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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].

Cognitive-behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials

MW Beltman, RC Oude Voshaar, and AE Speckens.

Review published: 2010.

CRD summary

This well-conducted review concluded that cognitive-behavioural therapy significantly reduced symptoms in patients with somatic disease, especially in those who meet the criteria for depressive disorder. The authors' conclusion is likely to be reliable, but variation in depressive disorder trials may limit the observed clinical benefits of cognitive-behavioural therapy.

Authors' objectives

To assess the effectiveness of cognitive-behavioural therapy for depression in people with underlying somatic diseases.

Searching

PubMed, PsycINFO and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to October 2008, with no language limitations. Search terms were reported. Reference lists of all identified randomised controlled trials (RCTs) were handsearched.

Study selection

RCTs that evaluated the effects of cognitive-behavioural therapy in participants with an underlying somatic disease were eligible for inclusion. Trials had to report results for depressive symptoms separately for each treatment arm at pre-treatment and post-treatment, include protocol-based psychological treatment (details reported in the paper), and report valid outcome measures (validated self-report questionnaire or clinical interview). Trials of problem-solving therapy and cognitive-behavioural stress management meeting pre-specified definitions of cognitive-behavioural therapy were also eligible for inclusion. Trials that examined depression associated with unexplained somatic symptoms, trials where cognitive-behavioural therapy was not distinguished from other elements of the intervention, and trials limited to specific psychiatric disorders were excluded.

The primary outcome measure was severity of depressive symptoms.

Most of the included trials were conducted in out-patient settings. Included trials assessed classic cognitive-behavioural therapy interventions, cognitive-behavioural stress management and problem-solving therapies. Treatment sessions were delivered in group, individual or telephone formats; the sessions ranged from six to 20 weeks. Underlying somatic diseases were varied; common conditions included cancer, HIV infection, and multiple sclerosis. Participants had varied depressive disorders, or they had depressive symptoms not meeting criteria for depressive disorder. The mean age of participants was 51 years. A variety of scales were used to measure depressive symptoms.

Two reviewers independently selected studies for inclusion. Disagreements were resolved through discussion or by involvement of a third reviewer.

Assessment of study quality

Trial quality was assessed using the Amsterdam-Maastricht consensus list, with scores that ranged from 0 (poor quality) to 19 (excellent quality). The authors reported that the maximum score was taken as 17, since it was impractical to mask participants and therapists in psychotherapy treatment conditions.

Two reviewers independently assessed trial quality; the authors did not report how any disagreements were resolved.

Data extraction

Data on means, standard deviations (SDs) and number of participants in experimental and control groups were extracted to calculate standardised mean differences (SMDs) and corresponding 95% confidence intervals (CIs). Authors were contacted for missing data; where SDs were not available from trial authors, they were calculated from t-tests, confidence intervals or standard errors.

Two reviewers independently extracted data into a coding form; disagreements were resolved by discussion or by involvement of a third reviewer.

Methods of synthesis

Pooled standardised mean differences and corresponding 95% confidence intervals were calculated using a fixed-effect model where no evidence of statistical heterogeneity was found, otherwise a random-effects model was used. Statistical heterogeneity was assessed using a X2 test (with p<0.10 considered significant) and I2 statistic. Publication bias was assessed visually using funnel plots.

Trials of patients with depressive disorder and depressive symptoms were analysed separately. Sensitivity analyses were performed to explore the association between trial quality and magnitude of observed effect sizes. Sub-group analyses were performed to assess the association between effect sizes and types of cognitive-behavioural therapy, control conditions, and treatment delivery (group or individual).

Results of the review

Twenty-nine RCTs were included in the review (n=3,000 patients). Thirteen trials included participants (n=1,139) with depressive disorders. Sixteen trials included participants (n=1,861) with depressive symptoms. Trial quality was reported to be highly varied; the Amsterdam-Maastricht score ranged from 8 to 16.

Depressive disorder studies: Cognitive-behavioural therapy was associated with significantly greater improvement in depressive symptoms (SMD -0.83, 95% CI -1.36 to 0.31; 13 RCTs; n=1,037 participants) compared with control conditions. There was evidence of high heterogeneity (I2=93.0%). This was largely explained by three trials regarded as 'outliers'; effect sizes were smaller (but still statistically significant) without the 'outliers'.

Depressive symptom studies: Cognitive-behavioural therapy was associated with significantly greater improvement in depressive symptoms (SMD -0.16, 95% CI -0.27 to -0.06; 16 RCTs; n=1,548 participants). There was no evidence of high heterogeneity (I2=28.0%).

Subgroup analyses: For trials of participants with depressive disorders, no significant differences were found in trials using other psychotherapy as a control group. For both trials of participants with depressive disorders and depressive symptoms, only individual treatment delivery had significant effects for cognitive-behavioural therapy.

Authors' conclusions

Cognitive-behavioural therapy significantly reduced depressive symptoms in patients with a somatic disease, especially in those who meet the criteria for a depressive disorder.

CRD commentary

The review addressed a clearly stated question, supported with explicit inclusion and exclusion criteria. Three relevant databases were searched without any language restrictions, which minimised the likelihood of language bias. Limited efforts were made to search for unpublished studies, so some relevant papers may have been missed. Publication bias was assessed and no evidence found. Review processes were performed in duplicate, which reduced the risk of error and bias.

Trial quality was assessed using appropriate criteria and was found to be varied. Statistical methods used to combine trial results appeared appropriate; random-effects meta-analysis was used where evidence of statistical heterogeneity was found. Differences between trials were investigated by subgroup and sensitivity analyses.

This was generally a well-conducted systematic review. The authors' conclusion is likely to be reliable. However, the clinical significance of the observed benefits of cognitive-behavioural therapy is uncertain given the significant heterogeneity in depressive disorder trials.

Implications of the review for practice and research

Practice: The authors stated that the results of the meta-analysis support the effectiveness of cognitive-behavioural therapy as the treatment of choice for depression in people with underlying somatic diseases.

Research: The authors stated that future studies should aim to identify components of cognitive-behavioural therapy that are more efficacious for individuals with underlying somatic diseases. They also recommended further studies to investigate the finding that individual treatment might be more effective than group therapy in somatically ill people with depressive disorder. Future studies should include long-term follow-up data for both depressive symptoms and prognosis of the underlying somatic disease.

Funding

Not stated.

Bibliographic details

Beltman MW, Oude Voshaar RC, Speckens AE. Cognitive-behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials. British Journal of Psychiatry 2010; 197(1): 11-19. [PubMed: 20592427]

Other publications of related interest

Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology 2008;76(6):909-922

Indexing Status

Subject indexing assigned by NLM

MeSH

Adult; Aged; Aged, 80 and over; Cognitive Therapy; Depression /etiology /therapy; Depressive Disorder /etiology /therapy; Disease /psychology; Female; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Sensitivity and Specificity; Treatment Outcome

AccessionNumber

12010005356

Database entry date

18/05/2011

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.

PMID: 20592427

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