Depressive disorders are common, have a strong impact on quality of life, and are associated with considerable morbidity and mortality. Along with antidepressants, psychotherapies are first-line treatments for depression, and both treatments are effective.
Cognitive behavioral therapy (CBT) is the most examined type of psychotherapy for depression, but other types of psychotherapy have also been evaluated in multiple trials. For all of them, there is evidence of effectiveness compared to controls in usual care and on the waiting list, although from comparative studies with little statistical power.
Only one network meta-analysis (MAR) has simultaneously examined the effects of different psychotherapies for depression, confirming the comparable effects of these therapies versus control conditions. However, this MAR is outdated (only included studies through 2012) and did not examine the acceptability of treatments.
Furthermore, the number of trials with low risk of bias was small. Long-term outcomes of psychotherapies were also not examined. It was therefore decided to conduct a new MAR examining the efficacy and acceptability of the main types of psychotherapy for depression in adults compared to usual care, wait list and placebo.
| Results |
A total of 331 randomized controlled trials met the inclusion criteria. The majority of studies were aimed at adults (43.8%). In 179 studies (54.1%), participants met criteria for a depressive disorder based on a diagnostic interview, while the other studies (45.9%) included participants who scored above a cutoff on a self-rating scale. depression.
CBT was examined in the majority of studies (63.7%), while other therapies were examined in 13 (3.9%; life review therapy) to 42 (12.7%; nondirective supportive counseling ) studies. The usual care control condition was used in 158 studies (47.7%), waiting list control in 112 studies (33.8%), and placebo in 10 studies (3%).
Most of the interventions had an individual treatment format (43.8%), 75 a group format (22.7%), 58 a guided self-help format (17.5%) and 53 a mixed or other format (16.%). Most studies were conducted in North America (40.5%) and Europe (37.5%).
A total of 184 studies reported adequate sequence generation (55.6%), 157 reported assignment to conditions by an independent group (47.4%), 105 reported the use of blinded outcome assessors (31.7% ), and 195 only used self-reported results (58.9%). Intention-to-treat analyzes were performed in 209 studies (63.1%). The risk of bias was low in 102 studies (30.8%), moderate in 148 studies (44.7%), and high in 81 studies (24.4%).
The network graph for treatment response (at least 50% reduction in depressive symptomatology) indicated a well-connected network, with no independent node. CBT was the best reviewed therapy and connected to all other nodes (except life review therapy).
Nondirective supportive counseling was also connected to most of the other nodes. The other therapies were not well connected to each other. All therapies were linked to usual care and the wait list, but not to placebo.
In pairwise meta-analyses, all therapies were more effective than usual care (except psychodynamic therapy) and wait-list (except nondirective supportive counseling and psychodynamic therapy).
There were no significant differences between the therapies, except that nondirective supportive counseling was less effective than CBT, problem-solving therapy, and psychodynamic therapy.
Treatment response results indicate that all therapies are more effective than usual care and waiting list, with few significant differences between them. Only nondirective supportive counseling was less effective.
All therapies except nondirective supportive counseling and psychodynamic therapy were also more effective than placebo. The results of remission and standardized mean difference (SMD) were very similar to those of response. Only the results for placebo differed considerably, possibly related to the small number of studies.
Acceptability of all therapies (except interpersonal psychotherapy and life review therapy) was significantly lower than waitlist. Psychodynamic therapy was significantly less acceptable than usual care. No significant differences in acceptability were found between any of the therapies.
The design-by-treatment interaction model showed global inconsistency in the network. Because of this, the sources of influential factors were searched, and 37 trials were detected as outliers. After excluding them, the overall inconsistency was no longer significant.
The MAR results after excluding these outliers were similar to the main analyses. Except for some comparisons that mainly involved active interventions vs. waiting list (CBT, behavioral activation therapy, “third wave” therapies, interpersonal psychotherapy, psychodynamic therapy, and life review therapy vs. waitlist, and behavioral activation therapy vs. usual care) that were moderately certain, all estimates were rated as having low to very low certainty of evidence.
Life review and behavioral activation therapies ranked highest in response and DME; behavioral activation and problem-solving therapy ranked first in remission; while nondirective supportive counseling and psychodynamic therapy ranked lowest for response, remission, and MDS. Psychodynamic therapy ranked lowest in acceptability, while life review therapy and interpersonal psychotherapy ranked highest.
In sensitivity analyzes in which only studies with low risk of bias were included, comparable results were found to the main analyses. Only differences between nondirective supportive counseling and most other therapies were not significant.
In the meta-regression analyses, only five predictors were found to be statistically significant (depressive disorder diagnosed for CBT vs. interpersonal psychotherapy, and CBT vs. waiting list; number of CBT sessions vs. behavioral activation therapy; Western countries vs. non-Western for CBT vs. usual care and risk of bias for CBT vs. behavioral activation therapy). Due to their correlative nature and the large number of analyzes performed, these findings should be interpreted with caution.
A MAR was performed on the 90 studies that reported response results at 12 (±6) months after randomization. Results indicated that CBT, behavioral activation therapy, problem-solving therapy, interpersonal psychotherapy, and psychodynamic therapy had significant effects compared with usual care at follow-up.
The same therapies, except behavioral activation therapy, also had significant effects compared to the wait list. Problem-solving therapy was significantly more effective than CBT, “third wave” therapies, and nondirective supportive counseling at follow-up.
Interpersonal psychotherapy was also significantly more effective than nondirective supportive counseling. Only nine studies reported outcomes at ≥18 months after randomization. Due to the small number of studies and different time periods, no analysis was performed with these studies.
| Discussion |
In this MAR, the effects of the eight most common types of psychotherapy for depression were compared with each other and with the main control conditions.
All therapies were found to have significant effects compared to usual care and the waitlist control condition.
The effects of the therapies did not differ significantly from each other , except for nondirective supportive counseling, which was less effective. These results were largely confirmed in a series of sensitivity analyses.
These findings are consistent with previous research on psychotherapies for depression. However, unlike previous meta-analyses, a considerable number of studies with low risk of bias could be included, which broadly confirmed the main results.
Non-directive supportive counseling was less effective than the other therapies, but these results were not significant when only studies with low risk of bias were included. This is in line with previous meta-analytic work. However, these findings may be related to the fact that, in many studies, counseling was used as a control condition and therapists may not have provided optimal treatments.
Life review therapy was not included in previous meta-analyses because the number of studies was too small. This psychotherapy is primarily used in older adults, has also been used successfully in cancer patients, and could very well be used in other populations without general medical disorders. More research is needed, but it can be considered a promising intervention that is likely to be effective in depression.
Overall, the findings of this MAR suggest that all psychotherapies examined, except nondirective supportive counseling, are effective and can be used in routine care. This means that when choosing a therapy, the patient’s preferences can play a prominent role.
Mental health professionals should facilitate access to up-to-date evidence-based information on the effects of treatment interventions and involve patients more in their daily care. It is possible that a more detailed characterization of each patient diagnosed with depression could lead to a more precise match between individual patients and individual psychotherapies.
An important finding of this study is that several psychotherapies still have significant effects at one-year follow-up, including CBT, behavioral activation therapy, problem-solving therapy, interpersonal psychotherapy, and psychodynamic therapy. We also found that problem-solving therapy may be somewhat more effective than other therapies during follow-up, although this should be considered with caution, due to the relatively small number of studies and the considerable risk of bias in most of them.
In a recent MAR, combined psychotherapy and pharmacotherapy were more effective than either alone in achieving a response, including in chronic and treatment-resistant depression. Therefore, combination treatments appear to be the best option for patients with moderate to severe depression.
A strength of this study is the large number of included trials. This is the largest MAR conducted in psychotherapies for depression. An important limitation is that the proportion of studies with low risk of bias was small (30.8%), although sufficient to perform sensitivity analyses.
Another important limitation is that some discrepancies were found between the direct and indirect evidence, and only after excluding outliers did the evidence point in the same direction. Furthermore only a small number of trials reported longer-term results, making these effects uncertain.
Despite these limitations, it can be concluded that the most important types of psychotherapy, including CBT, behavioral activation therapy, problem-solving therapy, “third wave” therapies, interpersonal psychotherapy, psychodynamic therapy, and life review therapy can be effective and acceptable in the treatment of adult depression, without significant differences between them.
