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Depression is a prevalent and impairing condition. Behavioral activation (BA) is a parsimonious, cost-effective, and easily disseminated psychological intervention for depression. The current meta-analysis expands on the existing literature supporting the efficacy of BA for depression by examining the effects of BA on additional relevant outcomes for patients with depression, namely the reduction in anxiety symptoms and increase in activation.
Randomized controlled trials of BA for depression compared to active and inactive control were identified via a systematic review. Effect sizes using Hedges's g were calculated for each outcome compared to both active and inactive control using random effects models. Subgroup analyses were used to examine the inclusion of a discussion of values as a moderator of depression symptom outcome in BA.
Twenty-eight studies were included. Meta-analyses of symptom change between groups from baseline-to-post intervention indicated that BA outperformed inactive control conditions for improvements in depression (g = 0.83), anxiety (g = 0.37), and activation (g = 0.64). The difference between BA and active control conditions was not significant for improvements in depression (g = 0.15), anxiety (g = 0.03), and activation (g = 0.04). There was no evidence for a discussion of values augmenting BA efficacy. Study quality was generally low, and there was evidence of publication bias.
In addition to improving depression, BA shows efficacy for reducing symptoms of anxiety and increasing activation. BA may not offer better outcomes relative to other active interventions. There is room for improvement in the quality of research in this area.
Problem-solving therapy (PST) is one of the best examined types of psychotherapy for adult depression. No recent meta-analysis has examined the effects of PST compared to control groups or to other treatments. We wanted to verify whether PST is effective, whether effects are comparable to those of other treatments, and whether we could identify the possible sources of high heterogeneity that was found in earlier meta-analyses.
We conducted systematic searches in bibliographical databases, including PubMed, PsycInfo, Embase and the Cochrane database of randomized trials.
We included 30 randomized controlled trials on PST (with 3530 patients), in which PST was compared to control conditions, with other therapies, and with pharmacotherapy. We could compare these 30 trials on PST also with 259 trials on other psychotherapies for adult depression. The effect size of PST versus control groups was g = 0.79 (0.57–1.01) with very high heterogeneity (I2 = 84; 95% CI: 77–88). The effect size from the 9 studies with low risk of bias was g = 0.34 (95% CI: 0.22–0.46) with low heterogeneity (I2 = 32; 95% CI: 0–68), which is comparable to the effects of other psychotherapies. PST was a little more effective than other therapies in direct comparisons, but that may be explained by the considerable number of studies with researcher allegiance towards PST. In meta-regression analyses of all controlled studies, no significant difference between PST and other therapies was found.
PST is probably an effective treatment for depression, with effect sizes that are small, but comparable to those found for other psychological treatments of depression.
Care-as-usual (CAU) is often used as a control condition in psychotherapy research, but it may vary considerably what that entails, ranging from no treatment, to routine treatment in primary care, general medical care, perinatal care, and specialized mental health care.
We conducted a meta-analysis of trials comparing psychotherapy for depression to CAU, with a focus on the different categories of CAU and countries where the studies were conducted. We used an existing database of randomized trials on psychotherapy for depression that is updated every year.
A total of 140 studies with 15 419 patients were included. We found no significant differences in effects between categories of CAU (effect sizes ranging from g = 0.43 for CAU in primary care to g = 0.73 for no treatment), but heterogeneity was high in all CAU categories. After stratifying effects across specific countries (within CAU categories) we found that heterogeneity was considerably lower and there were several significant differences between countries. Overall, effects were larger in non-Western countries (g = 0.84 to 1.28) compared to those in Western countries (g = 0.52; p for difference = 0.002). Effects were smaller in studies with risk of bias (p = 0.01).
There are no significant differences between major categories of CAU when compared to psychotherapy conditions in randomized trials. However, effects of psychotherapy differ considerably across CAU conditions in specific countries. CAU therefore is a heterogeneous control condition in psychotherapy research.
Little is known about potential harmful effects as a consequence of self-guided internet-based cognitive behaviour therapy (iCBT), such as symptom deterioration rates. Thus, safety concerns remain and hamper the implementation of self-guided iCBT into clinical practice. We aimed to conduct an individual participant data (IPD) meta-analysis to determine the prevalence of clinically significant deterioration (symptom worsening) in adults with depressive symptoms who received self-guided iCBT compared with control conditions. Several socio-demographic, clinical and study-level variables were tested as potential moderators of deterioration.
Randomised controlled trials that reported results of self-guided iCBT compared with control conditions in adults with symptoms of depression were selected. Mixed effects models with participants nested within studies were used to examine possible clinically significant deterioration rates.
Thirteen out of 16 eligible trials were included in the present IPD meta-analysis. Of the 3805 participants analysed, 7.2% showed clinically significant deterioration (5.8% and 9.1% of participants in the intervention and control groups, respectively). Participants in self-guided iCBT were less likely to deteriorate (OR 0.62, p < 0.001) compared with control conditions. None of the examined participant- and study-level moderators were significantly associated with deterioration rates.
Self-guided iCBT has a lower rate of negative outcomes on symptoms than control conditions and could be a first step treatment approach for adult depression as well as an alternative to watchful waiting in general practice.
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