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

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

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.