Comparison of cognitive therapy and behavior therapy in the treatment of depression

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and Morita therapy (MT); comparison of three established psychotherapies and possible common neural mechanisms of psychotherapies

Psychotherapies aim to relieve patients from mental distress by guiding them toward healthier attitudes and behaviors. Psychotherapies can differ substantially in concepts and approaches. In this review article, we compare the methods and science of three established psychotherapies: Morita Therapy (MT), which is a 100-year-old method established in Japan; Cognitive Behavioral Therapy (CBT), which-worldwide-has become the major psychotherapy; and Acceptance and Commitment Therapy (ACT), which is a relatively young psychotherapy that shares some characteristics with MT. The neuroscience of psychotherapy as a system is only beginning to be understood, but relatively solid scientific information is available about some of its important aspects such as learning, physical health, and social interactions. On average, psychotherapies work best if combined with pharmacotherapies. This synergy may rely on the drugs helping to "kickstart" the use of neural pathways (behaviors) to which a patient otherwise has poor access. Improved behavior, guided by psychotherapy, can then consolidate these pathways by their continued usage throughout a patient's life.

Comparative clinical trials in psychotherapy: Have large effects been replicated?

AIMS

The purpose of this review is to examine the replication attempts of psychotherapy clinical trials for depression and anxiety. We focus specifically on replications of trials that exhibit large differences between psychotherapies. The replicability of these trials is especially important for meta-analysis, where the inclusion of false-positive trials can lead to erroneous conclusions about treatment efficacy.

METHODS

Standard replication criteria were developed to distinguish direct from conceptual replication methodologies. Next, an exhaustive literature search was conducted for published meta-analyses of psychotherapy comparisons. Trials that exhibited large effects (d > 0.8) were culled from these meta-analyses. For each trial, a cited replication was conducted to determine if the trial had been subsequently replicated by either 'direct' or 'conceptual' methods. Finally, a broader search was conducted to examine the extent of replication efforts in the psychotherapy literature overall.

RESULTS

In the meta-analytic search, a total of N = 10 meta-analyses met the inclusion criteria. From these meta-analyses, N = 12 distinct trials exhibited large effect sizes. The meta-analyses containing more than two large effect trials reported evidence for treatment superiority. A cited replication search yielded no direct replication attempts (N = 0) for the trials with large effects, and N = 4 conceptual replication attempts of average or above average quality. However, of these four attempts, only two partially corroborated the results from their original trial.

CONCLUSION

Meta-analytic reviews are influenced by trials with large effects, and it is not uncommon for these reviews to contain several such trials. Since we find no evidence that trials with such large effects are directly replicable, treatment superiority conclusions from these reviews are highly questionable. To enhance the quality of clinical science, the development of authoritative replication criteria for clinical trials is needed. Moreover, quality benchmarks should be considered before trials are included in a meta-analysis, or replications are attempted.

Psychological Treatment of Depression in Primary Care: Recent Developments

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Acceptability and Efficacy of Group Behavioral Activation for Depression Among Adults: A Meta-Analysis

The evidence base for behavioral activation (BA) as a front-line treatment for depression is grounded in individual delivery. No valid previous meta-analytic reviews of BA delivered in groups have been conducted. This study therefore examined the efficacy and acceptability of group BA drawn from clinical trial evidence. Randomized controlled trials of group BA were identified using a comprehensive literature search. Depression outcomes at posttreatment/follow-up, recovery and dropout rates were extracted and analyzed using a random-effects meta-analysis. Treatment moderators were analyzed using meta-regression and subgroup analyses. Nineteen trials were quantitatively synthesized. Depression outcomes postgroup BA treatment were superior to controls (SMD 0.72, CI 0.34 to 1.10, k=13, N=461) and were equivalent to other active therapies (SMD 0.14, CI -0.18 to 0.46, k=15, N=526). Outcomes were maintained at follow-up for group BA and moderators of treatment outcome were limited. The dropout rate for group BA (14%) was no different from other active treatments for depression (17%). Further research is required to refine the conditions for optimum delivery of group BA and define robust moderators and mediators of outcome. However, BA delivered in groups produces a moderate to large effect on depressive symptoms and should be considered an appropriate front-line treatment option.

Reward Network Modulation as a Mechanism of Change in Behavioral Activation

Behavioral Activation (BA) is a contemporary third-wave psychosocial treatment approach that emphasizes helping individuals become more active in ways that are meaningful to them as a means of improving mood and quality of life. BA has been designated as a well-established, validated treatment for depression by the American Psychological Association following several decades of accumulated empirical support demonstrating that BA techniques successfully reduce depression symptoms and produce other desirable outcomes across a variety of populations and contexts. The purported mechanism of change underlying BA treatment lies in increasing activation, which in turn increases contact with positive reinforcement thereby reversing the cycle of depression. Current studies are further investigating how increasing activation and subsequent contact with mood reinforcers can influence mood and behavior. Specifically, there is growing evidence that BA modifies function of reward-related networks in the brain, and that these changes are associated with clinical improvement. Herein, we provide a brief history of BA, describe the primary components of BA treatment, and describe BA's purported mechanisms of change at behavioral, neural, and subjective activation levels. We present limitations as well as gaps in the current state of knowledge regarding mechanisms of action of BA.

Is behavioural activation effective in the treatment of depression in young people? A systematic review and meta-analysis

PURPOSE

Depression is currently the leading cause of illness and disability in young people. Evidence suggests that behavioural activation (BA) is an effective treatment for depression in adults but less research focuses on its application with young people. This review therefore examined whether BA is effective in the treatment of depression in young people.

METHODS

A systematic review (International Prospective Register of Systematic Reviews reference: CRD42015020453), following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was conducted to examine studies that had explored behavioural interventions for young people with depression. The electronic databases searched included the Cochrane Library, EMBASE, MEDLINE, CINAHL Plus, PsychINFO, and Scopus. A meta-analysis employing a generic inverse variance, random-effects model was conducted on the included randomized controlled trials (RCTs) to examine whether there were overall effects of BA on the Children's Depression Rating Scale - Revised.

RESULTS

Ten studies met inclusion criteria: three RCTs and seven within-participant designs (total n = 170). The review showed that BA may be effective in the treatment of depression in young people. The Cochrane risk of bias tool and the Moncrieff scale used to assess the quality of the included studies revealed a variety of limitations within each.

CONCLUSIONS

Despite demonstrating that BA may be effective in the treatment of depression in young people, the review indicated a number of methodological problems in the included studies meaning that the results and conclusions should be treated with caution. Furthermore, the paucity of studies in this area highlights the need for further research.

PRACTITIONER POINTS

Currently BA is included within National Institute for Health and Clinical Excellence (NICE, 2009) guidelines as an evidence-based treatment for depression in adults with extensive research supporting its effectiveness. It is important to investigate whether it may also be effective in treating young people. Included studies reported reductions in depression scores across a range of measures following BA. BA may be an effective treatment of depression in young people.

Self-Initiated Imaginal and Cognitive Components: Evaluation of Differential Effectiveness in Altering Unpleasant Moods

The purpose of the present study was to investigate the differential effectiveness of brief cognitive and imaginal techniques in the alleviation of experientially induced anger and sadness. Thirty-two male and female undergraduates recruited from an introductory psychology course were randomly assigned to one of two mood groups (i.e., anger or sadness) and either of two treatment orders (i.e., cognitive-imagery; imagery-cognitive). Likert-type scales were used to assess mood level at pre and posttreatments. Results indicate: self-initiated statements and self-generated images were both effective in altering unpleasant moods. Moreover, a significant order by repeated measures interaction suggests that treatment effectiveness is enhanced when personal images precede personal cognitions. Categorical analyses of imaginal and cognitive themes suggested that some classes of imaginal and cognitive themes were superior to others in reducing unpleasant affect.

Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

Since the introduction of Beck's cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive-behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders. Despite this, the relative contribution of cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.

The Efficacy of Group Therapy for Depression

This article reviews the empirical research on the efficacy of group therapy for depressive disorders from 1970 to 1986. The review was undertaken in light of a multidimensional classification system designed to clarify differences between conceptual and measurement parameters of the various studies. The results suggest that group interventions have shortterm efficacy in the alleviation of depressive symptomatology with an outpatient population. Although more research needs to be done before definitive conclusions can be drawn, the availablefollow-up data suggest that lasting well-being would be anticipated following successful group inten'ention. As there was nofocus on the process-outcome interaction, no conclusions could be drawn about factors responsible for the positive outcome found.

Treating Depressive Disorders

The present overview evaluates the evidence in favor of the efficacy of (traditional) behavior therapy, cognitive-behavior therapy, and cognitive therapy in the treatment of clinically significant depressions. The results of single-case and comparison group studies are used to highlight clinical issues that require more systematic attention and to suggest future research directions.

Perspectives in the Behavioral Treatment of Depression

In this article we critically consider the efficacy of psychotherapeutic strategies for the treatment of depressed outpatients. Problems with the design of each of the recent major studies are identified; suggestions for improved methodologies are offered. Comments on the current "status of the art" by leading experts in the field are considered. Finally, advances in the social skills treatment of depression are discussed. Factors requiring further research attention in the next decade are identified.

Life Enhancement Counseling and the Treatment of Depressed Cuban American Elders

This article reports on a demonstration project designed to develop a psychosocial model of services for treating depressed Cuban American elders. Data were collected to identify client variables (age, sex, time in the United States, and education) and treatment variables (life enhancement counseling, medication, and number of sessions) that are differentially predictive of treatment effectiveness with depressed Hispanic elders. Data are reported on a sample of 100 elders. Treatment effectiveness was measured using a factorially derived composite criterion. Residualized gain scores and factor-analytic techniques were used to conduct an analysis of the outcome criteria structures and to create the outcome composite. Multiple-regression techniques were employed to identify client and treatment variables differentially predictive of treatment effectiveness. The results of these analyses indicated that treatment success was independent of client variables, while two treatment variables, extent of life enhancement counseling and medication, were significantly predictive of treatment outcome.

PSYCHOLOGICAL TREATMENT OF DEPRESSION IN COLLEGE STUDENTS: A METAANALYSIS

BACKGROUND

Expanded efforts to detect and treat depression among college students, a peak period of onset, have the potential to bear high human capital value from a societal perspective because depression increases college withdrawal rates. However, it is not clear whether evidence-based depression therapies are as effective in college students as in other adult populations. The higher levels of cognitive functioning and IQ and higher proportions of first-onset cases might lead to treatment effects being different among college students relative to the larger adult population.

METHODS

We conducted a metaanalysis of randomized trials comparing psychological treatments of depressed college students relative to control groups and compared effect sizes in these studies to those in trials carried out in unselected populations of depressed adults.

RESULTS

The 15 trials on college students satisfying study inclusion criteria included 997 participants. The pooled effect size of therapy versus control was g = 0.89 (95% CI: 0.66∼1.11; NNT = 2.13) with moderate heterogeneity (I(2) = 57; 95% CI: 23∼72). None of these trials had low risk of bias. Effect sizes were significantly larger when students were not remunerated (e.g. money, credit), received individual versus group therapy, and were in trials that included a waiting list control group. No significant difference emerged in comparing effect sizes among college students versus adults either in simple mean comparisons or in multivariate metaregression analyses.

CONCLUSIONS

This metaanalysis of trials examining psychological treatments of depression in college students suggests that these therapies are effective and have effect sizes comparable to trials carried out among depressed adults.

Cognitive-Behaviour Therapy for Depression: Empirical Findings and Methodological Issues in the Evaluation of Outcome

The aim of this paper is to examine the treatment-outcome literature related to cognitive-behaviour therapy for depression in adults. Evidence for the effectiveness of cognitive-behaviour therapy is obtained from comparisons with waiting-list controls, non-specific controls, and other treatments, including pharmacotherapy. Short term effects are superior to those obtained with waitinglist controls, but are at least equivalent to pharmacotherapy. Longer term effects are difficult to evaluate due to methodological problems in such studies, particularly the lack of maintenance medication comparison groups. Nevertheless, the long term effects appear to be promising. Issues and data concerning the prediction and prevention of relapse are discussed. It is recommended that future research should focus on broader assessment goals and include cost-benefit analyses.

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.

Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis

BACKGROUND

Depression is a common, disabling condition for which psychological treatments are recommended. Behavioural activation has attracted increased interest in recent years. It has been over 5 years since our meta-analyses summarised the evidence supporting and this systematic review updates those findings and examines moderators of treatment effect.

METHOD

Randomised trials of behavioural activation for depression versus controls or anti-depressant medication were identified using electronic database searches, previous reviews and reference lists. Data on symptom level and study level moderators were extracted and analysed using meta-analysis, sub-group analysis and meta-regression respectively.

RESULTS

Twenty six randomised controlled trials including 1524 subjects were included in this meta-analysis. A random effects meta-analysis of symptom level post treatment showed behavioural activation to be superior to controls (SMD -0.74 CI -0.91 to -0.56, k = 25, N = 1088) and medication (SMD -0.42 CI -0.83 to-0.00, k = 4, N = 283). Study quality was low in the majority of studies and follow- up time periods short. There was no indication of publication bias and subgroup analysis showed limited association between moderators and effect size.

CONCLUSIONS

The results in this meta-analysis support and strengthen the evidence base indicating Behavioural Activation is an effective treatment for depression. Further high quality research with longer term follow-up is needed to strengthen the evidence base.

Behavioural therapies versus other psychological therapies for depression

BACKGROUND

Behavioural therapies represent one of several categories of psychological therapies that are currently used in the treatment of depression. However, the effectiveness and acceptability of behavioural therapies for depression compared with other psychological therapies remain unclear.

OBJECTIVES

1. To examine the effects of all BT approaches compared with all other psychological therapy approaches for acute depression.2. To examine the effects of different BT approaches (behavioural therapy, behavioural activation, social skills training and relaxation training) compared with all other psychological therapy approaches for acute depression.3. To examine the effects of all BT approaches compared with different psychological therapy approaches (CBT, third wave CBT, psychodynamic, humanistic and integrative psychological therapies) for acute depression.

SEARCH METHODS

We searched the Cochrane Depression Anxiety and Neurosis Group Trials Specialised Register (CCDANCTR, 31/07/2013), which includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE, (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also searched CINAHL (May 2010) and PSYNDEX (June 2010) and reference lists of the included studies and relevant reviews for additional published and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials that compared behavioural therapies with other psychological therapies for acute depression in adults.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently identified studies, assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Twenty-five trials involving 955 participants compared behavioural therapies with one or more of five other major categories of psychological therapies (cognitive-behavioural, third wave cognitive-behavioural, psychodynamic, humanistic and integrative therapies). Most studies had a small sample size and were assessed as being at unclear or high risk of bias. Compared with all other psychological therapies together, behavioural therapies showed no significant difference in response rate (18 studies, 690 participants, risk ratio (RR) 0.97, 95% confidence interval (CI) 0.86 to 1.09) or in acceptability (15 studies, 495 participants, RR of total dropout rate 1.02, 95% CI 0.65 to 1.61). Similarly, in comparison with each of the other classes of psychological therapies, low-quality evidence showed better response to cognitive-behavioural therapies than to behavioural therapies (15 studies, 544 participants, RR 0.93, 95% CI 0.83 to 1.05) and low-quality evidence of better response to behavioural therapies over psychodynamic therapies (2 studies, 110 participants, RR 1.24, 95% CI 0.84 to 1.82).When compared with integrative therapies and humanistic therapies, only one study was included in each comparison, and the analysis showed no significant difference between behavioural therapies and integrative or humanistic therapies.

AUTHORS' CONCLUSIONS

We found low- to moderate-quality evidence that behavioural therapies and other psychological therapies are equally effective. The current evidence base that evaluates the relative benefits and harms of behavioural therapies is very weak. This limits our confidence in both the size of the effect and its precision for our key outcomes related to response and withdrawal. Studies recruiting larger samples with improved reporting of design and fidelity to treatment would improve the quality of evidence in this review.

Estimating remission from untreated major depression: a systematic review and meta-analysis

BACKGROUND

Few studies have examined spontaneous remission from major depression. This study investigated the proportion of prevalent cases of untreated major depression that will remit without treatment in a year, and whether remission rates vary by disorder severity.

METHOD

Wait-list controlled trials and observational cohort studies published up to 2010 with data describing remission from untreated depression at ≤ 2-year follow-up were identified. Remission was defined as rescinded diagnoses or below threshold scores on standardized symptom measures. Nineteen studies were included in a regression model predicting the probability of 12-month remission from untreated depression, using logit transformed remission proportion as the dependent variable. Covariates included age, gender, study type and diagnostic measure.

RESULTS

Wait-listed compared to primary-care samples, studies with longer follow-up duration and older adult compared to adult samples were associated with lower probability of remission. Child and adolescent samples were associated with higher probability of remission. Based on adult samples recruited from primary-care settings, the model estimated that 23% of prevalent cases of untreated depression will remit within 3 months, 32% within 6 months and 53% within 12 months.

CONCLUSIONS

It is undesirable to expect 100% treatment coverage for depression, given many will remit before access to services is feasible. Data were drawn from consenting wait-list and primary-care samples, which potentially over-represented mild-to-moderate cases of depression. Considering reported rates of spontaneous remission, a short untreated period seems defensible for this subpopulation, where judged appropriate by the clinician. Conclusions may not apply to individuals with more severe depression.

Behavioural activation for depression: efficacy, effectiveness and dissemination

BACKGROUND

Depression being a prevalent psychobiological disorder across the world, there is a need to identify effective, evidence-based treatments that are time and cost-effective in an effort to increase the population's accessibility to treatments. Low-intensity interventions, such as guided self-help treatments, hold promise for the dissemination of evidence-based treatments. Behavioural activation, a component of cognitive-behavioural therapy, is receiving increasing attention and empirical support as a stand-alone psychological treatment for depression. This article reviews behavioural activation's theoretical foundations and efficacy in light of determining its potential as a low-intensity intervention.

METHOD

A systematic review of articles on low-intensity behavioural activation interventions for depression was conducted using the PsychInfo, Medline and Embase databases. Behavioural activation's potential for dissemination as a guided self-help treatment is discussed and future avenues of research are stressed.

LIMITATIONS

Studies on the efficacy of behavioural activation as a guided self-help treatment are very limited to date and there are significant variations among existing studies.

CONCLUSIONS

Based on the research literature, it can be concluded that behavioural activation could be a viable option as a low-intensity guided self-help psychological treatment for mild to moderate depression. Further research is required to better understand the optimal parameters and client-therapist characteristics of this form of low-intensity intervention.

The efficacy of non-directive supportive therapy for adult depression: a meta-analysis

The effects of non-directive supportive therapy (NDST) for adult depression have been examined in a considerable number of studies, but no meta-analysis of these studies has been conducted. We selected 31 studies on NDST from a comprehensive database of trials, examining psychotherapies for adult depression, and conducted meta-analyses in which NDST was compared with control groups, other psychotherapies and pharmacotherapy. We found that NDST is effective in the treatment of depression in adults (g=0.58; 95% CI: 0.45-0.72). NDST was less effective than other psychological treatments (differential effect size g=-0.20; 95% CI: -0.32 to -0.08, p<0.01), but these differences were no longer present after controlling for researcher allegiance. We estimated that extra-therapeutic factors (those processes operating in waiting-list and care-as-usual controls) were responsible for 33.3% of the overall improvement, non-specific factors (the effects of NDST compared with control groups) for 49.6%, and specific factors (the effects of NDST compared with other therapies) for 17.1%. NDST has a considerable effect on symptoms of depression. Most of the effect of therapy for adult depression is realized by non-specific factors, and our results suggest that the contribution of specific effects is limited at best.

Efficacy trial of a brief cognitive-behavioral depression prevention program for high-risk adolescents: effects at 1- and 2-year follow-up

OBJECTIVE

To evaluate the effects of a brief group cognitive-behavioral (CB) depression prevention program for high-risk adolescents with elevated depressive symptoms at 1- and 2-year follow-up.

METHOD

In this indicated prevention trial, 341 at-risk youths were randomized to a group CB intervention, group supportive expressive intervention, CB bibliotherapy, or educational brochure control condition.

RESULTS

Significantly greater reductions in depressive symptoms were shown by group CB participants relative to brochure control participants by 1-year follow-up and bibliotherapy participants by 1- and 2-year follow-up but not relative to supportive expressive participants. Supportive expressive participants showed greater symptom reduction than CB bibliotherapy participants did at 2-year follow-up. Risk for onset of major or minor depression over the 2-year follow-up was significantly lower for group CB participants (14%; odds ratio = 2.2) and CB bibliotherapy participants (3%; odds ratio = 8.1) than for brochure controls (23%).

CONCLUSIONS

Results indicate that this group CB intervention reduces initial symptoms and risk for future depressive episodes, although both supportive expressive therapy and CB bibliotherapy also produce intervention effects that persist long term. Indeed, CB bibliotherapy emerged as the least expensive method of reducing risk for future episodes of depression.

Cognitive Therapy of Depression: The Mechanisms of Change

Evidence is now accumulating for cognitive therapy as a promising treatment for depression. However, there is as yet little indication as to how it achieves its effects. The paper addresses this issue as it relates to the immediate impact of therapy, the achievement of change over the course of treatment as a whole, and the maintenance of improvement and prevention of relapse.

Socioeconomic status in the treatment of depression

This study examined outcomes and attrition across three treatments for depression in relation to socioeconomic status (SES). The study was based on data available from the Treatment of Depression Collaborative Research Program (TDCRP) of the National Institute of Mental Health (NIMH; Elkin, 1994), a multisite collaborative study that examined the effectiveness of two forms of psychotherapy, cognitive behavior therapy and interpersonal psychotherapy, and pharmacotherapy. Results indicated that lower SES, measured by the Hollingshead Index of Social Position, was associated with less improvement across all three treatments for depression. The effect of SES on outcome did not differ by treatment modality. Contrary to expectations, SES was not associated with attrition. These findings suggest that there may be limitations in the use of these empirically validated treatments with lower SES depressed patients, as their improvement rates may be less than those of middle SES depressed patients treated by the same modalities. The results of this study also suggest that a standardized measure of SES may be more sensitive to SES differences in outcome than the more easily obtained measures of education or income. Suggestions are provided for additional research in this area to address the potential mediators and moderators of the association between SES and outcome.

Characteristics of effective psychological treatments of depression: a metaregression analysis

Although many meta-analyses have shown that psychological therapies are effective in the treatment of depression, no comprehensive metaregression analysis has been conducted to examine which characteristics of the intervention, target population, and study design are related to the effects. The authors conducted such a metaregression analysis with 83 studies (135 comparisons) in which a psychological treatment was compared with a control condition. The mean effect size of all comparisons was 0.69 (95% confidence interval = 0.60-0.79). In multivariate analyses, several variables were significant: Studies using problem-solving interventions and those aimed at women with postpartum depression or specific populations had higher effect sizes, whereas studies with students as therapists, those in which participants were recruited from clinical populations and through systematic screening, and those using care-as-usual or placebo control groups had lower effect sizes.

Can the effects of a 1-day CBT psychoeducational workshop on self-confidence be maintained after 2 years? A naturalistic study

The continued high prevalence of depression in the general population has been in part attributed to a reluctance to consult and also to the limited capacity of psychological therapy services. In a previous randomized controlled trial, self-referral day-long workshops, each for 25 people, offering a cognitive-behavioral therapy approach, seemed to be effective at 3-month follow-up [Brown et al., 2004]. In this study, both experimental group participants and waiting list control participants who went on to attend the workshops (n=102) were followed up and 54.9% provided data after 2 years. The dropout mechanism was investigated and random effects models were used for all analyses. This is a naturalistic study that lacked a control group and had a relatively high attrition rate. The results nevertheless suggest that positive changes in depression, anxiety, distress, and self-esteem achieved at 3 months follow-up were largely maintained at 2 years for those who were "depressed" (Beck Depression Inventory [BDI] scores of 14 and above). However, nondepressed (BDI scores below 14) did not show any significant change. The overall results of this naturalistic study indicate that a very brief, intensive, and large-scale intervention can largely maintain its effects for participants with depression over a 2-year period.

Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: a randomized efficacy trial

In this depression prevention trial, 341 high-risk adolescents (mean age = 15.6 years, SD = 1.2) with elevated depressive symptoms were randomized to a brief group cognitive-behavioral (CB) intervention, group supportive-expressive intervention, bibliotherapy, or assessment-only control condition. CB participants showed significantly greater reductions in depressive symptoms than did supportive-expressive, bibliotherapy, and assessment-only participants at posttest, though only the difference compared with assessment controls was significant at 6-month follow-up. CB participants showed significantly greater improvements in social adjustment and reductions in substance use at posttest and 6-month follow-up than did participants in all 3 other conditions. Supportive-expressive and bibliotherapy participants showed greater reductions in depressive symptoms than did assessment-only controls at certain follow-up assessments but produced no effects for social adjustment and substance use. CB, supportive-expressive, and bibliotherapy participants showed a significantly lower risk for major depression onset over the 6-month follow-up than did assessment-only controls. The evidence that this brief CB intervention reduced risk for future depression onset and outperformed alternative interventions for certain ecologically important outcomes suggests that this intervention may have clinical utility.

The effectiveness of group cognitive behaviour therapy for unipolar depressive disorders

This paper evaluates the effectiveness of group cognitive behaviour therapy (GCBT) as an intervention for unipolar depressive disorders. PsychINFO and PubMed databases were selected to generate the 34 papers used for this review. Our results showed that effect sizes for GCBT over the control conditions range from small (0.1) to large (2.87) with the mean effect size of 1.10. The pre-post treatment effect sizes for GCBT range from 0.30 to 3.72 with a mean of 1.30. Convergent evidence was demonstrated across different outcome measures of GCBT. Our findings indicated that GCBT yielded outcomes better than no-treatment controls and was comparable with other treatments (including both bona fide and non-bona fide comparison treatments). It was concluded that GCBT was effective for the treatment of Unipolar depression and thus can be used with confidence. There is now an urgent need to develop and evaluate a coherent GCBT theory, in particular the roles of group processes in GCBT, before further major advancement in this area can be made.

Psychotherapeutic treatments for older depressed people

BACKGROUND

Despite a number of reviews advocating psychotherapy for the treatment of depression, there is relatively little evidence based on randomised controlled trials that specifically examines its efficacy in older people.

OBJECTIVES

To examine the efficacy of psychotherapeutic treatments for depression in older people.

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 11/9/2006. The International Journal of Geriatric Psychiatry and Irish Journal of Psychiatry were handsearched. Reference lists of previous published systematic reviews, included/excluded trial articles and bibliographies were scrutinised. Experts in the field were contacted..

SELECTION CRITERIA

All randomised controlled trials that included older adults diagnosed as suffering from depression (ICD or DSM criteria) were included. All types of psychotherapeutic treatments were included, categorised into cognitive behavioural therapies (CBT), psychodynamic therapy, interpersonal therapy and supportive therapies.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed, using odds ratios for dichotomous outcomes and weighted mean differences (WMD) for continuous outcomes, with 95% confidence intervals. Primary outcomes were a reduction in severity of depression, usually measured by clinician rated rating scales. Secondary outcomes, including dropout and life satisfaction, were also analysed.

MAIN RESULTS

The search identified nine trials of cognitive behavioural and psychodynamic therapy approaches, together with a small group of 'active control' interventions. No trials relating to other psychotherapeutic approaches and techniques were found. A total of seven trials provided sufficient data for inclusion in the comparison between CBT and controls. No trials compared psychodynamic psychotherapy with controls. Based on five trials (153 participants), cognitive behavioural therapy was more effective than waiting list controls (WMD -9.85, 95% CI -11.97 to -7.73). Only three small trials compared psychodynamic therapy with CBT, with no significant difference in treatment effect indicated between the two types of psychotherapeutic treatment. Based on three trials with usable data, CBT was superior to active control interventions when using the Hamilton Depression Rating Scale (WMD -5.69, 95% CI -11.04 to -0.35), but equivalent when using the Geriatric Depression Scale (WMD -2.00, 95% CI -5.31 to 1.32).

AUTHORS' CONCLUSIONS

Only a small number of studies and patients were included in the meta-analysis. If taken on their own merit, the findings do not provide strong support for psychotherapeutic treatments in the management of depression in older people. However, the findings do reflect those of a larger meta-analysis that included patients with broader age ranges, suggesting that CBT may be of potential benefit.

Randomized trial of a brief depression prevention program: an elusive search for a psychosocial placebo control condition

This trial compared a brief group cognitive-behavioral (CBT) depression prevention program to a waitlist control condition and four placebo or alternative interventions. High-risk adolescents with elevated depressive symptoms (N=225, M age=18, 70% female) were randomized to CBT, supportive-expressive group intervention, bibliotherapy, expressive writing, journaling, or waitlist conditions and completed assessments at baseline, termination, and 1- and 6-month follow-up. All five active interventions showed significantly greater reductions in depressive symptoms at termination than waitlist controls; effects for CBT and bibliotherapy persisted into follow-up. CBT, supportive-expressive, and bibliotherapy participants also showed significantly greater decreases in depressive symptoms than expressive writing and journaling participants at certain follow-up points. Findings suggest there may be multiple ways to reduce depressive symptoms in high-risk adolescents, although expectancies, demand characteristics, and attention may have contributed to the observed effects.

Behavioral activation treatments of depression: a meta-analysis

Activity scheduling is a behavioral treatment of depression in which patients learn to monitor their mood and daily activities, and how to increase the number of pleasant activities and to increase positive interactions with their environment. We conducted a meta-analysis of randomized effect studies of activity scheduling. Sixteen studies with 780 subjects were included. The pooled effect size indicating the difference between intervention and control conditions at post-test was 0.87 (95% CI: 0.60 - 1.15). This is a large effect. Heterogeneity was low in all analyses. The comparisons with other psychological treatments at post-test resulted in a non-significant pooled effect size of 0.13 in favor of activity scheduling. In ten studies activity scheduling was compared to cognitive therapy, and the pooled effect size indicating the difference between these two types of treatment was 0.02. The changes from post-test to follow-up for activity scheduling were non-significant, indicating that the benefits of the treatments were retained at follow-up. The differences between activity scheduling and cognitive therapy at follow-up were also non-significant. Activity scheduling is an attractive treatment for depression, not only because it is relatively uncomplicated, time-efficient and does not require complex skills from patients or therapist, but also because this meta-analysis found clear indications that it is effective.

Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome

OBJECTIVE

To determine which factors impact on the efficacy of cognitive behavioural therapy (CBT) for depression and anxiety. Factors considered include those related to clinical practice: disorder, treatment type, duration and intensity of treatment, mode of therapy, type and training of therapist and severity of patients. Factors related to the conduct of the trial were also considered, including: year of study, country of study, type of control group, language, number of patients and percentage of dropouts from the trial.

METHOD

We used the technique of meta-analysis to determine an overall effect size (standardized mean difference calculated using Hedges' g) and meta-regression to determine the factors that impact on this effect size. We included randomized controlled trials with a wait list, pill placebo or attention/psychological placebo control group. Study participants had to be 18 years or older and all have diagnosed depression, panic disorder (with or without agoraphobia) or generalized anxiety disorder (GAD). Outcomes of interest included symptom, functioning and health-related quality of life measures, reported as continuous variables at post-treatment.

RESULTS

Cognitive behavioural therapy for depression, panic disorder and GAD had an effect size of 0.68 (95% CI=0.51-0.84, n=33 studies, 52 comparisons). The heterogeneity in the effect sizes was fully explained by treatment, duration of therapy, inclusion of severe patients in the trial, year of study, country of study, control group, language and number of dropouts from the control group. Disorder was not a significant predictor of the effect size.

CONCLUSIONS

Cognitive behavioural therapy is significantly less effective for severe patients and trials that compared CBT to a wait-list control group found significantly larger effect sizes than those comparing CBT to an attention placebo, but not to a pill placebo. Further research is needed to determine whether CBT is effective when provided by others than psychologists and whether it is effective for non-English-speaking patient groups.

Can the Randomized Controlled Trial Literature Generalize to Nonrandomized Patients?

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.