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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis

S De Maat, J Dekker, R Schoevers, and F De Jonghe.

Review published: 2006.

CRD summary

The authors concluded that psychotherapy and pharmacology appear to be equally efficacious for depression in the short-term, but psychotherapy is associated with lower relapse rates at follow-up. The conclusions regarding the similar short-term efficacy of psychotherapy and pharmacotherapy appear reliable, but limitations of the follow-up data suggest that the conclusions about longer term effects might not be definitive.

Authors' objectives

To assess the relative efficacy of psychotherapy and pharmacotherapy for the treatment of depression.

Searching

MEDLINE, EMBASE, the Cochrane CENTRAL Register, the Cochrane Database of Systematic Reviews and PsycINFO were searched from 1980 to 2005; the search terms were reported. In addition, reference lists and book chapters were screened.

Study selection

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) were eligible for inclusion in the review. Among follow-up studies the duration of follow-up ranged from 1 to 2 years.

Specific interventions included in the review

Studies that compared psychotherapy and pharmacotherapy and focused on acute treatment were eligible for inclusion. The studies had to use a formal (i.e. based on behavioural, cognitive, psychodynamic or client-centred theory), time-limited (maximum of 6 months) individual psychotherapy and a regular dose of antidepressant therapy (approved by national authorities) administered by a registered clinician over a period of at least 4 weeks. The included studies evaluated different types of psychotherapy and pharmacotherapy. Psychotherapy was most commonly cognitive therapy or cognitive behaviour therapy; one study used interpersonal psychotherapy. Pharmacotherapy, where specified, included amitriptyline, clomipramine, nortriptyline, imipramine, desipramine, phenelzine, nefazodone and paroxetine. The duration of the included interventions ranged from 8 to 20 weeks.

Participants included in the review

Studies of adult psychiatric out-patients, aged 19 to 65 years, diagnosed with unipolar major depression according to the American Psychiatric Association's DSM-III-R, DSM-IV-R or research diagnostic criteria, were eligible for inclusion. Studies were grouped according to the chronicity of depression (chronic versus non-chronic) and the severity of depression (mild, moderate and severe). Most patients in those studies classified as chronic depression studies had depression of at least 2 years' duration (the mean duration of the last episode ranged from 46 months to 7.5 years). The severity of depression was classified according to the 17-item Hamilton Depression Rating Scale (HDRS), with mild representing 12 to 19 points and moderate representing 20 to 24 points; no studies were classified as having a severely depressed population.

Outcomes assessed in the review

Studies that reported remission rates and drop-out rates were eligible for inclusion. The primary review outcome was the remission rate at treatment termination (based on the 17-item HDRS score) and the relapse rate at follow-up. The included studies used different definitions for relapse; the review defined relapse using cut-off scores or depression scores. The other review outcome was drop-out rates.

How were decisions on the relevance of primary studies made?

Two reviewers independently selected the studies and agreed on the inclusions.

Assessment of study quality

Two reviewers independently assessed study quality using the following criteria: randomisation, equal treatment of study groups, reporting of selective drop-out according to treatment arms and blind outcome assessment. Both reviewers had to agree on the quality assessment, but it was not clear whether the criteria had to be met before the study was included.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

Where the studies reported 21-item and 24-item HDRS scores, these were converted to scores on the 17-item HDRS system (the methods were reported). For each study, the numbers of patients with events of interest and the difference in HDRS score from baseline were presented for each treatment group. For studies with more than two treatment groups, data on different types of the same intervention (psychotherapy or pharmacotherapy) were combined. The review based the remission rate at treatment termination on intention-to-treat analysis and the relapse rate at follow-up on all patients in remission at treatment termination.

Methods of synthesis

How were the studies combined?

The pooled relative risk (RR) and pooled odds ratio were calculated, with their respective 95% confidence intervals (CIs) using the fixed-effect Mantel-Haenszel model. The review focused on RRs. The number-needed-to-treat (NNT) was calculated, with 95% CI, to represent the number of patients that needed to be treated with psychotherapy to produce one remission that would not have occurred had patients been treated with antidepressants.

How were differences between studies investigated?

Statistical heterogeneity was assessed using the chi-squared statistic (p<0.10 indicated statistical heterogeneity) and the I-squared statistic (greater than 50% indicated notable heterogeneity). Where significant statistical heterogeneity was found, potential sources were discussed. Subgroup analysis was used to examine the effect of treatment in chronic and non- chronic depression and in mild and moderate depression. For follow-up studies, relapse rates were calculated separately for studies with 1 and 2 years' follow-up and after excluding one study that used placebo in the follow-up period.

Results of the review

Ten RCTs (n=1,233) were included, of which 6 were follow-up studies (n=231).

Drop-out rates were significantly greater among patients receiving pharmacotherapy compared with those receiving psychotherapy: 28.4% versus 23.6% (RR: 1.29, 95% CI: 1.07, 1.57, p=0.009). No statistically significant heterogeneity was detected (p=0.73).

There was no statistically significant difference in remission rates at treatment termination between psychotherapy and pharmacotherapy: 37.9% versus 34.8% (RR: 0.91, 95% CI: 0.79, 1.06, p=0.24). No statistically significant heterogeneity was detected (p=0.23). The NNT with psychotherapy to produce one remission from depression that would not have occurred had patients been treated with antidepressants was 32.

There was no statistically significant difference in remission rates at treatment termination between psychotherapy and pharmacotherapy for patients with either chronic depression (36.1% versus 36.6%, p=0.83; based on 3 studies) or non-chronic depression (41.1% versus 32.2%, p=0.12; based on 8 studies). No statistically significant heterogeneity was detected for either chronic (p=0.58) or non-chronic (p=0.14) subgroups. There was no significant difference in remission rates for chronic (p=0.31) and non-chronic (p=0.25) depression for either treatment.

There was no statistically significant difference in remission rates at treatment termination between psychotherapy and pharmacotherapy for patients with either mild depression (46.5% versus 44.4%, p=0.34; based on 5 studies) or moderate depression (33.2% versus 31.9%, p=0.44; based on 5 studies). No statistically significant heterogeneity was detected for the analysis of moderate depression (p=0.55) but statistically significant heterogeneity was detected for the analysis of mild depression (p=0.07; I-squared 54%). Remission rates were significantly greater for mild compared with moderate depression for both psychotherapy (46.5% versus 33.2%, p=0.001) and pharmacotherapy (44.4% versus 31.9%, p=0.003).

The risk of relapse at follow-up was significantly greater among patients receiving pharmacotherapy compared with those receiving psychotherapy: 56.5% versus 26.5% (RR: 0.46, 95% CI: 0.33, 0.65, p<0.0001). No statistically significant heterogeneity was detected (p=0.68).

Authors' conclusions

Psychotherapy and pharmacology appear to be of equal efficacy for depression in the short-term. Remission rates are higher in mild compared with moderate depression for both treatments. Remission rates for chronic and non-chronic depression are similar for both treatments. Psychotherapy is associated with lower relapse rates at follow-up.

CRD commentary

The review addressed a clear question and included clearly- defined inclusion and exclusion criteria for the participants, intervention, outcomes and study design. The strict inclusion criteria sought to minimise clinical heterogeneity between studies. Several relevant sources were searched but no specific attempts to minimise publication bias were reported; this could have resulted in the omission of other relevant studies. It is unclear whether any language restrictions were applied. Methods were used to minimise reviewer error and bias in the selection of studies and assessment of validity, but it is not clear whether similar steps were taken in the extraction of data. Validity was assessed using specified criteria but the results of the assessment were not reported. Adequate details of each included study were given. The studies were appropriately pooled using meta-analysis; statistical heterogeneity was assessed and specified subgroup analyses were conducted to examine treatment differences for different populations. In their discussion, the authors advised caution when interpreting the results on relapse in the follow-up period. The follow-up data were generally observational rather than part of RCTs, so this advice seems appropriate. Despite uncertainties surrounding the data extraction, the conclusions regarding the similar short-term efficacy of psychotherapy and pharmacotherapy appear reliable. However, limitations of the follow-up data suggest that the follow-up results might not be definitive.

Implications of the review for practice and research

The authors did not state any implications for practice or further research.

Bibliographic details

De Maat S, Dekker J, Schoevers R, De Jonghe F. Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis. Psychotherapy Research 2006; 16(5): 566-578.

Indexing Status

Subject indexing assigned by CRD

MeSH

Antidepressive Agents /therapeutic use; Behavior Therapy; Combined Modality Therapy; Depression /drug therapy /therapy; Depressive Disorder /drug therapy /therapy; Drug Therapy, Combination; Psychotherapy; Treatment Outcome

AccessionNumber

12006007655

Database entry date

31/03/2008

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.
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