Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis
Authors:
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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.
Please see later in the article for the Editors' Summary
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.1001454.
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
Academic Editor: Alexander C. Tsai, Massachusetts General Hospital, United States of America
Received: March 11, 2012; Accepted: April 9, 2013; Published: May 28, 2013
Copyright:
© 2013 Barth et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided
the original author and source are credited.
Funding: This
research was supported by a Swiss National Science Foundation Grant
(no. 105314-118312/1) awarded to JB, HJZ, and PJ. The funders had no
role in study design, data collection and analysis, decision to publish,
or preparation of the manuscript.
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, waitlist; T2, tau square
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