Characteristics of effective psychological treatments of depression: a metaregression analysis

Efficacy of metacognitive training for depression as add-on intervention for patients with depression in acute intensive psychiatric inpatient care: A randomized controlled trial

BACKGROUND

Metacognitive training for depression (D-MCT) is a novel low-intensity group training for economic treatment of depression. Previous studies demonstrate its efficacy in moderately depressed outpatients. The present study evaluated efficacy and patients' perspective of the D-MCT in severely depressed psychiatric inpatients.

METHODS

In a randomized-controlled trial, 75 individuals with a major depressive disorder (MDD) were allocated to D-MCT versus euthymic therapy as add-on (twice a week) to cognitive-behavioural-based (CBT) inpatient-care. Depressive symptoms (HDRS, BDI), dysfunctional (meta)cognition (DAS, MCQ-30) and subjective appraisal were assessed at baseline, 4 weeks (post) and 3 months (follow-up).

RESULTS

Participants in both conditions showed a large decline in depression at post and follow-up-assessment. No superior add-effect of D-MCT versus active control emerged for depression severity on top of the inpatient care. However, among patients with a diagnosis of MDD with no (vs. at least one) comorbidity, D-MCT participants showed a larger decline in depressive (meta-)cognition at follow-up with medium-to-large effect sizes. D-MCT was evaluated as superior in overall appraisal, treatment preference, motivation and satisfaction.

LIMITATIONS

The follow-up time interval of 3 months may have been too short to detect long-term effects. There is emerging evidence that modification of (meta)cognition unfolds its full effects only with time. Effects of CBT inpatient-care on outcome parameters cannot be differentiated.

CONCLUSIONS

Although D-MCT as an add-on was not superior in complete case analyses, results suggest greater benefit for patients with MDD and no comorbidity. D-MCT proved feasible in acute-psychiatric inpatient-care and was highly accepted by patients. Future studies should investigate the role of modified (meta)cognition on long-term treatment outcome, including dropout and relapse rates.

Large-Scale Transcriptomics Studies Provide Insight Into Sex Differences in Depression

Major depressive disorder (MDD) is a leading cause of disability, affecting more than 300 million people worldwide. We first review the well-known sex difference in incidence of MDD, with women being twice as likely to be diagnosed as men, and briefly summarize how the impact of MDD varies between men and women, with sex differences in symptoms, severity, and antidepressant drug response. We then attempt to deconstruct the biological bases for MDD and discuss implications for sex differences research. Next, we review findings from human postmortem studies, both from selected candidate gene studies and from well-powered, unbiased transcriptomics studies, which suggest distinct, and possibly opposite, molecular changes in the brains of depressed men and women. We then discuss inherent challenges of research on the human postmortem brain and suggest paths forward that rely on thoughtful cohort design. Although studies indicate that circulating gonadal hormones might underlie the observed sex differences in MDD, we discuss how additional sex-specific factors, such as genetic sex and developmental exposure to gonadal hormones, may also contribute to altered vulnerability, and we highlight various nuances that we believe should be considered when determining mechanisms underlying observed sex differences. Altogether, this review highlights not only how various sex-specific factors might influence susceptibility or resilience to depression, but also how those sex-specific factors might result in divergent pathology in men and women.

The Dismal State of Federal Funding for Experimental Evaluations of Interventions to Reduce Greenhouse Gas Emissions

The threats of climate change to human well-being are well-documented and are growing in number and intensity. Despite the international community investing heavily in technological innovation and policy initiatives to solve the problem, emissions continue to rise. Experts are recognizing that eliminating emissions cannot be achieved without modifying the human behavior of which emissions are a function. However, little attention has been allocated to expanding the use of strategies developed by the behavioral-science community to reduce emissions on large scales. One possible reason is that federal funding has not been arranged to select such research. Therefore, we conducted an analysis of six sources of information about federal funding to fight climate change (the Government Accountability Office, the National Science Foundation, the Environmental Protection Agency, the Department of Energy, the National Institutes of Health, and the Center for Disease Control) and examined the extent to which they are funding behavioral science research to reduce emissions. Our results show an appalling lack of funding for behavioral science research to reduce emissions, especially experimental evaluations of strategies for reducing them. Implications and recommendations for funding of future research are discussed.

Coached Mobile App Platform for the Treatment of Depression and Anxiety Among Primary Care Patients: A Randomized Clinical Trial

Importance

Depression and anxiety are common and disabling. Primary care is the de facto site for treating these mental health problems but is typically underresourced to meet the burden of these demands.

Objective

To evaluate the efficacy of a mobile intervention platform, IntelliCare, for addressing depression and anxiety among primary care patients.

Design, Setting, and Participants

Two-arm randomized clinical trial at internal medicine clinics at the University of Arkansas for Medical Sciences. Adult primary care patients (N = 146) who screened positive for depression on the Patient Health Questionnaire-8 (PHQ; score  ≥ 10) or anxiety on the Generalized Anxiety Disorder-7 (GAD-7; score ≥ 8) were recruited between July 17, 2018, and December 14, 2018.

Interventions

The coach-supported platform composed of a suite of apps, was delivered over 8 weeks. Wait list control participants received treatment as usual for 8 weeks, then the mobile platform.

Main Outcomes and Measures

Primary outcomes were changes in depression (PHQ-9) and anxiety (GAD-7) during the intervention period. Secondary outcomes were differences in the proportion of patients who achieved recovery (PHQ-9/GAD-7 <5 or 50% improvement from baseline), sustainment of intervention effects during 2-month follow-up, and app use during the intervention period.

Results

One hundred forty-six patients were included (119 of 146 were women [81.5%]; mean [SD] age, 42.3 [13.8] years). Of the 146 patients, 122 (83.6%) were diagnosed as having depression and 131 (89.7%) were diagnosed as having anxiety. A greater proportion of intervention vs wait list control participants achieved recovery from depression (n = 38 of 64 [59%] vs n = 18 of 58 [31%]; odds ratio, 3.25; 95% CI, 1.54-6.86) and anxiety (n = 37 of 65 [57%] vs n = 25 of 66 [38%]; odds ratio, 2.17; 95% CI, 1.08-4.36). Sustained effects were observed for depression (slope, 0.01; 95% CI, -0.09 to 0.10; P = .92) and anxiety scores (slope, 0.02; 95% CI, -0.08 to 0.12; P = .67) during follow-up. App use was high, with a median of 93 and 98 sessions among participants with depression and anxiety, respectively.

Conclusions and Relevance

In this trial, a mobile intervention app was effective for depression and anxiety among primary care patients. Findings also support designing digital mental health interventions as platforms containing simple, brief apps that can be bundled by users to meet their needs.

Trial Registration

ClinicalTrials.gov Identifier: NCT03500536.

The questionable efficacy of manualized psychological treatments for distressed breast cancer patients: An individual patient data meta-analysis

Previous meta-analyses conclude that psychological treatments are efficacious for emotional distress in breast cancer (BCa). However, the practical relevance of these meta-analyses is questionable; none focused specifically on clinically distressed patients or whether treatment effects were clinically significant. In a two-stage individual patient data (IPD) meta-analysis of 17 randomized controlled trials of manualized psychological treatments in BCa, we evaluated treatment efficacy in distressed BCa patients (n = 1591) using clinical significance and effect size analyses. Outcomes were anxiety, depression, and general distress, evaluated at post-treatment and follow-up. Moderators examined were treatment type, treatment format, therapists' profession, control condition, age, outcome measure, and trial quality. Treated patients were more likely than controls to recover from anxiety and general distress at post-treatment (14-15% more treated patients recovered), but not at mean 8-months follow-up. Overall recovery rates were low: across outcomes, at post-treatment, only 30-32% of treated patients and 15-25% of controls recovered; at follow-up, only 21-30% of treated patients and 18-35% of controls recovered. Small between-group effect sizes in favour of treatment were found across outcomes at post-treatment (g = 0.32-0.34) but not at follow-up. Across the different analysis methods, few moderator effects were found. More efficacious psychological treatments are needed for distressed BCa patients.

Therapeutic Alliance in Technology-Based Interventions for the Treatment of Depression: Systematic Review

Background

There is growing evidence that technology-based interventions (TBIs) are effective for the treatment of depression. As TBIs are gaining acceptance, a question arises whether good therapeutic alliance, considered a key aspect of psychotherapy, can be established without or with minimal face-to-face contact or rather changes if blended concepts are applied. While therapeutic alliance has been studied extensively in the context of face-to-face therapy, only few studies have reviewed evidence on alliance ratings in TBIs.

Objective

The purpose of this study was to examine therapeutic alliance in technology-based psychological interventions for the treatment of depression.

Methods

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PSYNDEX, CINAHL, clinical trial registers, and sources of grey literature for randomized controlled trials on TBIs in the treatment of adults with unipolar depression. All publications were selected according to prespecified criteria. Data were extracted by two independent reviewers.

Results

A total of eight out of 98 studies (9.5%) included in the review on TBIs for depression considered therapeutic alliance as part of their evaluation. The available data covered eight different treatment conditions, including four stand-alone treatments (face-to-face psychotherapy, email, telephone, and internet program) and four combined treatments (face-to-face psychotherapy plus a smartphone app and an internet program combined with face-to-face psychotherapy, treatment as usual, or email/telephone). On average, patients rated the alliance positively across all groups. Importantly, no relevant group differences regarding therapeutic alliance sum scores were found in any of the studies. Five studies investigated the relationship between patients’ alliance ratings and treatment outcome, revealing mixed results.

Conclusions

Our results suggest that it is possible to establish a positive therapeutic alliance across a variety of different TBIs for depression, but this is based on a small number of studies. Future research needs to determine on what basis therapeutic alliance is formed in settings that do not allow for additional nonverbal cues, perhaps with adapted instruments to measure therapeutic alliance.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413)

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028042

Why did she leave? Development of working alliance in a case of psychotherapy for depression

The present case study aims to explore the unfolding of the working alliance in a case that ended with the client dropping out of psychotherapy, unilaterally cutting off her contact with the therapist. However, both quantitative and qualitative outcome assessments strongly suggested that. An analysis of session transcripts, the Client Change Interview, and the Interpersonal Process Recall interviews for three selected sessions was used to analyze the development of the working alliance and its contribution to the dropout. This case study illustrates how the working alliance is constructed differently during the different phases of the therapeutic process. Specifically, the fruitful problem-solving in the first part of psychotherapy helped the client to improve her functioning. Yet this intervention seemed to exhaust its potential over time, and later the dyad had trouble finding another useful mode of interaction due to the interpersonal context, leading to more serious ruptures and, eventually, to the dropout. The findings are discussed in terms of therapist responsiveness and of its role in the continuous negotiation of the working alliance.

Control Conditions That Are Neither Usual Care Nor No Treatment in Randomized Trials of Psychoeducational Palliative Care Interventions: A Systematic Review

BACKGROUND:

Determining intervention efficacy depends as much on the control group as on the intervention, but little attention has been given to the control condition in psychoeducational trials in palliative care.

OBJECTIVES:

To examine (1) research practice regarding control conditions that are neither usual care nor no-treatment controls in randomized trials of psychoeducational palliative care interventions and (2) the rationale and completeness of the descriptions of control conditions in trial reports.

METHODS:

PubMed, EMBASE, PsycINFO, and Web of Science were searched. After screening 1603 articles, 70 full-text articles were assessed for eligibility. The final sample included 9 trial reports. We used the Delphi list for quality assessment and the modified intervention taxonomy checklist to assess active intervention and control conditions.

RESULTS:

Four trials used an attention control designed to be equivalent to the structure of the active intervention. In another 4, the control condition included some aspects of attention control such that the mode of contact was similar to that in the active intervention, but either the amount or the intensity of attention was not similar. Only 3 trial reports explicitly stated the rationale for the choice of control condition. Although most reports contained delivery mode, materials, duration, frequency, and sequence, none described the qualifications or training required to deliver the control condition. Only 1 report mentioned the fidelity monitoring method, and none included fidelity data.

CONCLUSION:

Our review of psychoeducational trials in palliative care calls for researchers' attention to appropriate selection, design, conduct and report of control conditions.

Evaluating feasibility and acceptability of a group WHO trans-diagnostic intervention for women with common mental disorders in rural Pakistan: a cluster randomised controlled feasibility trial

AIMS

The aim of this feasibility trial was to evaluate the feasibility and acceptability of the locally adapted Group Problem Management Plus (PM+) intervention for women in the conflict affected settings in Swat, Pakistan.

METHODS

This mixed-methods study incorporated a quantitative component consisting of a two arm cluster randomised controlled feasibility trial, and qualitative evaluation of the acceptability of the Group PM+ to a range of stakeholder groups. For the quantitative component, on average from each of the 20 Lady Health Workers (LHWs) catchment area (20 clusters), six women were screened and recruited for the trial with score of >2 on the General Health Questionnaire and score of >16 on the WHO Disability Assessment Schedule. These LHW clusters were randomised on a 1 : 1 allocation ratio using a computer-based software through a simple randomisation method to the Group PM+ intervention or Enhanced Usual Care. The Group PM+ intervention consisted of five weekly sessions of 2 h duration delivered by local non-specialist females under supervision. The primary outcome was individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 7th week after baseline. Secondary outcomes include symptoms of depression, post-traumatic stress disorder (PTSD), general psychological profile, levels of functioning and generalised psychological distress. Intervention acceptability was explored through in-depth interviews.

RESULTS

The results show that lay-helpers with no prior mental health experience can be trained to achieve the desired competency to successfully deliver the intervention in community settings under supervision. There was a good intervention uptake, with Group PM+ considered useful by participants, their families and lay-helpers. The outcome evaluation, which was not based on a large enough study to identify statistically significant results, indicated statistically significant improvements in depression, anxiety, general psychological profile and functioning. The PTSD symptoms and depressive disorder scores showed a trend in favour of the intervention.

CONCLUSION

This trial showed robust acceptance in the local settings with delivery by non-specialists under supervision by local trained females. The trial paves the way for further adaptation and exploration of the outcomes through larger-scale implementation and definitive randomised controlled trials in the local settings.

Web-Based Interventions for Depression in Individuals with Diabetes: Review and Discussion

Background

Depression is twice as common in people with diabetes, and this comorbidity worsens the course of both pathologies. In clinical practice guidelines, screening and treatment of depression in patients with diabetes are highly recommended. However, depression is still both underrecognized and undertreated. To find ways to enhance their reach, psychological treatments have taken advantage of benefits of internet and technological devices as delivery formats, providing interventions that require considerably less (or even no) interaction time with therapists. Web-based treatments hold promise for effective interventions at low cost with positive results.

Objective

The objectives of this review were to describe Web-based interventions for depression in individuals with diabetes and to discuss these studies’ procedures and findings in light of evidence from a wider range of interventions for depression and diabetes.

Methods

A comprehensive literature search was conducted in PsycINFO and MEDLINE electronic databases. Studies were included when they met the following selection criteria: the study was available in a peer-reviewed journal mainly publishing studies written in either English or Spanish; the studied sample comprised individuals with diabetes; the intervention targeted depression symptomatology; the intervention was accessible via the internet; and the intervention was accessible via the internet with little or no clinician support.

Results

Overall, 5 research studies were identified in the review. All studies were randomized controlled trials, and most used a wait list as a control; 4 studies reported treatment dropout, rates of which varied from 13% to 42%. Studies supported the notion that the Web-based format is a suitable psychology service delivery option for diabetic individuals with depression (effect size range for completers 0.7-0.89). Interventions varied in their characteristics but most were clinical-assisted, had a cognitive behavioral therapy approach, used diabetes-specific topics, had a weekly modular display, used homework assignments, and had some adherence management strategy. These characteristics are consistent with the intervention features associated with positive results in the literature.

Conclusions

The analyzed studies’ findings and procedures are discussed in light of evidence drawn from a wider range of reviews on Web-based interventions for depression and diabetes. Consistent with previous research on depression treatment, Web-based interventions for depression among individuals with diabetes have shown positive results. Future research should contribute new evidence as to why these interventions are effective, for whom, and which particular aspects can increase patients’ adherence.

Mobile technology for medication adherence in people with mood disorders: A systematic review

BACKGROUND

Medication non-adherence is a critical challenge for many patients diagnosed with mood disorders (Goodwin and Jamison, 1990). There is a need for alternative strategies that improve adherence among patients with mood disorders that are cost-effective, able to reach large patient populations, easy to implement, and that allow for communication with patients outside of in-person visits. Technology-based approaches to promote medication adherence are increasingly being explored to address this need. The aim of this paper is to provide a systematic review of the use of mobile technologies to improve medication adherence in patients with mood disorders.

METHODS

A total of nine articles were identified as describing mobile technology targeting medication adherence in mood disorder populations.

RESULTS

Results showed overall satisfaction and feasibility of mobile technology, and reduction in mood symptoms; however, few examined effectiveness of mobile technology improving medication adherence through randomized control trials.

LIMITATIONS

Given the limited number of studies, further research is needed to determine long term effectiveness.

CONCLUSIONS

Mobile technologies has the potential to improve medication adherence and can be further utilized for symptom tracking, side effects tracking, direct links to prescription refills, and provide patients with greater ownership over their treatment progress.

Systematic review of control groups in nutrition education intervention research

Background

Well-designed research trials are critical for determining the efficacy and effectiveness of nutrition education interventions. To determine whether behavioral and/or cognition changes can be attributed to an intervention, the experimental design must include a control or comparison condition against which outcomes from the experimental group can be compared. Despite the impact different types of control groups can have on study outcomes, the treatment provided to participants in the control condition has received limited attention in the literature.

Methods

A systematic review of control groups in nutrition education interventions was conducted to better understand how control conditions are described in peer-reviewed journal articles compared with experimental conditions. To be included in the systematic review, articles had to be indexed in CINAHL, PubMed, PsycINFO, WoS, and/or ERIC and report primary research findings of controlled nutrition education intervention trials conducted in the United States with free-living consumer populations and published in English between January 2005 and December 2015. Key elements extracted during data collection included treatment provided to the experimental and control groups (e.g., overall intervention content, tailoring methods, delivery mode, format, duration, setting, and session descriptions, and procedures for standardizing, fidelity of implementation, and blinding); rationale for control group type selected; sample size and attrition; and theoretical foundation.

Results

The search yielded 43 publications; about one-third of these had an inactive control condition, which is considered a weak study design. Nearly two-thirds of reviewed studies had an active control condition considered a stronger research design; however, many failed to report one or more key elements of the intervention, especially for the control condition. None of the experimental and control group treatments were sufficiently detailed to permit replication of the nutrition education interventions studied.

Conclusions

Findings advocate for improved intervention study design and more complete reporting of nutrition education interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0546-3) contains supplementary material, which is available to authorized users.

Psychosocial therapies for the adjunctive treatment of bipolar disorder in adults: network meta-analysis

BackgroundFew trials have compared psychosocial therapies for people with bipolar affective disorder, and conventional meta-analyses provided limited comparisons between therapies.AimsTo combine evidence for the efficacy of psychosocial interventions used as adjunctive treatment of bipolar disorder in adults, using network meta-analysis (NMA).MethodSystematic review identified studies and NMA was used to pool data on relapse to mania or depression, medication adherence, and symptom scales for mania, depression and Global Assessment of Functioning (GAF).ResultsCarer-focused interventions significantly reduced the risk of depressive or manic relapse. Psychoeducation alone and in combination with cognitive-behavioural therapy (CBT) significantly reduced medication non-adherence. Psychoeducation plus CBT significantly reduced manic symptoms and increased GAF. No intervention was associated with a significant reduction in depression symptom scale scores.ConclusionsOnly interventions for family members affected relapse rates. Psychoeducation plus CBT reduced medication non-adherence, improved mania symptoms and GAF. Novel methods for addressing depressive symptoms are required.

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.

Personalized Psychotherapy for Adult Depression: A Meta-Analytic Review

Personalized medicine is aimed at identifying which characteristics of an individual predict the outcome of a specific treatment, in order to get a better match between the individual and the treatment received. We conducted a systematic review and meta-analysis of randomized trials comparing two psychotherapies directly in a group of depressed patients with a specific characteristic. We focused on the six most examined types of psychotherapy for adult depression. Our searches resulted in 41 studies with 2,741 patients who met inclusion criteria. These 41 studies examined 27 specific characteristics of patients. Power calculations indicated that we would need 4 studies for each characteristic to find a clinically relevant effect size set at g = 0.50 and 16 studies for an effect size of 0.24. Only 3 patient characteristics were found to have sufficient power and to significantly moderate treatment outcomes. Cognitive-behavioral therapy was found to be more effective than other therapies in older adults (g = 0.29), in patients with comorbid addictive disorders (g = 0.31), and in university students (g = 0.46). Risk of bias was considerable in most of the included studies. It was estimated that it will take another 326 years to have sufficient statistical power for showing an effect size of g = 0.50 of the 27 characteristics, and 1,372 years to show an effect size of 0.24. Although several dozens of studies have compared the effects of psychotherapies in specific target groups, we will need to develop more powerful alternatives to comparative outcome studies in order to identify personalized treatments for depression.

Predicting treatment outcome in psychological treatment services by identifying latent profiles of patients

BACKGROUND

The outcomes of psychological therapies for anxiety and depression vary across individuals and symptom domains. Being able to predict treatment response from readily available patient data at presentation has potentially important benefits in aiding decisions about the most suitable interventions for a patient. This paper presents a method of identifying subgroups of patients using latent profile analysis, and comparing response to psychological treatments between these profiles.

METHODS

All outpatients taken into treatment at two psychological treatment services in London, UK and who provided basic demographic information and standardized symptom measures were included in the analysis (n=16636).

RESULTS

Latent Profile Analysis was performed on intake data to identify statistically different groups of patients, which were then examined in longitudinal analyses to determine their capacity to predict treatment outcomes. Comparison between profiles showed considerable variation in recovery (74-15%), deterioration rates (5-20%), and levels of attrition (17-40%). Further variation in outcomes was found within the profiles when different intensities of psychological intervention were delivered.

LIMITATIONS

Latent profiles were identified using data from two services, so generalisability to other services should be considered. Routinely collected patient data was included, additional patient information may further enhance utility of the profiles.

CONCLUSIONS

These results suggest that intake data can be used to reliably classify patients into profiles that are predictive of outcome to different intensities of psychological treatment in routine care. Algorithms based on these kinds of data could be used to optimize decision-making and aid the appropriate matching of patients to treatment.

Effects of a Psychological Internet Intervention in the Treatment of Mild to Moderate Depressive Symptoms: Results of the EVIDENT Study, a Randomized Controlled Trial

BACKGROUND

Mild to moderate depressive symptoms are common but often remain unrecognized and treated inadequately. We hypothesized that an Internet intervention in addition to usual care is superior to care as usual alone (CAU) in the treatment of mild to moderate depressive symptoms in adults.

METHODS

This trial was controlled, randomized and assessor-blinded. Participants with mild to moderate depressive symptoms (Patient Health Questionnaire, PHQ-9, score 5-14) were recruited from clinical and non-clinical settings and randomized to either CAU or a 12-week Internet intervention (Deprexis) adjunctive to usual care. Outcomes were assessed at baseline, 3 months (post-assessment) and 6 months (follow-up). The primary outcome measure was self-rated depression severity (PHQ-9). The main analysis was based on the intention-to-treat principle and used linear mixed models.

RESULTS

A total of 1,013 participants were randomized. Changes in PHQ-9 from baseline differed signixFB01;cantly between groups (t825 = 6.12, p < 0.001 for the main effect of group). The post-assessment between-group effect size in favour of the intervention was d = 0.39 (95% CI: 0.13-0.64). It was stable at follow-up, with d = 0.32 (95% CI: 0.06-0.69). The rate of participants experiencing at least minimally clinically important PHQ-9 change at the post-assessment was higher in the intervention group (35.6 vs. 20.2%) with a number needed to treat of 7 (95% CI: 5-10).

CONCLUSIONS

The Internet intervention examined in this trial was superior to CAU alone in reducing mild to moderate depressive symptoms. The magnitude of the effect is clinically important and has public health implications.

Reporting of Positive Results in Randomized Controlled Trials of Mindfulness-Based Mental Health Interventions

Background

A large proportion of mindfulness-based therapy trials report statistically significant results, even in the context of very low statistical power. The objective of the present study was to characterize the reporting of “positive” results in randomized controlled trials of mindfulness-based therapy. We also assessed mindfulness-based therapy trial registrations for indications of possible reporting bias and reviewed recent systematic reviews and meta-analyses to determine whether reporting biases were identified.

Methods

CINAHL, Cochrane CENTRAL, EMBASE, ISI, MEDLINE, PsycInfo, and SCOPUS databases were searched for randomized controlled trials of mindfulness-based therapy. The number of positive trials was described and compared to the number that might be expected if mindfulness-based therapy were similarly effective compared to individual therapy for depression. Trial registries were searched for mindfulness-based therapy registrations. CINAHL, Cochrane CENTRAL, EMBASE, ISI, MEDLINE, PsycInfo, and SCOPUS were also searched for mindfulness-based therapy systematic reviews and meta-analyses.

Results

108 (87%) of 124 published trials reported ≥1 positive outcome in the abstract, and 109 (88%) concluded that mindfulness-based therapy was effective, 1.6 times greater than the expected number of positive trials based on effect size d = 0.55 (expected number positive trials = 65.7). Of 21 trial registrations, 13 (62%) remained unpublished 30 months post-trial completion. No trial registrations adequately specified a single primary outcome measure with time of assessment. None of 36 systematic reviews and meta-analyses concluded that effect estimates were overestimated due to reporting biases.

Conclusions

The proportion of mindfulness-based therapy trials with statistically significant results may overstate what would occur in practice.

Effectiveness of music intervention in ameliorating cancer patients' anxiety, depression, pain, and fatigue: a meta-analysis

BACKGROUND

This is the first study to use meta-analysis as a scientific technique to provide an integrated analysis of the effectiveness of music intervention in cancer patients.

OBJECTIVES

The purpose of this study was, using the meta-analysis method, to present a summary of existing research and explore the effectiveness of music intervention in ameliorating anxiety, depression, pain, and fatigue in cancer patients.

METHODS

The present study collected quantitative study designs sought of music intervention for cancer patients published from 2002 to 2012. These studies were then cross-referenced using Medical Subject Headings for topics on music intervention and cancer patients. Outcome indicators were anxiety, depression, pain, and fatigue. The quality of the studies was evaluated using Cochrane Collaboration Guidelines. The effect size on outcome indicators used the formula devised by Hedges and Olkin (1985).

RESULTS

Results showed that music interventions were significantly effective in ameliorating anxiety (g = -0.553), depression (g = -0.510), pain (g = -0.656), and fatigue (g = -0.422) in cancer patients. Subgroup analyses revealed that age and who selected the music were major factors influencing the effect size on anxiety reduction.

CONCLUSIONS

Music interventions significantly ameliorate anxiety, depression, pain, and fatigue in cancer patients, especially adults. Music interventions were more effective in adults than in children or adolescents and more effective when patients, rather than researchers, chose the music.

IMPLICATIONS FOR PRACTICE

Our findings provide important information for future music-intervention planners to improve the design and processes that will benefit patients in such programs.

Control condition design and implementation features in controlled trials: a meta-analysis of trials evaluating psychotherapy for depression

ABSTRACT

Control conditions are the primary methodology used to reduce threats to internal validity in randomized controlled trials (RCTs). This meta-analysis examined the effects of control arm design and implementation on outcomes in RCTs examining psychological treatments for depression. A search of MEDLINE, PsycINFO, and EMBASE identified all RCTs evaluating psychological treatments for depression published through June 2009. Data were analyzed using mixed-effects models. One hundred twenty-five trials were identified yielding 188 comparisons. Outcomes varied significantly depending control condition design (p < 0.0001). Significantly smaller effect sizes were seen when control arms used manualization (p = 0.006), therapist training (p = 0.002), therapist supervision (p = 0.009), and treatment fidelity monitoring (p = 0.003). There were no significant effects for differences in therapist experience, level of expertise in the treatment delivered, or nesting vs. crossing therapists in treatment arms. These findings demonstrate the substantial effect that decisions regarding control arm definition and implementation can have on RCT outcomes.

The effect of psychotherapy for depression on improvements in social functioning: a meta-analysis

BACKGROUND

Patients with depression often report impairments in social functioning. From a patient perspective, improvements in social functioning might be an important outcome in psychotherapy for depression. Therefore, it is important to examine the effects of psychotherapy on social functioning in patients with depression.

METHOD

We conducted a meta-analysis on studies of psychotherapy for depression that reported results for social functioning at post-treatment. Only studies that compared psychotherapy to a control condition were included (31 studies with 2956 patients).

RESULTS

The effect size of psychotherapy on social functioning was small to moderate, before [Hedges' g = 0.46, 95% confidence interval (CI) 0.32-0.60] and after adjusting for publication bias (g = 0.40, 95% CI 0.25-0.55). Univariate moderator analyses revealed that studies using care as usual as a control group versus other control groups yielded lower effect sizes, whereas studies conducted in the USA versus other countries and studies that used clinician-rated instruments versus self-report yielded higher effect sizes. Higher quality studies yielded lower effect sizes whereas the number of treatment sessions and the effect size of depressive symptoms were positively related to the effect size of social functioning. When controlling for these and additional characteristics simultaneously in multivariate meta-regression, the effect size of depressive symptoms, treatment format and number of sessions were significant predictors. The effect size of social functioning remained marginally significant, indicating that improvements in social functioning are not fully explained by improvements in depressive symptoms.

CONCLUSIONS

Psychotherapy for depression results in small to moderate improvements in social functioning. These improvements are strongly associated with, but not fully explained by, improvements in depressive symptoms.

Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis

OBJECTIVE

Various control conditions have been employed in psychotherapy trials, but there is growing suspicion that they may lead to different effect size estimates. The present study aims to examine the differences among control conditions including waiting list (WL), no treatment (NT) and psychological placebo (PP).

METHOD

We comprehensively searched for all randomized controlled trials (RCTs) comparing cognitive-behaviour therapies (CBT) against various control conditions in the acute phase treatment of depression, and applied network meta-analysis (NMA) to combine all direct and indirect comparisons among the treatment and control arms.

RESULTS

We identified 49 RCTs (2730 participants) comparing WL, NT, PP and CBT. This network of evidence was consistent, and the effect size estimates for CBT were substantively different depending on the control condition. The odds ratio of response for NT over WL was statistically significant at 2.9 (95% CI: 1.3-5.7). However, the quality of evidence, including publication bias, was less than ideal and none of the preplanned sensitivity analyses limiting to high-quality studies could be conducted, while findings of significant differences did not persist in post hoc sensitivity analyses trying to adjust for publication bias.

CONCLUSION

There may be important differences in control conditions currently used in psychotherapy trials.

A relaxation technique enhances psychological well-being and immune parameters in elderly people from a nursing home: a randomized controlled study

Background

The aging process involves a decline in immune functioning that renders elderly people more vulnerable to disease. In residential programs for the aged, it is vital to diminish their risk of disease, promote their independence, and augment their psychological well-being and quality of life.

Methods

We performed a randomized controlled study, evaluating the ability of a relaxation technique based on Benson’s relaxation response to enhance psychological well-being and modulate the immune parameters of elderly people living in a geriatric residence when compared to a waitlist control group. The study included a 2-week intervention period and a 3-month follow-up period. The main outcome variables were psychological well-being and quality of life, biomedical variables, immune changes from the pre-treatment to post-treatment and follow-up periods.

Results

Our findings reveal significant differences between the experimental and control groups in CD19, CD71, CD97, CD134, and CD137 lymphocyte subpopulations at the end of treatment. Furthermore, there was a decrease in negative affect, psychological discomfort, and symptom perception in the treatment group, which increased participants’ quality of life scores at the three-month follow-up.

Conclusions

This study represents a first approach to the application of a passive relaxation technique in residential programs for the elderly. The method appears to be effective in enhancing psychological well-being and modulating immune activity in a group of elderly people. This relaxation technique could be considered an option for achieving health benefits with a low cost for residential programs, but further studies using this technique in larger samples of older people are needed to confirm the trends observed in the present study.

Trial registration

International Standard Randomised Controlled Trial Number Register ISRCTN85410212

Quantity and quality of psychotherapy trials for depression in the past five decades

BACKGROUND

Over the years randomized controlled trials (RCTs) of various psychotherapies for treating depression have provided evidence to demonstrate the interventions' efficacy/effectiveness. However, recent researches suggest that the quality of some RCTs were actually less than ideal, which could hence have biased their results. The present study aims to assess (1) the changes in characteristics of RCTs of psychotherapies for treating adult depression; (2) the temporal changes in their trial quality, and (3) the quality differences among different therapeutic approaches.

METHODS

We included 135 RCTs of psychotherapies treating adult depression published from year 1969 to 2011. Temporal changes in trials' characteristics including their quantity and quality were assessed at study-level and arm-level. Quality differences among different schools of psychotherapy were assessed at arm-level.

RESULTS

Changes in quantity and improvements in methodological quality were found at study-level. Positive changes in trial quality at arm-level were observed in most aspects. Comparisons made across different schools of psychotherapy revealed statistically significant differences among them, with earlier behavior therapy trials doing worst and more recent third wave cognitive-behavior therapy doing best.

LIMITATIONS

We could not determine whether the observed changes in quality resulted from actual improvement in trial quality and/or from improved reporting. The relatively smaller number of arms for several types of interventions could weaken the representativeness when making comparisons across psychotherapeutic approaches.

CONCLUSION

Our study revealed positive temporal changes in both trial quantity and quality over the past five decades and has also spotted possible areas for further improvement.

The effects of psychotherapies for major depression in adults on remission, recovery and improvement: a meta-analysis

BACKGROUND

Standardised effect sizes have been criticized because they are difficult to interpret and offer little clinical information. This meta-analyses examine the extent of actual improvement, the absolute numbers of patients no longer meeting criteria for major depression, and absolute rates of response and remission.

METHODS

We conducted a meta-analysis of 92 studies with 181 conditions (134 psychotherapy and 47 control conditions) with 6937 patients meeting criteria for major depressive disorder. Within these conditions, we calculated the absolute number of patients no longer meeting criteria for major depression, rates of response and remission, and the absolute reduction on the BDI, BDI-II, and HAM-D.

RESULTS

After treatment, 62% of patients no longer met criteria for MDD in the psychotherapy conditions. However, 43% of participants in the control conditions and 48% of people in the care-as-usual conditions no longer met criteria for MDD, suggesting that the additional value of psychotherapy compared to care-as-usual would be 14%. For response and remission, comparable results were found, with less than half of the patients meeting criteria for response and remission after psychotherapy. Additionally, a considerable proportion of response and remission was also found in control conditions. In the psychotherapy conditions, scores on the BDI were reduced by 13.42 points, 15.12 points on the BDI-II, and 10.28 points on the HAM-D. In the control conditions, these reductions were 4.56, 4.68, and 5.29.

DISCUSSION

Psychotherapy contributes to improvement in depressed patients, but improvement in control conditions is also considerable.

Comparison of psychotherapies for adult depression to pill placebo control groups: a meta-analysis

BACKGROUND

The effects of antidepressants for treating depressive disorders have been overestimated because of selective publication of positive trials. Reanalyses that include unpublished trials have yielded reduced effect sizes. This in turn has led to claims that antidepressants have clinically insignificant advantages over placebo and that psychotherapy is therefore a better alternative. To test this, we conducted a meta-analysis of studies comparing psychotherapy with pill placebo.

METHOD

Ten 10 studies comparing psychotherapies with pill placebo were identified. In total, 1240 patients were included in these studies. For each study, Hedges' g was calculated. Characteristics of the studies were extracted for subgroup and meta-regression analyses.

RESULTS

The effect of psychotherapy compared to pill placebo at post-test was g = 0.25 [95% confidence interval (CI) 0.14-0.36, I² = 0%, 95% CI 0-58]. This effect size corresponds to a number needed to treat (NNT) of 7.14 (95% CI 5.00-12.82). The psychotherapy conditions scored 2.66 points lower on the Hamilton Depression Rating Scale (HAMD) than the placebo conditions, and 3.20 points lower on the Beck Depression Inventory (BDI). Some indications for publication bias were found (two missing studies). We found no significant differences between subgroups of the studies and in meta-regression analyses we found no significant association between baseline severity and effect size.

CONCLUSIONS

Although there are differences between the role of placebo in psychotherapy and pharmacotherapy research, psychotherapy has an effect size that is comparable to that of antidepressant medications. Whether these effects should be deemed clinically relevant remains open to debate.

Improving the cost-effectiveness of a healthcare system for depressive disorders by implementing telemedicine: a health economic modeling study

OBJECTIVES

Depressive disorders are significant causes of disease burden and are associated with substantial economic costs. It is therefore important to design a healthcare system that can effectively manage depression at sustainable costs. This article computes the benefit-to-cost ratio of the current Dutch healthcare system for depression, and investigates whether offering more online preventive interventions improves the cost-effectiveness overall.

METHODS

A health economic (Markov) model was used to synthesize clinical and economic evidence and to compute population-level costs and effects of interventions. The model compared a base case scenario without preventive telemedicine and alternative scenarios with preventive telemedicine. The central outcome was the benefit-to-cost ratio, also known as return-on-investment (ROI).

RESULTS

In terms of ROI, a healthcare system with preventive telemedicine for depressive disorders offers better value for money than a healthcare system without Internet-based prevention. Overall, the ROI increases from €1.45 ($1.72) in the base case scenario to €1.76 ($2.09) in the alternative scenario in which preventive telemedicine is offered. In a scenario in which the costs of offering preventive telemedicine are balanced by reducing the expenditures for curative interventions, ROI increases to €1.77 ($2.10), while keeping the healthcare budget constant.

CONCLUSIONS

For a healthcare system for depressive disorders to remain economically sustainable, its cost-benefit ratio needs to be improved. Offering preventive telemedicine at a large scale is likely to introduce such an improvement.

Evidence for the management of adolescent depression

Adolescent depression is a prevalent and disabling condition resulting in emotional suffering and social and educational dysfunction. Care for adolescent depression is suboptimal and could be improved through the development and use of quality indicators (QIs). This article reports on the development of a care pathway and QIs for the primary and specialty care management of adolescent depression from case identification through symptom remission. It presents evidence from a review of adolescent clinical practice guidelines and research literature to support QIs at critical nodes in the pathway, and describes implications for practice based on existing evidence. Barriers to measure development are identified, including gaps in empirical evidence, and a research agenda is suggested.

A randomized controlled trial evaluating a manualized TeleCoaching protocol for improving adherence to a web-based intervention for the treatment of depression

BACKGROUND

Web-based interventions for depression that are supported by coaching have generally produced larger effect-sizes, relative to standalone web-based interventions. This is likely due to the effect of coaching on adherence. We evaluated the efficacy of a manualized telephone coaching intervention (TeleCoach) aimed at improving adherence to a web-based intervention (moodManager), as well as the relationship between adherence and depressive symptom outcomes.

METHODS

101 patients with MDD, recruited from primary care, were randomized to 12 weeks moodManager+TeleCoach, 12 weeks of self-directed moodManager, or 6 weeks of a waitlist control (WLC). Depressive symptom severity was measured using the PHQ-9.

RESULTS

TeleCoach+moodManager, compared to self-directed moodManager, resulted in significantly greater numbers of login days (p = 0.01), greater time until last use (p = 0.007), greater use of lessons (p = 0.03), greater variety of interactive tools used (p = 0.02), but total instances of tool use did not reach statistical significance. (p = 0.07). TeleCoach+moodManager produced significantly lower PHQ-9 scores relative to WLC at week 6 (p = 0.04), but there were no other significant differences in PHQ-9 scores at weeks 6 or 12 (ps>0.20) across treatment arms. Baseline PHQ-9 scores were no significantly related to adherence to moodManager.

CONCLUSIONS

TeleCoach produced significantly greater adherence to moodManager, relative to self-directed moodManager. TeleCoached moodManager produced greater reductions in depressive symptoms relative to WLC, however, there were no statistically significant differences relative to self-directed moodManager. While greater use was associated with better outcomes, most users in both TeleCoach and self-directed moodManager had dropped out of treatment by week 12. Even with telephone coaching, adherence to web-based interventions for depression remains a challenge. Methods of improving coaching models are discussed.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00719979.

Comparing bona fide psychotherapies of depression in adults with two meta-analytical approaches

Objective

Despite numerous investigations, the question whether all bona fide treatments of depression are equally efficacious in adults has not been sufficiently answered.

Method

We applied two different meta-analytical techniques (conventional meta-analysis and mixed treatment comparisons). Overall, 53 studies with 3,965 patients, which directly compared two or more bona fide psychotherapies in a randomized trial, were included. Meta-analyses were conducted regarding five different types of outcome measures. Additionally, the influence of possible moderators was examined.

Results

Direct comparisons of cognitive behavior therapy, behavior activation therapy, psychodynamic therapy, interpersonal therapy, and supportive therapies versus all other respective treatments indicated that at the end of treatment all treatments but supportive therapies were equally efficacious whereas there was some evidence that supportive therapies were somewhat less efficacious than all other treatments according to patient self-ratings and clinical significance. At follow-up no significant differences were present. Age, gender, comorbid mental disorders, and length of therapy session were found to moderate efficacy. Cognitive behavior therapy was superior in studies where therapy sessions lasted 90 minutes or longer, behavior activation therapy was more efficacious when therapy sessions lasted less than 90 minutes. Mixed treatment comparisons indicated no statistically significant differences in treatment efficacy but some interesting trends.

Conclusions

This study suggests that there might be differential effects of bona fide psychotherapies which should be examined in detail.

A randomized controlled trial of combined exercise and psycho-education for low-SES women: short- and long-term outcomes in the reduction of stress and depressive symptoms

Exercise may have both a preventive and a therapeutic impact on mental health problems. The Exercise without Worries intervention aims to reduce stress and depressive symptoms in low-SES women by means of a group-based program combining physical exercise and psycho-education. Between September 2005 and May 2008, 161 Dutch low-SES women with elevated stress or depressive symptom levels were randomly assigned to the combined exercise/psycho-education intervention (EP), exercise only (E) or a waiting list control condition (WLC). The E condition provided low to moderate intensity stretching, strength, flexibility, and body focused training as well as relaxation, while the EP program integrated the exercise with cognitive-behavioral techniques. Depressive symptoms (CES-D) and perceived stress (PSS) were measured before and immediately after the intervention and at 2, 6 and 12 month follow-up. Multilevel linear mixed-effects models revealed no differential patterns in reduction of CES-D or PSS scores between the EP, E and WLC groups on the short (post-test and 2 month follow-up) or long term (6 and 12 months follow-up). Depressive symptom outcomes were moderated by initial depressive symptom scores: women from the EP and E groups with fewer initial symptoms benefited from participation on the short term. Further, women in the EP and E groups with the lowest educational level reported more stress reduction at post-test than women with higher educational levels. In the overall target population of low-SES women, no indications were found that the Exercise without Worries course reduced depressive symptom and stress levels on the short or long term. The findings do suggest, however, that exercise alone or in combination with psycho-education may be a viable prevention option for certain groups of disadvantaged women. Especially those low-SES women with less severe initial problems or those with low educational attainment should be targeted for future depression prevention practice.

Psychological treatment of anxiety in primary care: a meta-analysis

BACKGROUND

Guidelines and mental healthcare models suggest the use of psychological treatment for anxiety disorders in primary care but systematic estimates of the effect sizes in primary care settings are lacking. The aim of this study was to examine the effectiveness of psychological therapies in primary care for anxiety disorders.

METHOD

The Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Medline, PsycINFO and Pubmed databases were searched in July 2010. Manuscripts describing psychological treatment for anxiety disorders/increased level of anxiety symptoms in primary care were included if the research design was a randomized controlled trial (RCT) and if the psychological treatment was compared with a control group.

RESULTS

In total, 1343 abstracts were identified. Of these, 12 manuscripts described an RCT comparing psychological treatment for anxiety with a control group in primary care. The pooled standardized effect size (12 comparisons) for reduced symptoms of anxiety at post-intervention was d = 0.57 [95% confidence interval (CI) 0.29-0.84, p = 0.00, the number needed to treat (NNT) = 3.18]. Heterogeneity was significant among the studies (I 2 = 58.55, Q = 26.54, p < 0.01). The quality of studies was not optimal and missing aspects are summarized.

CONCLUSIONS

We found a moderate effect size for the psychological treatment of anxiety disorders in primary care. Several aspects of the treatment are related to effect size. More studies are needed to evaluate the long-term effects given the chronicity and recurrent nature of anxiety.

The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and meta-analysis

BACKGROUND

Although treatment guidelines suggest that suicidal patients with depression should be treated for depression with psychotherapy, it is not clear whether these psychological treatments actually reduce suicidal ideation or suicide risk.

METHODS

We conducted a systematic review and meta-analysis of studies on psychotherapy for depression in which outcomes on suicidality were reported. We also focused on outcomes on hopelessness because this is strongly associated with suicidal behavior in depression.

RESULTS

Thirteen studies (with 616 patients) were included, three of which examined the effects of psychotherapy for depression on suicidal ideation and suicide risk, and eleven on hopelessness. No studies were found with suicide attempts or completed suicides as the outcome variables. The effects on suicidal ideation and suicide risk were small (g=0.12; 95% CI: -0.20-0.44) and not statistically significant. A power calculation showed that these studies only had sufficient power to find an effect size of g=0.47. The effects on hopelessness were large (g=1.10; 95% CI: 0.72-1.48) and significant, although heterogeneity was very high. Furthermore, significant publication bias was found. After adjustment of publication bias the effect size was reduced to g=0.60.

DISCUSSION

At this point, there is insufficient evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression. Although psychotherapy of depression may have small positive effects on suicidality, available data suggest that psychotherapy for depression cannot be considered to be a sufficient treatment. The effects on hopelessness are probably higher.

Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis

BACKGROUND

Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomised controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression.

METHODS AND FINDINGS

We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d = -0.62 to d = -0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d = 0.01 to d = -0.30). Interpersonal therapy was significantly more effective than supportive therapy (d = -0.30, 95% credibility interval [CrI] [-0.54 to -0.05]). Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate (Δd = 0.29 [-0.01 to 0.58]; p = 0.063) and large size (Δd = 0.33 [0.08 to 0.61]; p = 0.012) and those that had adequate outcome assessment (Δd = 0.38 [-0.06 to 0.87]; p = 0.100). Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioural therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared to waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions.

CONCLUSIONS

Overall our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments.

Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis

OBJECTIVES

Although cognitive behaviour therapy (CBT) and pharmacotherapy are equally effective in the acute treatment of adult depression, it is not known how they compare across the longer term. In this meta-analysis, we compared the effects of acute phase CBT without any subsequent treatment with the effects of pharmacotherapy that either were continued or discontinued across 6-18 months of follow-up.

DESIGN

We conducted systematic searches in bibliographical databases to identify relevant studies, and conducted a meta-analysis of studies meeting inclusion criteria.

SETTING

Mental healthcare.

PARTICIPANTS

Patients with depressive disorders.

INTERVENTIONS

CBT and pharmacotherapy for depression.

OUTCOME MEASURES

Relapse rates at long-term follow-up.

RESULTS

9 studies with 506 patients were included. The quality was relatively high. Short-term outcomes of CBT and pharmacotherapy were comparable, although drop out from treatment was significantly lower in CBT. Acute phase CBT was compared with pharmacotherapy discontinuation during follow-up in eight studies. Patients who received acute phase CBT were significantly less likely to relapse than patients who were withdrawn from pharmacotherapy (OR=2.61, 95% CI 1.58 to 4.31, p<0.001; numbers-needed-to-be-treated, NNT=5). The acute phase CBT was compared with continued pharmacotherapy at follow-up in five studies. There was no significant difference between acute phase CBT and continued pharmacotherapy, although there was a trend (p<0.1) indicating that patients who received acute phase CBT may be less likely to relapse following acute treatment termination than patients who were continued on pharmacotherapy (OR=1.62, 95% CI 0.97 to 2.72; NNT=10).

CONCLUSIONS

We found that CBT has an enduring effect following termination of the acute treatment. We found no significant difference in relapse after the acute phase CBT versus continuation of pharmacotherapy after remission. Given the small number of studies, this finding should be interpreted with caution pending replication.

An overview of the effectiveness of psychological therapy for depression and stepped care service delivery models

Depression is one of the most prevalent health disorders globally and causes significant distress and cost to the sufferer and society. Psychological therapy for depression has been recommended over a number of decades; however, access to these treatments remains limited. Cognitive behaviour therapy, behavioural activation, self-help approaches, interpersonal therapy and non-directive therapy all demonstrate moderate to large effect sizes when compared to treatment as usual. Differences between psychological interventions however are small and unstable when reviewed in meta-analyses suggesting that for most people adding complexity to treatment does not result in improved outcomes. Stepped care is one system used to organise delivery of psychological therapy that stratifies interventions across several levels of symptom severity. There is debate regarding the ideal design and operation of this complex system resulting in considerable variability in its use in clinical settings. Further research is needed to identify the most cost effective approach to the delivery of psychological therapies for depression as we need to continue to reduce the gap between demand and access to therapy.

A Time-Series Study of Depression Using Cognitive-Behavioral Techniques Subsequent to Short-Term Psychodynamic Psychotherapy

This study examined the sequential use of two distinct treatment modalities in the care of a client with depression and comorbid anxiety. The client was initially treated with 16 sessions of short-term psychodynamic psychotherapy (STPP) followed by seven sessions of cognitive-behavioral therapy (CBT). Simulation modeling analysis was used to assess the symptom changes across both treatment phases. Symptoms tracked included level of self-esteem, degree of sadness, and overall distress. Results indicated that the client did not experience any significant changes in response to STPP, but did experience a reduction in distress and sadness, and an increase in self-esteem subsequent to CBT. This study highlights the importance of clinical flexibility in cases in which a particular treatment modality may not be effective. Complicating factors and implications are also discussed.

Cognitive behavioral therapy for depression in older people: a meta-analysis and meta-regression of randomized controlled trials

OBJECTIVES

To review the effectiveness of cognitive behavioral therapy (CBT) for depression in older people, together with factors associated with its efficacy.

DESIGN

Online literature databases and registers were searched for randomized controlled trials (RCTs) of CBT for depression in older people. Random-effects meta-analysis and meta-regression were conducted.

SETTING

Studies involving participants from the community and inpatient and outpatient clinical settings were included in the meta-analysis.

PARTICIPANTS

Older people with major or minor depression, dysthymia, or depressive symptoms.

MEASUREMENTS

Evidence-based outcome measures of depression.

RESULTS

Four hundred eighty-five studies were identified, of which 23 were included. At the end of the intervention, CBT was significantly more effective at reducing depressive symptoms (irrespective of whether rated by clinicians or participants) than treatment as usual (TAU) or being on a waiting list but not than active controls. The same pattern of results was found for 6-month follow-up. At all other time-points, pooled effect sizes in favor of CBT were nonsignificant. Clinician-rated outcome measures resulted in larger effect sizes in favor of CBT than self-rated measures. No significant differences in efficacy were found between CBT and other treatment (pharmacotherapy and other psychotherapies). Meta-regression analyses revealed four factors that predicted effect sizes for comparisons between CBT and control conditions, including whether concurrent pharmacotherapy was allowed.

CONCLUSION

CBT for depression in older people is more effective than waiting list or TAU, but greater efficacy than active controls or other treatment has not been demonstrated. More high-quality RCTs comparing CBT with active controls need to be conducted before firm conclusions can be drawn about the efficacy of CBT for depression in older people. Other treatment approaches that could be contrasted with or augment CBT (e.g., pharmacotherapy) also need to be explored further.

The systematic activation method as a nursing intervention in depressed elderly: a protocol for a multi-centre cluster randomized trial

BACKGROUND

Depression in later life is a common mental disorder with a prevalence rate of between 3% and 35% for minor depression and approximately 2% for Major Depressive Disorder (MDD). The most common treatment modalities for MDD are antidepressant medication and psychological interventions. Recently, Behavioral Activation (BA) has gained renewed attention as an effective treatment modality in MDD. Although BA is considered an easy accessible intervention for both patients and health care workers (such as nurses), there is no research on the effectiveness of the intervention in inpatient depressed elderly.The aim of study, described in the present proposal, is to examine the effects of BA when executed by nurses in an inpatient population of elderly persons with MDD.

METHODS/DESIGN

The study is designed as a multi-center cluster randomized controlled trial. BA, described as The Systematic Activation Method (SAM) will be compared with Treatment as Usual (TAU). We aim to include ten mental health care units in the Netherlands that will each participate as a control unit or an experimental unit. The patients will meet the following criteria: (1) a primary diagnosis of Major Depressive Disorder (MDD) according to the DSM-IV criteria; (2) 60 years or older; (3) able to read and write in Dutch; (4) have consented to participate via the informed consent procedure. Based on an effect size d = 0.7, we intend to include 51 participants per condition (n = 102). The SAM will be implemented within the experimental units as an adjunctive therapy to Treatment As Usual (TAU). All patients will be assessed at baseline, after eight weeks, and after six months. The primary outcome will be the level of depression measured by means of the Beck Depression Inventory (Dutch version). Other assessments will be activity level, mastery, costs, anxiety and quality of life.

DISCUSSION

To our knowledge this is the first study to test the effect of Behavioral Activation as a nursing intervention in an inpatient elderly population. This research has been approved by the medical research ethics committee for health-care settings in the Netherlands (No. NL26878.029.09) and is listed in the Dutch Trial Register (NTR No.1809).

A spirituality teaching program for depression: a randomized controlled trial

OBJECTIVE

This randomized controlled trial assessed the efficacy of a Spirituality Teaching Program to treat unipolar major depression.

METHOD

A randomized controlled, assessor blinded trial design was used. A total of 84 individuals aged 18 years or older with unipolar major depression of mild to moderate severity were recruited in Calgary, Canada and randomized to two study arms: 1) Spirituality Teaching Program Group (8 week, home-based Spirituality Teaching Program); and 2) Waitlist Control Group (no intervention followed by Spirituality Teaching Program starting at week 9). Outcome measures (depression severity, response rate, remission rate) were assessed at baseline, 8, 16, and 24 weeks using the Hamilton Depression Rating Scale (HAM-D).

RESULTS

The two trial groups were similar in their demographic and disease characteristics at baseline. At the 8-week point, the change in depression severity was significantly different between the two groups (change in HAM-D score: 8.5 for the Spirituality Group and 2.3 for the Waitlist Control Group, p < 0.001). The Spirituality Teaching Program Group had significantly higher response (36% vs. 4.4%, p < 0.001) and remission rates (31% vs. 4.4%, p < 0.001) than the Waitlist Control Group. The benefits remained throughout the observation period for the Spirituality Teaching Program Group participants with response rates of 56.4% at 16 weeks and 58.9% at 24 weeks.

CONCLUSION

The Spirituality Program significantly reduced depression severity and increased response and remission rates. This non-drug treatment program should be investigated further as a treatment option for depression.

Meta-analysis of efficacy of interventions for elevated depressive symptoms in adults diagnosed with cancer

BACKGROUND

Cancer patients are at increased risk for depression compared with individuals with no cancer diagnosis, yet few interventions target depressed cancer patients.

METHODS

Efficacy of psychotherapeutic and pharmacologic interventions for depression in cancer patients who met an entry threshold for depressive symptoms was examined by meta-analysis. Five electronic databases were systematically reviewed to identify randomized controlled trials meeting the selection criteria. Effect sizes were calculated using Hedges' g and were pooled to compare pre- and postrandomization depressive symptoms with a random effects model. Subgroup analyses tested moderators of effect sizes, such as comparison of different intervention modalities, with a mixed effects model. All statistical tests were two-sided.

RESULTS

Ten randomized controlled trials (six psychotherapeutic and four pharmacologic studies) met the selection criteria; 1362 participants with mixed cancer types and stages had been randomly assigned to treatment groups. One outlier trial was removed from analyses. The random effects model showed interventions to be superior to control conditions on reducing depressive symptoms postintervention (Hedges' g = 0.43, 95% confidence interval = 0.30 to 0.56, P < .001). In the four psychotherapeutic trials with follow-up assessment, interventions were more effective than control conditions up to 12-18 months after patients were randomly assigned to treatment groups (P < .001). Although each approach was more effective than the control conditions in improving depressive symptoms (P < .001), subgroup analyses showed that cognitive behavioral therapy appeared more effective than problem-solving therapy (P = .01), but not more effective than pharmacologic intervention (P = .07).

CONCLUSIONS

Our findings suggest that psychological and pharmacologic approaches can be targeted productively toward cancer patients with elevated depressive symptoms. Research is needed to maximize effectiveness, accessibility, and integration into clinical care of interventions for depressed cancer patients.

Psychodynamic guided self-help for adult depression through the internet: a randomised controlled trial

Background and aims

Psychodynamic psychotherapy (PDT) is an effective treatment for major depressive disorder (MDD), but not all clients with MDD can receive psychotherapy. Using the Internet to provide psychodynamic treatments is one way of improving access to psychological treatments for MDD. The aim of this randomised controlled trial was to investigate the efficacy of an Internet-based psychodynamic guided self-help treatment for MDD.

Methods

Ninety-two participants who were diagnosed with MDD according to the Mini-International Neuropsychiatric Interview were randomised to treatment or an active control. The treatment consisted of nine treatment modules based on psychodynamic principles with online therapist contact. The active control condition was a structured support intervention and contained psychoeducation and scheduled weekly contacts online. Both interventions lasted for 10 weeks. The primary outcome measure was the Beck Depression Inventory-II (BDI-II).

Results

Mixed-effects model analyses of all randomised participants showed that participants receiving Internet-based PDT made large and superior improvements compared with the active control group on the BDI-II (between-group Cohen's d = 1.11). Treatment effects were maintained at a 10-month follow-up.

Conclusions

Internet-based psychodynamic guided self-help is an efficacious treatment for MDD that has the potential to increase accessibility and availability of PDT for MDD.

Trial Registration

Clinicaltrials.gov: NCT01324050

Tailored vs. standardized internet-based cognitive behavior therapy for depression and comorbid symptoms: a randomized controlled trial

BACKGROUND AND AIMS

Major depression can be treated by means of cognitive behavior therapy, delivered via the Internet as guided self-help. Individually tailored guided self-help treatments have shown promising results in the treatment of anxiety disorders. This randomized controlled trial tested the efficacy of an Internet-based individually tailored guided self-help treatment which specifically targeted depression with comorbid symptoms. The treatment was compared both to standardized (non-tailored) Internet-based treatment and to an active control group in the form of a monitored online discussion group. Both guided self-help treatments were based on cognitive behavior therapy and lasted for 10 weeks. The discussion group consisted of weekly discussion themes related to depression and the treatment of depression.

METHODS

A total of 121 participants with diagnosed major depressive disorder and with a range of comorbid symptoms were randomized to three groups. The tailored treatment consisted of a prescribed set of modules targeting depression as well as comorbid problems. The standardized treatment was a previously tested guided self-help program for depression.

RESULTS

From pre-treatment to post-treatment, both treatment groups improved on measures of depression, anxiety and quality of life. The results were maintained at a 6-month follow-up. Subgroup analyses showed that the tailored treatment was more effective than the standardized treatment among participants with higher levels of depression at baseline and more comorbidity, both in terms of reduction of depressive symptoms and on recovery rates. In the subgroup with lower baseline scores of depression, few differences were seen between treatments and the discussion group.

CONCLUSIONS

This study shows that tailored Internet-based treatment for depression is effective and that addressing comorbidity by tailoring may be one way of making guided self-help treatments more effective than standardized approaches in the treatment of more severe depression.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01181583.