Psychological interventions for major depression in primary care: A meta-analytic review of randomized controlled trials

Institute of Psychiatry, Bologna University, Viale C. Pepoli, 5IT-40123 Bologna, Italy.
General Hospital Psychiatry (Impact Factor: 2.61). 07/2008; 30(4):293-302. DOI: 10.1016/j.genhosppsych.2008.04.001
Source: PubMed


Various studies have tested psychological therapies in the treatment of depression in primary care. Yet, concerns over their clinical effectiveness, as compared to usual general practitioner (GP) care or treatment with antidepressants, have been raised. The present meta-analysis was aimed at assessing currently available evidence on the topic.
A systematic search of electronic databases identified 10 randomized controlled trials comparing psychological forms of intervention with either usual GP care or antidepressant medication for major depression. Meta-analytical procedures were used to examine the impact of psychological intervention in primary care on depression, as compared to usual GP care and antidepressant treatment.
The main analyses showed greater effectiveness of psychological intervention over usual GP care in both the short term [standardized mean difference (SMD)=-0.42, 95% confidence interval (CI)=-0.59 to -0.26, n=408] and long term (SMD=-0.30, 95% CI=-0.45 to -0.14, n=433). The heterogeneity test was not significant in the short term at the P<.05 level (df=5, P=.57, I(2)=0%), but it was significant in the long term (df=5, P=.004, I(2)=70.9%). The comparison between psychological forms of intervention and antidepressant medication yielded no effectiveness differences, for either the short term or the long term.
Psychological forms of intervention are significantly linked to clinical improvement in depressive symptomatology and may be useful for supplementing usual GP care.

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    • "Please cite this article as: Sighinolfi C, et al, Collaborative care for depression in European countries: A systematic review and meta-analysis, J Psychosom Res (2014), showed higher effect size values in previous reviews and metaanalyses [47]. Nevertheless, collaborative care is a " system level " intervention [14], where primary care is the main setting of treatment. "
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    ABSTRACT: Objectives: This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries. Methods: A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure. Results: The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care. Conclusions: The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.
    Journal of Psychosomatic Research 08/2014; 77(4). DOI:10.1016/j.jpsychores.2014.08.006 · 2.74 Impact Factor
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    • "CBT is based on three fundamental propositions: cognitive activity affects behavior, cognitive activity can be monitored and altered, and desired behavior change may be affected through cognitive change [7]. Twelve systematic reviews evaluating CBT in individuals suffering from depression have demonstrated that CBT reduces depressive symptoms [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], with the most current and rigorous meta-analysis reporting a pooled standardized mean difference (SMD) of 0.69 (95% confidence interval [CI] of 0.59 to 0.79) [13]. "
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    ABSTRACT: To systematically summarize the randomized trial evidence regarding the relative effectiveness of cognitive behavioural therapy (CBT) in patients with depression in receipt of disability benefits in comparison to those not receiving disability benefits. All relevant RCTs from a database of randomized controlled and comparative studies examining the effects of psychotherapy for adult depression (, electronic databases (MEDLINE, EMBASE, PSYCINFO, AMED, CINAHL and CENTRAL) to June 2011, and bibliographies of all relevant articles. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTION: Adult patients with major depression, randomly assigned to CBT versus minimal/no treatment or care-as-usual. Three teams of reviewers, independently and in duplicate, completed title and abstract screening, full text review and data extraction. We performed an individual patient data meta-analysis to summarize data. Of 92 eligible trials, 70 provided author contact information; of these 56 (80%) were successfully contacted to establish if they captured receipt of benefits as a baseline characteristic; 8 recorded benefit status, and 3 enrolled some patients in receipt of benefits, of which 2 provided individual patient data. Including both patients receiving and not receiving disability benefits, 2 trials (227 patients) suggested a possible reduction in depression with CBT, as measured by the Beck Depression Inventory, mean difference [MD] (95% confidence interval [CI]) = -2.61 (-5.28, 0.07), p = 0.06; minimally important difference of 5. The effect appeared larger, though not significantly, in those in receipt of benefits (34 patients) versus not receiving benefits (193 patients); MD (95% CI) = -4.46 (-12.21, 3.30), p = 0.26. Our data does not support the hypothesis that CBT has smaller effects in depressed patients receiving disability benefits versus other patients. Given that the confidence interval is wide, a decreased effect is still possible, though if the difference exists, it is likely to be small.
    PLoS ONE 11/2012; 7(11):e50202. DOI:10.1371/journal.pone.0050202 · 3.23 Impact Factor
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    • "In a first step a basic collection of studies will be compiled from existing systematic reviews restricted to randomized trials in primary care of tricyclic antidepressants and SSRIs [8-10], psychological therapies [11,12], as well as from a Cochrane review on hypericum extracts [17,18]. In order to identify further potentially relevant treatment interventions we will screen meta-analyses of other treatments for trials performed in primary care. "
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    ABSTRACT: Several systematic reviews have summarized the evidence for specific treatments of primary care patients suffering from depression. However, it is not possible to answer the question how the available treatment options compare with each other as review methods differ. We aim to systematically review and compare the available evidence for the effectiveness of pharmacological, psychological, and combined treatments for patients with depressive disorders in primary care. To be included, studies have to be randomized trials comparing antidepressant medication (tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), hypericum extracts, other agents) and/or psychological therapies (e.g. interpersonal psychotherapy, cognitive therapy, behavioural therapy, short dynamically-oriented psychotherapy) with another active therapy, placebo or sham intervention, routine care or no treatment in primary care patients in the acute phase of a depressive episode. Main outcome measure is response after completion of acute phase treatment. Eligible studies will be identified from available systematic reviews, from searches in electronic databases (Medline, Embase and Central), trial registers, and citation tracking. Two reviewers will independently extract study data and assess the risk of bias using the Cochrane Collaboration's corresponding tool. Meta-analyses (random effects model, inverse variance weighting) will be performed for direct comparisons of single interventions and for groups of similar interventions (e.g. SSRIs vs. tricyclics) and defined time-windows (up to 3 months and above). If possible, a global analysis of the relative effectiveness of treatments will be estimated from all available direct and indirect evidence that is present in a network of treatments and comparisons. Practitioners do not only want to know whether there is evidence that a specific treatment is more effective than placebo, but also how the treatment options compare to each other. Therefore, we believe that a multiple treatment systematic review of primary-care based randomized controlled trials on the most important therapies against depression is timely.
    BMC Family Practice 11/2011; 12(1):127. DOI:10.1186/1471-2296-12-127 · 1.67 Impact Factor
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