Review ArticleSystematic Reviews

Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-Analysis

Klaus Linde, Kirsten Sigterman, Levente Kriston, Gerta Rücker, Susanne Jamil, Karin Meissner and Antonius Schneider
The Annals of Family Medicine January 2015, 13 (1) 56-68; DOI: https://doi.org/10.1370/afm.1719

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Standardized mean differences for posttreatment depression scores of psychological treatments compared with control (usual care or placebo).

    CBT = cognitive behavioral therapy; SD = standard deviation; SMD = standard mean difference; IV = inverse variance.

    aStudies included patients with major depression.

    bStudies included patients with mixed/unclear depression.

    cStudies included patients minor depression/dysthymia.

  • Figure 2
    Figure 2

    Funnel plot plotting study precision against size of the treatment effect.

    SE = standard error; SMD = standardized mean difference

Tables

  • Table 1

    Characteristics of Included Studies

    First Author Risk of BiasNo.aRecruitmentDepression Diagnosis% Female Mean Age, yGroup 1 (No. of Sessions; Clinician)Group 2 (No. of Sessions; Clinician)Further GroupsWeek Posttreatment Measurement Score and InstrumentResponse Remission
    Face-to-face CBT
    Laidlaw 200844ReferralMajor depression72CBTUsual care18HRSD (i)
     u (luuul)74(8; psychologist)BDIHRSD (i)
    Scott 199748ReferralMajor depression67Brief CTUsual care7HRSD (i)
     h (uuuhh)41(6; therapist)BDIHRSD (i)
    Serfaty 2009137Mainly screeningDepression79CBTUsual careTalking controlb16BDI (i)
     l (llhul)74(≤12; therapist)BDIBDI (i)
    Smit 2006116ReferralMajor depression64CBTUsual careRecurrence preventionb12BDI (i)
     l (llhll)43(10–12; therapist)BDIBDI (i)
    Teasdale 198444ScreeningMajor depression94CTUsual careca 16HRSD
     h (uuhhl)38(≤20; psychologist)BDI (i)BDI
    Face-to-face problem-solving therapy
    Barrett 2001161ReferralDysthymia, minor depression64Problem solvingPlaceboParoxetineb11nr
     u (luuuu)44(6; psychologist)HSCL-D (c, i)HRSD ≤6
    Mynor-Wallis 199560ReferralMajor depression77Problem solvingPlaceboAmitriptyline12HRSD (i)
     h (uuuhl)37(6; trained physician)BDIHRSD (i)
    Oxman 2008141ScreeningMinor depression58Problem solvingUsual care9MADRS (i)
     u (llhuu)55(6; counselor)MADRSMADRS (i)
    Williams 2000278Referral or screeningDysthymia or minor depression41Problem solvingPlaceboParoxetineb11HSCL-D (i)
     h (llhlh)71(6; psychologist/counselor)HSCL-D (c)HAD-D
    Face-to-face interpersonal psychotherapy
    Schulberg 1996185ScreeningMajor depression83Interpersonal PTUsual careNortriptylineb26HRSD (i)
     h (uuuhh)38(16; psychologist/psychiatrist)HRSD (i)HRSD (i)
    Van Schaik 2006143ScreeningMajor depression69Interpersonal PTUsual care26MADRS
     u (ulhul)68(10; psychologist/nurse)MADRSMADRS
    Other face-to-face psychosocial therapies
    Casanas 2012231ReferralMajor depression89PsychoeducationUsual care12BDI (i)
     l (llhul)53(12; nursec)BDIBDI (i)
    Corney 198487ReferralDepression100Social workUsual careUnclearImprovement
     h (huhuh)30(Unclear; social worker)nrnr
    Corney 2005181ScreeningDepression80CounselingUsual care26BDI (i)
     l (luhll)(≥6 mo)43(6–12; counselorc)BDIBDI (i)
    MacPherson 2013453ReferralDepression73CounselingUsual careAcupunctureb12PHQ-9 (i)
     l (llhul)44(12; counselors)PHQ-9PHQ-9 (i)
    Three-armed trials with face-to-face CBT and other face-to-face psychosocial therapies
    Scott 1992121ReferralMajor depression76CBTCounselingHRSD (i)
     u (uuuul)32(10; psychologist)(13; social worker)Usual care16HRSD
    Ward 2000197ReferralDepression77CBTCounselingAmitriptylinebHRSDBDI (i)
     l (ulhll)37(6–12; psychologist)(6–12; counselorc)Usual care16BDI (i)
    Remote therapist-led CBT
    Dwight-Johnson 2011101ScreeningDepression78Telephone CBTUsual care12HSCL-D
     l (llhul)40(8; trained therapist)HSCL-Dnr
    Kessler 2009297ReferralMajor depression68Online CBTUsual care16BDI (i)
     h (llhhl)35(≤10; psychologist)BDIBDI (i)
    Simon 2004393ReferralDepression76Telephone CBTUsual care26HSCL-D
     u (llhuu)44(8; psychotherapist)HSCL-DHSCL-D
    Remote therapist-led problem-solving therapy
    Lynch 199729ScreeningMinor depression86Telephone problem solvingUsual care,6nr
     h (uuhhu)48(6; trained student)no treatmentBDI (i)BDI (i)
    Lynch 200454ScreeningMild depression83Telephone problem solvingUsual care6nr
     h (uuhhh)38(6; nurse)BDIBDI (i)
    Guided self-help CBT
    Joling 2011170ScreeningSubthreshold depression54BibliotherapyUsual care12CES-D reduction ≥5
     u (luhul)81(3; nurse)CES-DCES-D ≤16
    Proudfoot 2004274Referral or screeningDepression74Computerized CBTUsual care9BDI (i)
     u (ulhuu)44(≤80 min; nursec)BDIBDI (i)
    Watkins 201282ScreeningDepression55Guided self-help concreteness trainingUsual care8HRSD (i)
     l (llull)46(≤4; psychologist)Relaxation controlbBDIHRSD (i)
    Williams 2013281ReferralDepression68Guided self-help CBTUsual care16BDI
     u (ulhul)42(3; psychologist)BDIBDI (i)
    No/minimal contact CBT
    de Graaf 2009303ScreeningDepression57Computerized CBTdUsual care
     l (llhll)458BDI reliable change
    Levesque 2011350ScreeningDepression67Computer behavioral intervention (TTM)Usual care, no interventionBDIBDI (i)
     h (luhhl)4739BDI ≤9+ significant change
    Levin 2011191ReferralDepression77Computer CBTUsual careBDI
     l (luhll)44BDI (i)
    Naylor 201038ScreeningDepression84BibliotherapyUsual care6SCID symptoms (i)
     h (luhhl)51CES-Dnr
    6BDI-FS (i)
    BDI-FSBDI-FS (i)

    • BDI = Beck Depression Inventory; BDI-FS = Beck Depression Inventory-Fast Screen; c = only change from baseline data available; ca = circa; CBT = cognitive behavioral therapy; CES-D = Center for Epidemiologic Studies-Depression Scale; CT = cognitive therapy; HAD-D = Hospital Anxiety and Depression Scale subscale depression; HRSD = Hamilton Rating Scale for Depression; HSCL-D = Hopkins Symptom Checklist Depression Scale; i = imputed data; MADRS = Montgomery Asberg Depression Rating Scale; nr = not measured or reported; PHQ-9 = Patient Health Questionnaire for Depression; PT = psychotherapy; RDC = Research Diagnostic Criteria; SCID = Structured Clinical Interview for DSM Disorders; TTM = transtheoretical model.

      Note: Risk of bias: l = low, u = unclear, h = high. First letter indicates the overall risk of blinding, not taking blinding into account; letters in parentheses sequentially indicate the risk of bias for the following 5 items: sequence generation, concealment, blinding, attrition, and selective reporting, respectively.

    • ↵a Number of patients randomized (only in groups included in analyses).

    • ↵b Comparator or control group not included in analyses.

    • ↵c Trial included 2 separate groups (computerized CBT alone and in combination with usual care), which were pooled.

    • ↵d Person providing the treatment was explicitly or probably a routine member of the primary care team.

  • Table 2

    Pooled Estimates for Response, Remission, and Study Discontinuation

    TherapyResponseNNTa (95%-CI)RemissionNNTb (95% CI)Study Discontinuation
    Face-to-face CBT10 (5–47)na
     OR (95% CI)1.58 (1.11 to 2.26)1.49 (0.90 to 2.46)0.98 (0.52 to 1.86)
     I2, %03525
     No. of trials776
    Face-to-face problem-solving therapynana
     OR (95% CI)1.56 (0.85 to 2.86)1.29 (0.83 to 2.02)0.60 (0.23 to 1.57)
     I2, %554480
     No. of trials344
    Face-to-face interpersonal psychotherapynana
     OR (95% CI)1.28 (0.80 to 2.05)1.37 (0.81 to 2.34)0.98 (0.40 to 2.38)
     I2, %012na
     No. of trials221
    Other face-to-face psychological therapies11 (6–31)10 (5–35)
     OR (95% CI)1.54 (1.17 to 2.03)1.68 (1.17 to 2.41)1.04 (0.65 to 1.67)
     I2, %0037
     No. of trials655
    Remote therapist-led CBT6 (4–13)na
     OR (95% CI)2.04 (1.44 to 2.90)1.51 (0.98 to 2.32)1.05 (0.29 to 3.75)
     I2, %233675
     No. of trials332
    Remote therapist-led problem-solving therapyNo dataNo datana
     OR (95% CI)1.22 (0.23 to 6.57)1.32 (0.33 to 5.26)
     I2, %2046
     No. of trials22
    Guided self-help CBT9 (5–24)9 (5–28)
     OR (95% CI)1.67 (1.22 to 2.28)1.73 (1.21 to 2.50)1.54 (1.00 to 2.37)
     I2, %0032
     No. of trials444
    No/minimal contact CBT11 (6–58)na
     OR (95% CI)1.52 (1.09 to 2.13)1.46 (0.96 to 2.23)1.32 (0.88 to 2.00)
     I2, %000
     No. of trials434
    Test for subgroup differences
     χ23.325.804.44
     P value.85.67.82
     I2, %000
    All treatments10 (8–14)15 (10–25)
     OR (95% CI)1.59 (1.40 to 1.80)1.42 (1.24 to 1.62)1.08 (0.85 to 1.38)
     I2, %0046
     No. of trials272827

    • CBT = cognitive behavioral therapy; I2 = measure of statistical heterogeneity; na = not applicable; NNT = number needed to treat; OR = odds ratio.

      Note: NNTs for study discontinuation cannot be calculated in a valid manner as the confidence intervals of all odds ratios include the value 1.

    • ↵a Proportion of control group patients with response = 27%.

    • ↵b Proportion of control group patients with remission = 23%.

  • Table 3

    Subgroup Analyses

    VariablePosttreatment Scores
    SMD (95% CI)I2, %No. of Comparisons
    Diagnostic subgroups
     Major depression−0.38 (−0.50 to −0.25)510
     Mixed/unclear−0.31 (−0.41 to −0.21)3314
     Minor depression and/or dysthymia−0.09 (−0.26 to 0.07)186
     Test for subgroup differences, P value = .03
    Delivery mode
     Face-to-face−0.23 (−0.33 to −0.14)1718
     Remote therapist-led−0.43 (−0.62 to −0.25)205
     Guided self-help and no/minimal contact−0.33 (−0.48 to −0.17)538
     Test for subgroup differences, P value = .14
    Treatment concept
     CBT (all delivery modes)−0.34 (−0.44 to −0.25)2918
     PST (all delivery modes)−0.19 (−0.45 to 0.07)516
     Interpersonal psychotherapy (face-to-face)−0.24 (−0.47 to −0.02)02
     Counseling intervention (face-to-face)−0.27 (−0.50 to −0.05)394
     Psychoeducation (face-to-face)−0.29 (−0.55 to −0.03)na1
     Test for subgroup differences, P value = .77
    Recruitment
     Referral−0.31 (−0.41 to −0.22)2014
     Screening−0.28 (−0.40 to −0.16)4417
     Test for subgroup differences, P value = .68
    Age-group
     Adults−0.31 (−0.41 to −0.23)3926
     Only elderly−0.17 (−0.32 to −0.02)05
     Test for subgroup differences, P value = .08
    Number of treatment sessions
     >6−0.33 (−0.48 to −0.17)538
     6 to 9−0.25 (−0.38 to −0.11)3513
     ≥10−0.32 (−0.44 to −0.21)1210
     Test for subgroup differences, P value = .65
    Risk of bias
     Low−0.27 (−0.38 to −0.15)2411
     Unclear−0.24 (−0.39 to −0.09)4810
     High−0.40 (−0.54 to −0.262110
     Test for subgroup difference, P value = .24
    Sample size
     Up to median (≤152 patients)−0.33 (−0.47 to −0.19)2216
     Above median−0.28 (−0.37 to −0.19)4615
     Test for subgroup differences, P value = .58

    • CBT = cognitive behavioral therapy; na = not applicable; PST = problem-solving therapy; SMD = standardized mean difference.

Additional Files

  • Supplemental Appendix

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  • The Article in Brief

    Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-Analysis

    Klaus Linde , and colleagues

    Background Psychological interventions have a central role in treating depressive disorders. This analysis of currently available evidence looks at whether psychological treatments are effective for treating depressed primary care patients compared to usual care or placebo, taking type of therapy and its delivery method into account.

    What This Study Found Overall, psychological treatments, including cognitive behavioral therapy (CBT), are superior to usual care alone, with small to moderate effect sizes. Differences between different types of psychological treatments are minor, with remote therapist-led, guided self-help and minimal-contact approaches appearing to produce effects similar to more intensive, personalized face-to-face therapies. However, the finding that remote, reduced or minimal contact CBT-based interventions seem to be similarly effective to intense face-to-face treatments should be interpreted carefully, in light of the limited number and moderate size of the identified studies.

    Implications

    • The authors conclude that these findings are reassuring for patients and clinicians wishing to pursue treatment options other than drugs.
    • Although the available evidence for non-drug treatment of depression in primary care is promising, it is still not sufficient to guide practice and health policy. The authors call for large pragmatic trials comparing long-term outcomes and acceptability of different psychological treatment strategies in primary care patients with depression.
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