Friday, May 31, 2013

Different Types of Psychotherapy Have Similar Benefits for Depression


Most studies one reads on depression are examining the benefits or effects of antidepressant medications on depression, and sometimes they even analyze the added benefits of medication with psychotherapy (usually CBT).

In this new study from PLos MED, researchers looked at how seven different types of "talk therapy" (interpersonal psychotherapy, behavioural activation, cognitive behavioural therapy, problem solving therapy, psychodynamic therapy, social skills training and supportive counselling) and how they impact subjective experience of depression. According to the study, they all performed equally well:  "Overall, we found that different psychotherapeutic interventions for depression have comparable, moderate-to-large effects."

That's good news for those who would rather not deal with the troubling and sometimes disabling side effects of antidepressant medications.

On a related side note there are several studies suggesting that psychodynamic/psychoanalytic therapy continues to decrease symptoms and increase well-being even after leaving therapy (Jonathan Shedler, [2009], The Efficacy of Psychodynamic Psychotherapy). This would seem to give an advantage to that form of therapy over the other six used in the study.

Full Citation:
Barth J, Munder T, Gerger H, Nüesch E, Trelle S, et al. (2013). Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454

Different Types of Psychotherapy Have Similar Benefits for Depression


May 28, 2013 — Treatments for depression that don't involve antidepressant drugs but rather focus on different forms of talking therapy (referred to as psychotherapeutic interventions) are all beneficial, with no one form of therapy being better than the others, according to a study by international researchers published in this week's PLOS Medicine.

These findings are important as they suggest that patients with depression should discuss different forms of non-drug therapy with their doctors and explore which type of psychotherapy best suits them.

The researchers, led by Jürgen Barth from the University of Bern in Switzerland, reached these conclusions by reviewing 198 published studies involving over 15,000 patients receiving one of seven types of psychotherapeutic intervention: Interpersonal psychotherapy, behavioural activation, cognitive behavioural therapy, problem solving therapy, psychodynamic therapy, social skills training and supportive counselling (definitions of each type of therapy are below). The authors compared each of the therapies with each other and with a control -- patients on a waiting list or continuing usual case -- and combined the results.

The authors found that all seven therapies were better at reducing symptoms of depression than waiting list and usual care and that there were no significant differences between the different types of therapy. They also found that the therapies worked equally well for different patient groups with depression, such as for younger and older patients and for mothers who had depression after having given birth. Furthermore, the authors found no substantial differences when comparing individual with group therapy or with face-to-face therapy compared with internet-based interactions between therapist and patient.

The authors say: "We found evidence that most of the seven psychotherapeutic interventions under investigation have comparable effects on depressive symptoms and achieve moderate to large effects vis-à-vis waitlist."

They continue: "All seven psychotherapeutic interventions achieved a small to moderate effect compared to usual care."

The authors add: "Overall, we found that different psychotherapeutic interventions for depression have comparable, moderate-to-large effects."

Notes:

"Interpersonal psychotherapy" is short and highly structured, using a manual to focus on interpersonal issues in depression.

"Behavioral activation" raises the awareness of pleasant activities and seeks to increase positive interactions between the patient and his or her environment.

"Cognitive behavioural therapy" focuses on a patient's current negative beliefs, evaluates how they affect current and future behaviour, and attempts to restructure the beliefs and change the outlook. "Problem solving therapy" aims to define a patient's problems, propose multiple solutions for each problem, and then select, implement, and evaluate the best solution.

"Psychodynamic therapy" focuses on past unresolved conflicts and relationships and the impact they have on a patient's current situation.

In "social skills therapy," patients are taught skills that help to build and maintain healthy relationships based on honesty and respect.

"Supportive counselling" is a more general therapy that aims to get patients to talk about their experiences and emotions and to offer empathy without suggesting solutions or teaching new skills.

Funding: This research was supported by a Swiss National Science Foundation Grant (no. 105314-118312/1) awarded to JB, HJZ, and PJ.
Here is the beginning of the source research article:

Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis


Jürgen Barth, Thomas Munder, Heike Gerger, Eveline Nüesch, Sven Trelle, Hansjörg Znoj, Peter Jüni, Pim Cuijpers


Abstract



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.


Editors' Summary

Background

Depression is a very common condition. One in six people will experience depression at some time during their life. People who are depressed have recurrent feelings of sadness and hopelessness and might feel that life is no longer worth living. The condition can last for months and often includes physical symptoms such as headaches, sleeping problems, and weight gain or loss. Treatment of depression can include non-drug treatments (psychotherapy), antidepressant drugs, or a combination of the two. Especially for people with mild or intermediate depression, psychotherapy is often considered the preferred first option. Psychotherapy describes a range of different psychotherapies, and a number of established types of psychotherapies have all shown to work for at least some patients.

Why Was This Study Done?

While it is broadly accepted that psychotherapy can help people with depression, the question of which type of psychotherapy works best for most patients remains controversial. While many scientific studies have compared one psychotherapy with control conditions, there have been few studies that directly compared multiple treatments. Without such direct comparisons, it has been difficult to establish the respective merits of the different types of psychotherapy. Taking advantage of a recently developed method called “network meta-analysis,” the authors re-examine the evidence on seven different types of psychotherapy to see how well they have been shown to work and whether some work better than others.

What Did the Researchers Do and Find?

The researchers looked at seven different types of psychotherapy, which they defined as follows. “Interpersonal psychotherapy” is short and highly structured, using a manual to focus on interpersonal issues in depression. “Behavioral activation” raises the awareness of pleasant activities and seeks to increase positive interactions between the patient and his or her environment. “Cognitive behavioral therapy” focuses on a patient's current negative beliefs, evaluates how they affect current and future behavior, and attempts to restructure the beliefs and change the outlook. “Problem solving therapy” aims to define a patient's problems, propose multiple solutions for each problem, and then select, implement, and evaluate the best solution. “Psychodynamic therapy” focuses on past unresolved conflicts and relationships and the impact they have on a patient's current situation. In “social skills therapy,” patients are taught skills that help to build and maintain healthy relationships based on honesty and respect. “Supportive counseling” is a more general therapy that aims to get patients to talk about their experiences and emotions and to offer empathy without suggesting solutions or teaching new skills.

The researchers started with a systematic search of the medical literature for relevant studies. The search identified 198 articles that reported on such clinical trials. The trials included a total of 15,118 patients and compared one of the seven psychotherapies either with another one or with a common “control intervention”. In most cases, the control (no psychotherapy) was deferral of treatment by “wait-listing” patients or continuing “usual care.” With network meta-analysis they were able to summarize the results of all these trials in a meaningful way. They did this by integrating direct comparisons of several psychotherapies within the same trial (where those were available) with indirect comparisons across all trials (using no psychotherapy as a control intervention).

Based on the combined trial results, all seven psychotherapies tested were better than wait-listing or usual care, and the differences were moderate to large, meaning that the average person in the group that received therapy was better off than about half of the patients in the control group. When comparing the therapies with each other, the researchers saw small or no differences, meaning that none of them really stood out as much better or much worse than the others. They also found that the treatments worked equally well for different patient groups with depression (younger or older patients, or mothers who had depression after having given birth). Similarly, they saw no big differences when comparing individual with group therapy, or person-to-person with internet-based interactions between therapist and patient.

However, they did find that smaller and less rigorous studies generally found larger benefits of psychotherapies, and most of the studies included in the analysis were small. Only 36 of the studies had at least 50 patients who received the same treatment. When they restricted their analysis to those studies, the researchers still saw clear benefits of cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy, but not for the other four therapies.

What Do these Findings Mean?

Similar to earlier attempts to summarize and make sense of the many study results, this one finds benefits for all of the seven psychotherapies examined, and none of them stood as being much better than some or all others. The scientific support for being beneficial was stronger for some therapies, mostly because they had been tested more often and in larger studies.

Treatments with proven benefits still do not necessarily work for all patients, and which type of psychotherapy might work best for a particular patient likely depends on that individual. So overall this analysis suggests that patients with depression and their doctors should consider psychotherapies and explore which of the different types might be best suited for a particular patient.

The study also points to the need for further research. Whereas depression affects large numbers of people around the world, all of the trials identified were conducted in rich countries and Western societies. Trials in different settings are essential to inform treatment of patients worldwide. In addition, large high-quality studies should further explore the potential benefits of some of therapies for which less support currently exists. Where possible, future studies should compare psychotherapies with one another, because all of them have benefits, and it would not be ethical to withhold such beneficial treatment from patients. 
Additional Information

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1​001454.

Citation: Barth J, Munder T, Gerger H, Nüesch E, Trelle S, et al. (2013) Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454

Competing interests: PJ is an unpaid member of steering group or executive committee of trials funded by Abbott Vascular, Biosensors, Medtronic and St. Jude Medical. CTU Bern, which is part of the University of Bern, has a staff policy of not accepting individual honoraria or consultancy fees. However, CTU Bern is involved in design, conduct, or analysis of clinical studies funded by Abbott Vascular, Ablynx, Amgen, AstraZeneca, Biosensors, Biotronic, Boehrhinger Ingelheim, Eisai, Eli Lilly, Exelixis, Geron, Gilead Sciences, Nestlé, Novartis, Novo Nordisc, Padma, Roche, Schering-Plough, St. Jude Medical, and Swiss Cardio Technologies. The other authors declare that no competing interests exist.

Abbreviations: ACT, behavioural activation; CBASP, cognitive behavioural-analysis system of psychotherapy; CBT, cognitive-behavioural therapy; CI, confidence interval; CrI, credibility interval; d, effect size; D, Somer's D; DYN, psychodynamic therapy; ES, d effect size; IPT, interpersonal therapy; k, number of comparisons; M, mean; p, p-value; PLA, placebo; PST, problem solving therapy; SD, standard deviation; SST, social skills training; SUP, supportive counselling; UC, usual care; WL, wait-list; T2, tau square
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