p=0,004).Conclusão: foi evidenciada alta prevalência de depressão entre os idosos da APS da região metropolitana do Distrito Federal do sexo feminino com idades entre 70 e 79 anos. Variáveis como escolaridade, nível de instrução, renda mensal, osteoporose, artrite/artrose, quedas e uso de antidepressivos apresentaram diferenças estatisticamente significativas naqueles com depressão. Assim, é fundamental o rastreio precoce dos sintomas depressivos, mais precisão no diagnóstico e no tratamento desse transtorno, com intervenções não farmacológicas e farmacológicas, executadas por equipe multidisciplinar especializada, capacitada para assistir aos idosos da rede de APS, evitando os efeitos deletérios na qualidade de vida dos indivíduos desse grupo.

Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care: A Network Meta-Analysis

PURPOSE

Most patients with depression are treated by general practitioners, and most of those patients prefer psychotherapy over pharmacotherapy. No network meta-analyses have examined the effects of psychotherapy compared with pharmacotherapy, combined treatment, care as usual, and other control conditions among patients in primary care.

METHODS

We conducted systematic searches of bibliographic databases to identify randomized trials comparing psychotherapy with pharmacotherapy, combined treatment, care as usual, waitlist, and pill placebo. The main outcome was treatment response (50% improvement of depressive symptoms from baseline to end point).

RESULTS

A total of 58 studies with 9,301 patients were included. Both psychotherapy and pharmacotherapy were significantly more effective than care as usual (relative risk [RR] for response = 1.60; 95% CI, 1.40-1.83 and RR = 1.65; 95% CI, 1.35-2.03, respectively) and waitlist (RR = 2.35; 95% CI, 1.57-3.51 and RR = 2.43; 95% CI, 1.57-3.74, respectively) control groups. We found no significant differences between psychotherapy and pharmacotherapy (RR = 1.03; 95% CI, 0.88-1.22). The effects were significantly greater for combined treatment compared with psychotherapy alone (RR = 1.35; 95% CI, 1.00-1.81). The difference between combined treatment and pharmacotherapy became significant when limited to studies with low risk of bias and studies limited to cognitive behavior therapy.

CONCLUSIONS

Psychotherapy is likely effective for the treatment of depression when compared with care as usual or waitlist, with effects comparable to those of pharmacotherapy. Combined treatment might be better than either psychotherapy or pharmacotherapy alone.

Mediators of focused psychosocial support interventions for children in low-resource humanitarian settings: analysis from an Individual Participant Dataset with 3,143 participants

BACKGROUND

Research on psychosocial interventions has been focused on the effectiveness of psychosocial interventions on mental health outcomes, without exploring how interventions achieve beneficial effects. Identifying the potential pathways through which interventions work would potentially allow further strengthening of interventions by emphasizing specific components connected with such pathways.

METHODS

We conducted a preplanned mediation analysis using individual participant data from a dataset of 11 randomized controlled trials (RCTs) which compared focused psychosocial support interventions versus control conditions for children living in low- and middle-income countries (LMICs) affected by humanitarian crises. Based on an ecological resilience framework, we hypothesized that (a) coping, (b) hope, (c) social support, and (d) functional impairment mediate the relationship between intervention and outcome PTSD symptoms. A systematic search on the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed, PyscARTICLES, Web of Science, and the main local LMICs databases was conducted up to August 2018. The hypotheses were tested by using individual participant data obtained from study authors of all the studies included in the systematic review.

RESULTS

We included 3,143 children from 11 studies (100% of data from included studies), of which 1,877 from six studies contributed to the mediation analysis. Functional impairment was the strongest mediator for focused psychosocial interventions on PTSD (mediation coefficient -0.087, standard error 0.040). The estimated proportion of effect mediated by functional impairment, and adjusted for confounders, was 31%.

CONCLUSIONS

Findings did not support the proposed mediation hypotheses for coping, hope, and social support. The mediation through functional impairment may represent unmeasured proxy measures or point to a broader mechanism that impacts self-efficacy and agency.

A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

No network meta-analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long-term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop-out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment-resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random-effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta-analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14-1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14-1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92-1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05-1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02-1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment-resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long-term effects of treatments (including cost-effectiveness), on the impact of specific pharmacological and non-pharmacological approaches, and on the effects in specific populations of patients.

Psychological Treatment of Depression in Primary Care: Recent Developments

PURPOSE OF REVIEW

We give an overview of recent developments on psychological treatments of depression in primary care.

RECENT FINDINGS

In recent years, it has become clear that psychotherapies can effectively be delivered through e-health applications. Furthermore, several studies in low and middle income countries have shown that lay health counselors can effectively deliver psychological therapies. Behavioral activation, a relatively simple form of therapy, has been found to be as effective as cognitive behavior therapy. Treatment of subthreshold depression has been found to not only reduce depressive symptoms but also prevent the onset of major depression. In addition, therapies are effective in older adults, patients with general medical disorders and in perinatal depression. Psychological therapies are effective in the treatment of depression in primary care, have longer lasting effects than drugs, are preferred by the majority of patients, and can be applied flexibly with different formats and across different target groups.

Psychological and mind-body interventions for endometriosis: A systematic review

Endometriosis is a common gynecological condition associated with debilitaing pain and poor mental health. This review examines the evidence for psychological and mind-body (PMB) interventions to improve endometriosis pain, psychological distress, sleep and fatigue. Electronic databases searched included PsychINFO, MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus, and PubMed. Inclusion criteria were women with endometriosis, and interventions that used psychological or mind-body interventions; there were no exclusion criteria regarding study design. Studies were identified and coded using standard criteria, and risk of bias was assessed with established tools relevant to the study design. A total of 12 publications relating to 9 separate studies were identified:- 3 randomized controlled trials, 1 controlled trial, 2 single-arm studies, 1 retrospective cohort study, and 2 case series. Interventions included yoga, mindfulness, relaxation training, cognitive behavioural therapy combined with physical therapy, Chinese medicine combined with psychotherapy, and biofeedback. Results indicate that no studies have yet used gold-standard methodology and, thus, definitive conclusions cannot be offered about PMB efficacy. However, the results of these pilot studies suggest that PMB interventions show promise in alleviating pain, anxiety, depression, stress and fatigue in women with endometriosis, and future well-designed RCTs including active control groups are warranted.

Should antidepressants be used in minor depression?

Minor/subthreshold depression is associated with functional impairment, reduced quality of life, and the risk of developing into major depression. Therefore, it should be treated. Watchful waiting should be an option only for patients who, despite adequate information, are not interested in any kind of treatment. Psychotherapy has been found to be effective, but due to methodological problems (control group, blinding), efficacy derived from randomized trials might be over-estimated. Studies on the efficacy of antidepressants in the treatment of minor depression have found clinically relevant benefits over placebo, particularly the newer, better-controlled trials. One major advantage of antidepressants over psychotherapy is their immediate availability and the short period required to evaluate efficacy. Aside from the severity of depression, the patient's attitude towards psychotherapy or antidepressant treatment is of major relevance and should be explored. In a shared decision-making process, the patient should receive appropriate information on treatment options, state her or his preferences, and then receive the treatment of choice.

Effectiveness of psychotherapy for treatment-resistant depression: a meta-analysis and meta-regression

Despite substantial advances in treatment and management strategies for major depression, less than 50% of patients respond to first-line antidepressant treatment or psychotherapy. Given the growing number of controlled studies of psychotherapy for treatment-resistant depression (TRD) and the preference for psychotherapy of depressed subjects as a treatment option, we conducted a meta-analysis and meta-regression analysis to investigate the effectiveness of psychotherapy for TRD. Seven different psychotherapies were studied in 21 trials that included a total of 25 comparisons. In three comparisons of psychotherapy v. treatment as usual (TAU) we found no evidence to conclude that there is a significant benefit of psychotherapy as compared with TAU. In 22 comparisons of add-on psychotherapy plus TAU v. TAU only, we found a moderate general effect size of 0.42 (95% CI 0.29-0.54) in favor of psychotherapy plus TAU. The meta-regression provided evidence for a positive association between baseline severity as well as group v. individual therapy format with the treatment effect. There was no evidence for publication bias. Most frequent investigated treatments were cognitive behavior therapy, interpersonal psychotherapy, mindfulness-based cognitive therapy, and cognitive behavioral analysis system of psychotherapy. Our meta-analysis provides evidence that, in addition to pharmacological and neurostimulatory treatments, the inclusion of add-on of psychotherapy to TAU in guidelines for the treatment of TRD is justified and will provide better outcomes for this difficult-to-treat population.

Was Eysenck right after all? A reassessment of the effects of psychotherapy for adult depression

AIMS

In the 1950s, Eysenck suggested that psychotherapies may not be effective at all. Twenty-five years later, the first meta-analysis of randomised controlled trials showed that the effects of psychotherapies were considerable and that Eysenck was wrong. However, since that time methods have become available to assess biases in meta-analyses.

METHODS

We examined the influence of these biases on the effects of psychotherapies for adult depression, including risk of bias, publication bias and the exclusion of waiting list control groups.

RESULTS

The unadjusted effect size of psychotherapies compared with control groups was g = 0.70 (limited to Western countries: g = 0.63), which corresponds to a number-needed-to-treat of 4.18. Only 23% of the studies could be considered as a low risk of bias. When adjusting for several sources of bias, the effect size across all types of therapies dropped to g = 0.31.

CONCLUSIONS

These results suggest that the effects of psychotherapy for depression are small, above the threshold that has been suggested as the minimal important difference in the treatment of depression, and Eysenck was probably wrong. However, this is still not certain because we could not adjust for all types of bias. Unadjusted meta-analyses of psychotherapies overestimate the effects considerably, and for several types of psychotherapy for adult depression, insufficient evidence is available that they are effective because too few low-risk studies were available, including problem-solving therapy, interpersonal psychotherapy and behavioural activation.

Placebo Effects in Psychotherapy: A Framework

The issue of placebo response and the extent of its effect on psychotherapy is complex for two specific reasons: i) Current standards for drug trials, e.g., true placebo interventions, double-blinding, cannot be applied to most psychotherapy techniques, and ii) some of the "nonspecific effects" in drug therapy have very specific effects in psychotherapy, such as the frequency and intensity of patient-therapist interaction. In addition, different psychotherapy approaches share many such specific effects (the "dodo bird verdict") and lack specificity with respect to therapy outcome. Here, we discuss the placebo effect in psychotherapy under four aspects: a) nonspecific factors shared with drug therapy (context factors); b) nonspecific factors shared among all psychotherapy traditions (common factors); c) specific placebo-controlled options with different psychotherapy modalities; and d) nonspecific control options for the specific placebo effect in psychotherapy. The resulting framework proposes that the exploration and enumeration of context factors, common factors, and specific factors contributes to the placebo effects in psychotherapy.

Control conditions for randomised trials of behavioural interventions in psychiatry: a decision framework

In psychiatry, comparative analyses of therapeutic options and the aggregation of data from clinical trials across different therapeutic approaches play an important role in clinical decision making, treatment guidelines, and health policy. This approach assumes that trials of pharmacological and behavioural therapies generally produce the same level of evidence when properly designed. However, trial design for behavioural interventions has some unique characteristics and control groups vary widely, which influence the effects observed in any given trial. In this Personal View, we review various control conditions typically used in psychiatry, outline their effect on the internal validity and expected effect size of a trial, and propose a decision framework for choosing a control condition depending on the risk to the patient population and the stage of development of the therapeutic intervention. We argue that the choice of control group and its justification need to be taken into consideration when comparing behavioural and pharmacological therapies.

Effects of Cognitive Behavior Therapy on Heart Rate Variability in Young Females with Constipation-predominant Irritable Bowel Syndrome: A Parallel-group Trial

Background/Aims

The relation between heart rate variability (HRV) as non-invasive biomarkers of autonomic function and cognitive behavior therapy (CBT) as non-pharmacological treatments has rarely been examined in patients with constipation-predominant irritable bowel syndrome (IBS-C). The purpose of this study is to evaluate the efficacy of an 8-week CBT intervention on HRV and IBS symptoms, and the correlation of changes in HRV with changes in IBS symptoms among young female nursing students with IBS-C.

Methods

This study consisted of an exploratory subgroup analysis of 43 participants with IBS-C who had been randomly assigned to receive either 8 weeks of CBT (n = 23) or general medical information (control, n = 20). At baseline and 8, 16, and 24 weeks, participants completed a questionnaire assessing their gastrointestinal (GI) symptoms, anxiety, depression, and stress, and their HRV was measured via electrocardiography.

Results

At the 8-week follow-up, the high-frequency (HF) power was significantly higher, and the low-frequency (LF)/HF ratio was lower in the CBT group than in the control group (P < 0.001 for both), and the severity of GI symptoms (P = 0.003), anxiety (P < 0.001), depression (P < 0.001), and stress (P < 0.001) was significantly lower in the CBT group than in the control group. Changes in the HF power were significantly and inversely associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from -0.37 to -0.68). Changes in the LF/HF ratio were also significantly and positively associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from 0.38 to 0.60).

Conclusions

CBT was effective in managing symptoms in young IBS-C patients and the improvement of symptoms was sustained at 24 weeks following the completion of CBT. Furthermore, indirect measurement of autonomic function using HRV may be a useful objective parameter for assessing response to CBT in young IBS-C patients.

Minor depression in older, long-term unemployed people seeking vocational support

BACKGROUND

Prevalence rates of minor and major depression vary from 0.7 to 6.8 (minor) and 3.8 to 10.9 (major) for the general population. Twenty-two percent of older, long-term unemployed people suffer from major depression. However, the prevalence rate of minor depression (depression on a subthreshold level with less than 5, but more than 1 depression symptom) in this population is unknown. The first aim of this study is to identify that prevalence rate, because we already know that minor depression increases the risk of developing a major depression and this in turn reduces the chances of reemployment what increases social and individual costs at the same time. The second aim is to find out whether there are symptoms that distinguish the different groups "no depression", "minor depression" and "major depression" in this population. In contrast to the general population, the most frequent symptoms within major and minor depression in older, long-term unemployed people are unknown so far.

METHODS

A total of 234 long-term unemployed people (response rate 59%) were included in a study within a project of the Department of Psychiatry and Psychotherapy at the University of Leipzig and an unemployment agency. Based on the results of the Patient Health Questionnaire, the participants were classified as non depressive, minor depressive or major depressive. Descriptive statistics and chi-square tests were performed to identify whether there are symptoms stated by the participants that are more frequent than others, and if the classified groups differ in this regard.

RESULTS

Fifty percent had no depression, 15.6% had a minor depression and 34.4% were suffering from major depression. Difficulty with concentration is the symptom that differentiated the last two groups the most. Fatigue, depressed mood and anhedonia were the symptoms that distinguished participants with minor depression the most from participants with no depression. Main limitations are: The sample was determined by programme conditions, e.g. not all potentially available people participated. The sample may therefore not be representative for the general long-term unemployed. Due to limited resources the PHQ 9 was used instead of a clinical interview to assess minor and major depression.

CONCLUSIONS

Results indicate that minor depression in older, long-term unemployed persons is significant, as, almost 16% of the participants were affected in the study. Especially when fatigue is present for a period of more than 2 weeks, people should be informed about the option to consult a primary care physician or professionals from the unemployment agency in order to prevent the possible onset of major depression.

Complementary and Alternative Medicine Use and Its Association with Emotional Status and Quality of Life in Patients with a Solid Tumor: A Cross-Sectional Study

Objectives: Complementary and alternative medicine (CAM) has been used widely in various populations for various purposes, including emotional support and improvement of quality of life (QOL). However, CAM use and purposes for using CAM are less clear among Korean patients with a solid tumor. The purpose of this study was to determine the prevalence and type of CAM use, and the association between CAM use and anxiety, depression, and QOL in patients with a solid tumor.

Design: A cross-sectional survey.

Setting: A cancer center in Korea.

Subjects: Two hundred and sixteen patients diagnosed with a solid tumor.

Outcome measures: Standard questionnaires on CAM use, Hospital Anxiety and Depression Scale, and European Organization for Research and Treatment of Cancer QLQ-C30.

Results: One hundred thirty one patients (60.6%) reported using CAM. CAM users, compared with non-CAM users, were significantly younger (57.8 vs. 60.9 years, p = 0.05), had higher level of education (p = 0.008), had higher income (p = 0.008), were less likely to seek physician consultation on CAM use (p = 0.002), and had a more advanced stage of tumor (p = 0.003) with more distant metastasis (p = 0.001). The most commonly used CAM was herbal medicine (n = 89, 67.9%). CAM users had significantly lower anxiety (t = 5.21, p < 0.001) and depression (t = 4.90, p < 0.001) than non-CAM users. When the effects of CAM use were tested on anxiety, depression, and QOL, controlling for covariates, CAM use was significantly associated with 8.7% and 8.8% of variance in decreasing anxiety and depression, but there was no unique association of CAM use with variance in QOL.

Conclusions: CAM use is prevalent and younger age, higher education levels, higher income, less physician consultation, and higher cancer stage are significant correlates to CAM use. Controlling for covariates (e.g., gender, BMI), CAM use is significantly associated with lower anxiety and depression compared with those of non-CAM users.

Biases in research: risk factors for non-replicability in psychotherapy and pharmacotherapy research

Replicability of findings is an essential prerequisite of research. For both basic and clinical research, however, low replicability of findings has recently been reported. Replicability may be affected by research biases not sufficiently controlled for by the existing research standards. Several biases such as researcher allegiance or selective reporting are well-known for affecting results. For psychotherapy and pharmacotherapy research, specific additional biases may affect outcome (e.g. therapist allegiance, therapist effects or impairments in treatment implementation). For meta-analyses further specific biases are relevant. In psychotherapy and pharmacotherapy research these biases have not yet been systematically discussed in the context of replicability. Using a list of 13 biases as a starting point, we discuss each bias's impact on replicability. We illustrate each bias by selective findings of recent research, showing that (1) several biases are not yet sufficiently controlled for by the presently applied research standards, (2) these biases have a pernicious effect on replicability of findings. For the sake of research credibility, it is critical to avoid these biases in future research. To control for biases and to improve replicability, we propose to systematically implement several measures in psychotherapy and pharmacotherapy research, such as adversarial collaboration (inviting academic rivals to collaborate), reviewing study design prior to knowing the results, triple-blind data analysis (including subjects, investigators and data managers/statisticians), data analysis by other research teams (crowdsourcing), and, last not least, updating reporting standards such as CONSORT or the Template for Intervention Description and Replication (TIDieR).

The efficacy of psychotherapy, pharmacotherapy and their combination on functioning and quality of life in depression: a meta-analysis

BACKGROUND

There is growing recognition of the importance of both functioning and quality of life (QoL) outcomes in the treatment of depressive disorders, but the meta-analytic evidence is scarce. The objective of this meta-analysis of randomized controlled trials (RCTs) was to determine the absolute and relative effects of psychotherapy, pharmacotherapy and their combination on functioning and QoL in patients with depression.

METHOD

One hundred and fifty-three outcome trials involving 29 879 participants with depressive disorders were identified through database searches in Pubmed, PsycINFO and the Cochrane Central Register of Controlled Trials.

RESULTS

Compared to control conditions, psychotherapy and pharmacotherapy yielded small to moderate effect sizes for functioning and QoL, ranging from g = 0.31 to g = 0.43. When compared directly, initial analysis yielded no evidence that one of them was superior. After adjusting for publication bias, psychotherapy was more efficacious than pharmacotherapy (g = 0.21) for QoL. The combination of psychotherapy and medication performed significantly better for both outcomes compared to each treatment alone yielding small effect sizes (g = 0.32 to g = 0.39). Both interventions improved depression symptom severity more than functioning and QoL.

CONCLUSION

Despite the small number of comparative trials for some of the analyses, this study reveals that combined treatment is superior, but psychotherapy and pharmacotherapy alone are also efficacious for improving functioning and QoL. The overall relatively modest effects suggest that future tailoring of therapies could be warranted to better meet the needs of individuals with functioning and QoL problems.

Psychotherapy Versus Pharmacotherapy of Depression: What's the Evidence?

OBJECTIVES

Depression may be treated by psychotherapy or pharmacotherapy or their combination. There is an ongoing debate whether one of these approaches is possibly superior. A recent meta-analysis reported results in favour of pharmacotherapy.

METHODS

Individual studies and meta-analyses on the comparative efficacy of psychotherapy vs. pharmacotherapy were reviewed.

RESULTS

Evidence suggests that psychotherapy and pharmacotherapy are equally efficacious in the short-term, but psychotherapy is superior in the long-term. For the recently stated hypothesis that pharmacotherapy is superior to psychotherapy in studies without a pill placebo condition, which implies equally including a positive expectancy effect for both pharmacotherapy and psychotherapy no evidence was found.

CONCLUSION

Depression may be treated by psychotherapy or pharmacotherapy with equivalent results in the short-term and advantages for psychotherapy in the long-term. As the rates of response and remission are still limited in both treatments, further improvement of treatments is required.