Psychology review protocol

Clinical questionIn the treatment of depression for people with a chronic physical health problem, which psychosocial/psychological interventions improve outcomes compared with other interventions (including treatment as usual)?
Sub-questionsWhich psychosocial/psychological interventions improve outcomes when compared with alternative psychosocial/pharmacological management strategies?
Topic groupPsychosocial/psychological
Sub-section leadFrancis Creed
Search strategyDatabases: CINAHL, CENTRAL, EMBASE, MEDLINE, PsycINFO
Additional sources: Reference lists of included studies, systematic reviews
Existing reviews
Not updated
Search filters usedDepression guideline update [RCT, mainstream]; depression guideline update-dysthymia, mild depression, subthreshold depression [mainstream, systematic review]; depression guideline update [systematic review, mainstream]; depression in adults with a chronic physical health problem [RCT, CENTRAL] Mar08; depression in adults with a chronic physical health problem [RCT, mainstream] Mar08; depression in adults with a chronic physical health problem [systematic review, mainstream] Mar08
Question specific search filterN/A
Amendments to filter/search strategyN/A
Eligibility criteria
InterventionCognitive behavioural interventions

CBT: Discrete, time-limited, structured psychological intervention, derived from the cognitive behavioural model of affective disorders and where the patient:
  • works collaboratively with the therapist to identify the types and effects of thoughts, beliefs and interpretations on current symptoms, feelings states and/or problem areas
  • develops skills to identify, monitor and then counteract problematic thoughts, beliefs and interpretations related to the target symptoms/problems
  • learns a repertoire of coping skills appropriate to the target thoughts, beliefs and/or problem areas.
Problem solving: a psychological intervention, that focuses on learning to cope with specific problems areas and where:
  • therapist and patient work collaboratively to identify and prioritise key problem areas, to break problems down into specific, manageable tasks, problem solve and develop appropriate coping behaviours for problems.
Guided self-help: a self-administered intervention designed to treat depression, which makes use of a range of books or a self-help manual that is based on an evidence-based intervention and designed specifically for the purpose. A healthcare professional (or paraprofessional) would facilitate the use of this material by introducing, monitoring and reviewing the outcome of such treatment. This intervention would have no other therapeutic goal, and would be limited in nature — usually no more than three contacts.

CCBT: a form of CBT delivered using a computer (including CD-ROM and the internet). It can be used as the primary treatment intervention, with minimal therapist involvement or as augmentation to a therapist-delivered programme where the introduction of CCBT supplements the work of the therapist.

IPT: a discrete, time-limited, structured psychological intervention, derived from the interpersonal model of affective disorders that focuses on interpersonal issues and where therapist and patient:
  • work collaboratively to identify the effects of key problematic areas related to interpersonal conflicts, role transitions, grief and loss, and social skills, and their effects on current symptoms, feelings states and/or problems
  • seek to reduce symptoms by learning to cope with or resolve these interpersonal problem areas.
Counselling: counselling was defined as a discrete, usually time-limited, psychological intervention where:
  • the intervention may have a facilitative approach often with a strong focus on the therapeutic relationship, but may also be structured and, at times, directive.
An intervention was classified as counselling if the intervention(s) offered in the study did not fulfil all the criteria for any other psychological intervention. If a study using counsellors identified a single approach, such as cognitive behavioural or interpersonal, it has been analysed in that category.

Psychodynamic psychotherapy: psychological interventions, derived from a psychodynamic/psychoanalytic model, and where therapist and patient explore and gain insight into conflicts and how these are represented in current situations and relationships including the therapy relationship (for example, transference and counter-transference). This leads to patients being given an opportunity to explore feelings, and conscious and unconscious conflicts, originating in the past, with a technical focus on interpreting and working though conflicts. Therapy is non-directive and recipients are not taught specific skills (for example, thought monitoring, re-evaluating, or problem-solving).

Behavioural couples therapy: time-limited, psychological interventions derived from a model of the interactional processes in relationships where:
  • interventions are aimed to help participants understand the effects of their interactions on each other as factors in the development and/or maintenance of symptoms and problems
  • the aim is to change the nature of the interactions so that they may develop more supportive and less conflictual relationships. The style of the therapy can vary and reflect different approaches, for example, cognitive behavioural or psychodynamic.
Family intervention: family sessions with a specific supportive or treatment function based on systemic, cognitive behavioural or psychoanalytic principles, which must contain at least one of the following:
  • psychoeducational intervention, and/or
  • problem solving/crisis management work, and/or
  • intervention with the identified patient.
Studies included were also required to use an intervention that was at least 6 weeks in duration.

Psychoeducation: psychoeducation (or ‘patient teaching’, ‘patient instruction’ and ‘patient education’) was defined as:
  • any group or individual programme involving an explicitly described educational interaction between the information provider and the patient/carer as the prime focus of the study
  • programmes had to address the illness from a multidimensional viewpoint, including familial, social, biological and pharmacological perspectives
  • studies in which patients/carers are provided with information, support and different management strategies (characteristic of most programmes) were included
  • programmes of ten or fewer sessions were classified as ‘brief’, and 11 or more as ‘standard’ for this review
  • interventions including elements of behavioural training, such as social skills or life skills training were excluded
  • educational programmes performed by service user peers, and staff education studies were excluded.
Physical activity: for the purposes of the guideline, this was defined as a structured, achievable physical activity characterised by frequency, intensity and duration and used as a treatment for depression. It can be undertaken individually or in a group.

Physical activity may be divided into aerobic forms (training of cardio-respiratory capacity) and anaerobic forms (training of muscular strength/endurance and flexibility/coordination/relaxation) (American College of Sports Medicine, 1980).

The aerobic forms of physical activity, especially jogging or running, have been most frequently investigated. In addition to the type of activity, the frequency, duration and intensity should be described.

Occupational therapy: occupational therapy enables people to achieve health, well-being and life satisfaction through participation in occupation, that is, daily activities that reflect cultural values, provide structure to living and meaning to individuals. These activities meet human needs for self-care, enjoyment and participation in society.

Non-statutory support: a range of community-based interventions often not provided by healthcare professionals, which provide support, activities and social contact in order to improve the outcome of depression.

Programmes to facilitate employment:

Pre-vocational training: any approach to vocational rehabilitation in which participants are expected to undergo a period of preparation before being encouraged to seek competitive employment. This preparation phase could involve either work in a sheltered environment (such as a workshop or work unit), or some form of pre-employment training or transitional employment. This included both traditional (sheltered workshop) and clubhouse approaches.

Supported employment: any approach to vocational rehabilitation that attempted to place clients immediately in competitive employment. It was acceptable for supported employment to begin with a short period of preparation, but this had to be of less than 1-month's duration and not involve work placement in a sheltered setting, or training, or transitional employment.

Modifications of vocational rehabilitation programs: either pre-vocational training or supported employment that had been enhanced by some technique to increase participants' motivation. Typically, such techniques consist of payment for participation in the programme, or some form of psychological intervention.
ComparatorTreatment as usual
Sub-question: alternative psychosocial/pharmacological management strategies
Population (including age, gender and so on)Adults >18 years with a chronic physical health problem and a diagnosis of depression (including those scoring above cut-off on recognised depression identification tools)

Populations excluded:
  • Mortality (suicide and natural causes)
  • Global state (including remission and relapse)
  • Depression (HAM-D, BDI, MADRS and so on)
  • Physical health outcomes
  • Psychosocial functioning
  • Quality of life
  • Satisfaction with treatment/subjective well-being
Study designRCT
Publication status[Published and unpublished (if criteria met)]
Year of studyInception to date (9 March 2008)
DurationAll durations considered at present
Minimum sample sizeAll sample sizes considered at present

Exclude studies with >50% attrition from either arm of trial (unless adequate statistical methodology has been applied to account for missing data)
Study settingPrimary care, hospital, residential and nursing, tertiary care and so on
Additional assessmentsStudies were categorised as short term (<12 weeks), medium term (12 to 51 weeks) and long term (>52 weeks)

From: Appendix 8, Clinical review protocol template

Cover of Depression in Adults with a Chronic Physical Health Problem
Depression in Adults with a Chronic Physical Health Problem: Treatment and Management.
NICE Clinical Guidelines, No. 91.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society; 2010.
Copyright © 2010, The British Psychological Society & The Royal College of Psychiatrists.

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