Effectiveness of Psychological and Educational Interventions to Prevent Depression in Primary Care: A Systematic Review and Meta-Analysis

Sonia Conejo-Cerón; Patricia Moreno-Peral; Alberto Rodríguez-Morejón; Emma Motrico; Desirée Navas-Campaña; Alina Rigabert; Carlos Martín-Pérez; Antonina Rodríguez-Bayón; María Isabel Ballesta-Rodríguez; Juan de Dios Luna; Javier García-Campayo; Miquel Roca; Juan Ángel Bellón

doi:10.1370/afm.2031

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Figure 1
Flowchart of the studies reviewed.
CENTRAL = Cochrane Central Register of Controlled Trials; WOS = Web of Science.
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Figure 2
Forest plot of comparison: intervention vs control group, using a random-effects model.
Std diff = standardized difference.

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Table 1

Inclusion and Exclusion Criteria for Included Studies

Aspect Considered	Inclusion Criteria	Exclusion Criteria
Setting	Primary health care^a	Other settings
Population	Primary care population not depressed at baseline^b	Primary care population depressed at baseline
Type of intervention	Psychological or educational intervention^c	Pharmacological and physical interventions
Comparator	Care as usual, no intervention, waiting list, attention control, or placebo	Other controls
Design	RCT	Other designs
Outcome	Prevention of depression (incidence of depression or reduction of depressive symptoms)	Other outcomes
Language	All languages	No restrictions

RCT = randomized controlled trial.
↵a All patients included in the RCTs must be recruited in primary care, health centers, or general practices.
↵b The entire spectrum of nondepressed patients included ranges from nondepressive symptoms (0 symptoms) to subthreshold forms of depression (eg, minor depression or subsyndromal depression).
↵c Educational interventions provide information about depression through lectures or fact sheets, whereas psychological interventions attempt to change how people think using a variety of different strategies (eg, cognitive behavioral or interpersonal therapy).

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Table 2

Randomized Clinical Trials to Prevent Depression in Primary Care

Author, Year Country	Target Population, Type of Prevention	Inclusion Criteria	Sample (Control/Intervention) No.	Care Management	Intervention Orientation (No. of Sessions/Format)	Clinician	Main Outcome	Follow-up	Risk of Bias^a
Barrett et al,⁴⁹ 2001^b (United States)	Adults (18–59 y) Indicated^c	Minor depression (HRSD ≥10; PRIME-MD)	74 (38/36)	1. PST-PC 2. Placebo plus clinical management	CB (6/individual)	Psychologists	Depressive symptoms (HSCL-D-20 depression scale)	11 wk	1 (llulll)
Bellón et al,⁴⁷ 2016 (Spain)	Adults (18–75 y) Universal^d	No MD in past 6 mo (CIDI)	3,326 (1,663/1,663)	1. Biopsychosocial intervention 2. CAU	Biopsychosocial personalized (3/individual)	Primary care physicians who received a 10- to 15-h training workshop	Incidence MD (CIDI)	6-12-18 mo	2 (llhlll)
Brugha et al,⁴⁴ 2011 (United Kingdom)	Women postnatally Selective^e	No depression (EPDS <12)	2,241 (767/1,474)	1. CBA/PCA 2. CAU	CBA/PCA (8/individual)	Community nurse (health visitor) with 6 half-days training and access to regular supervision sessions	Proportion of women scoring ≥12 EPDS	6-12-18 mo	5 (luhhll)
Brugha et al,⁴⁵ 2016 (United Kingdom)	Pregnant women Selective^e	No depression (EPDS <12)	186 (83/103)	1. CBA 2. CAU	CBA (3/individual)	Community midwife with 8-d training in psychological care (1 d exclusively in the use of the EPDS)	Proportion of women scoring ≥12 EPDS	22 wk	4 (llhlhl)
Frank et al,³⁸ 2002^b (United States)	Adults (≥18 y) Indicated^c	Minor depression (HRSD ≥10; PRIME-MD)	168 (89/79)	1. PST-PC 2. Placebo plus clinical management	CB (6/individual)	Psychologists, social workers, counselors	Depressive symptoms (HSCL-D-20 depression scale)	11 wk	3 (llulhl)
García-Campayo et al,⁴³ 2010 (Spain)	Adults (18–65 y) Selective^e	No DSM-IV Axis I psychiatric disorders (SPPI)	104 (52/52)	1. Psychoeducational 2. No intervention	Psychoeducational and CB (5/group)	Primary care physicians with specific training in mental health and group therapy	Prevalence of somatoform disorders (SPPI)	3-6-60 mo	3 (llhlul)
Gillham et al,⁴⁰ 2006 (United States)	Early adolescents (11–12 y) Indicated^c	No MD (CDI ≥7/9; DICA-R)	271 (124/147)	1. CBT (PRP) 2. CAU	CB (12/group)	Child psychologists, child social workers	Depressive symptoms (CDI)	6-12-18-24 mo	7 (lhhhul)
González et al,⁵⁰ 2006 (Spain)	Adults (25–55 y) Indicated^c	No depressive disorder (DSM-IV)	60 (NR/NR)	1. CBT 2. Encouraging personal resources 3. Social support 4. Waiting list	CB (6/group)	Psychologists	Depressive symptoms (BDI)	6-12 mo	9 (uhhhhl)
Lynch et al,³⁷ 1997 (United States)	Adults (≥18 y) Indicated^c	Minor depression (MOS Depression Screening Inventory >cutoff; DIS)	29 (14/15)	1. PST 2. CAU	CB (6/individual by telephone)	Student therapist, medical student, graduate nursing student	Depressive symptoms (BDI)	7 wk	7 (uhhlhl)
Muñoz et al,³⁶ 1993–1995 (United States)	Adults (≥18 y) Selective^e	No MD in past 6 months (DIS)	150 (78/72)	1. CBT 2. No intervention or information by videotape	CB (8/group)	Psychologists	Incidence of depression (DIS), depressive symptoms (BDI, CES-D)	6-12 mo	2 (llhlll)
van’t Veer-Tazelaar et al,^41,42 2009–2011^f (the Netherlands)	Elderly (≥75 y) Indicated^c	Subthreshold depressive symptoms, no MDE (CES-D ≥16; MINI)	170 (84/86)	1. Stepped-care program 2. CAU	CB (10/individual)	Home care nurse, specially trained (CBT-bibliotherapy), community psychiatric nurse (CBT + PST), primary care physician to give psychotropic medication (only for participants with continuously elevated CES-D scores)	Cumulative incidence of MDD (MINI)	6-12-24 mo	4 (lhhlll)
Willemse et al,³⁹ 2004 (the Netherlands)	Adults (18–65 y) Indicated^c	Subthreshold depression, no MDD in past 12 mo (CIDI)	216 (109/107)	1. CBT 2. CAU	CB (CWD) (7/individual)	Prevention specialist, clinician from a community mental health center	Incidence of depression (CIDI), depressive symptoms (CES-D)	12 mo	4 (lhhlll)
Williams et al,⁴⁸ 2000^b (United States)	Older adults (≥60 y) Indicated^c	Minor depression (HRSD ≥10; PRIME-MD)	130 (67/63)	1. PST-PC 2. Placebo plus clinical management	CB (6/individual)	Psychologists, social workers, counselors	Depressive symptoms (HSCL-D-20 depression scale)	11 wk	1 (llulll)
Zhang et al,⁴⁶ 2014^f (China)	Adults (≥18 y) Indicated^c	Subthreshold depression, no MD (CES-D ≥16; SCID)	240 (119/121)	1. Stepped-care program 2. CAU	CB (12/individual)	Social workers with at least 3 y counseling experience, primary care physician to give psychotropic medication (only for participants with continuously elevated CES-D scores) or referred to see a psychiatrist	Incidence MD (SCID), depressive symptoms (CES-D)	3-6-9-12-15 mo	3 (llhlul)

BDI = Beck Depression Inventory; CAU = care as usual; CB = cognitive behavioral; CBA = cognitive behavioral approach; CBT = cognitive behavioral therapy; CDI = Children’s Depression Inventory; CES-D = Center for Epidemiologic Studies of Depression; CIDI = Composite International Diagnostic Interview; DICA-R = Diagnostic Inventory for Children and Adolescents; DIS = Diagnostic Interview Schedule; DSM = Diagnostic and Statistical Manual of Mental Disorders; EPDS = Edinburgh Postnatal Depression Scale; HDRS = Hamilton Depression Rating Scale; HSCL-D = Hopkins Symptom Checklist for Depression; MD = major depression; MDD = major depressive disorder; MDE = major depressive episode; MINI = Mini International Neuropsychiatric Interview; MOS = Medical Outcome Study; NR = not reported; PCA = person centered approach; PRIME-MD = The Primary Care Evaluation of Mental Disorders; PRP = Penn Resiliency Program; PST = problem solving therapy; PST-PC = problem solving treatment for primary care; SCID = Structured Clinical Interview for DSM-IV; SPPI = Standardized Polyvalent Psychiatric Interview.
Note: CB, CBA, and CBT focus on the development of personal coping strategies that target solving current problems and changing unhelpful patterns in cognitions (eg, thoughts, beliefs, and attitudes), behaviors, and emotional regulation.
↵a High score means higher risk of bias. Low risk (l) = 0 points; unclear risk (u) = 1 point; or high risk (h) = 2 points; indicate rating of 6 quality criteria: random sequence, allocation concealment, blinding of participants and clinicians, blinding of outcome assessment, incomplete outcome data, selective reporting.
↵b These studies had 3 arms (paroxetine, placebo and problem-solving therapy), but we only used placebo vs problem-solving therapy.
↵c Patients with minor or subthreshold depression.
↵d General population.
↵e Patients with some risk factors for depression.
↵f In these studies, we collected only depression data.

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Table 3

Analysis of the Studies Included in the Meta-Analysis of Psychological and Educational Interventions to Prevent Depression in Primary Care

Analysis	No.	SMD	95% CI	I²	P Value^a
Sensitivity
At first evaluation	13	−0.166	−0.272 to −0.059	20.6	.002
At last evaluation	13	−0.154	−0.269 to −0.040	20.6	.008
García-Campayo⁴³ excluded	12	−0.143	−0.220 to −0.065	0.00	.000
Brugha⁴⁵ excluded	12	−0.163	−0.262 to −0.065	27.1	.001
García-Campayo⁴³ and Brugha⁴⁵ excluded	11	−0.141	−0.223 to −0.059	4.9	.001
Subgroup
Type of prevention
Indicated	8	−0.134	−0.283 to 0.015	31.9	.715
Selective	4	−0.236	−0.434 to −0.037	29.9
Universal	1	−0.156	−0.293 to −0.020	NA
Country
United States	6	−0.092	−0.280 to 0.097	29.2	.430
Europe	6	−0.211	−0.322 to −0.099	17.9
China	1	−0.068	−0.344 to 0.207	NA
Age
Adults	10	−0.156	−0.268 to −0.045	28.7	.903
Elderly	2	−0.233	−0.588 to 0.121	49.2
Adolescent	1	−0.133	−0.414 to 0.148	NA
Comparator
CAU/no intervention	10	−0.199	−0.297 to −0.100	19.4	.049
Placebo	3	0.039	−0.176 to 0.255	0.00
Clinician
Primary care staff	4	−0.197	−0.346 to −0.048	32.8	.577
Mental health specialists	9	−0.141	−0.272 to 0.010	23.3
Intervention format
Individual	10	−0.139	−0.235 to −0.043	13.8	.327
Group	3	−0.278	−0.539 to −0.017	43.2
Number of sessions
3–6	7	−0.172	−0.377 to 0.033	51.22	.736
7–10	4	−0.193	−0.322 to −0.065	0.00
>10	2	−0.100	−0.297 to 0.097	0.00
Sample size
≤150	5	−0.274	−0.602 to 0.054	58.8	.752
151–280	6	−0.143	−0.269 to −0.017	0.00
>2,000	2	−0.145	−0.254 to −0.035	0.00

CAU = care as usual; NA = not applicable; SMD = standardized mean difference.
↵a Test for subgroup differences, P value.

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The Article in Brief

Effectiveness of Psychological and Educational Interventions to Prevent Depression in Primary Care: A Systematic Review and Meta-Analysis

Sonia Conejo-Ceron , and colleagues

Background With major depressive disorder projected to become the single leading cause of global disease burden in high-income countries by 2030, there is increased interest in preventing depression. Primary care is an ideal setting in which to undertake disease prevention strategies for depression, yet little is known about the effectiveness of psychological and educational interventions to prevent depression in primary care.

What This Study Found This systematic review of 14 randomized controlled trials involving 7,365 patients examined the effects of interventions to prevent depression in nondepressed patients. There was a modest but positive effect of psychological and/or educational interventions to prevent depression in primary care. Based on these findings, the authors conclude the incidence of new episodes of depression could be reduced on average by 26 percent if primary care managers and physicians were to implement programs and interventions to prevent depression.

Implications

The authors call for further RCTs to determine which programs and interventions are most efficient in primary care.
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