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In low-resource settings, e-mental health may substantially increase access to evidence-based interventions for common mental disorders. We conducted a systematic literature search to identify randomised trials examining the effects of digital interventions with or without therapeutic guidance compared to control conditions in individuals with anxiety and/or depression symptoms in low- and middle-income countries (LMICs).
The main outcome was the reduction in symptoms at the post-test. Secondary outcomes included improvements in quality of life and longer-term effects (≥20 weeks post-randomisation). The effect size Hedges’ g was calculated using the random effects model.
A total of 21 studies (23 comparisons) with 5.296 participants were included. Digital interventions were more effective than controls in reducing symptoms of common mental disorders at the post-test (g = −0.89, 95% confidence interval [CI] −1.26 to −0.52, p < 0.001; NNT = 2.91). These significant effects were confirmed when examining depressive (g = −0.77, 95% CI −1.11; −0.44) and anxiety symptoms separately (g = −1.02, 95% CI −1.53 to −0.52) and across all other sensitivity analyses. Digital interventions also resulted in a small but significant effect in improving quality of life (g = 0.32, 95% CI 0.19 to 0.45) at the post-test. Over the longer term, the effects were smaller but remained significant for all examined outcomes. Heterogeneity was moderate to high in all analyses. Subgroup and meta-regression analyses did not result in significant outcomes in any of the examined variables (e.g., guided vs. unguided interventions).
Digital interventions, with or without guidance, may effectively bridge the gap between treatment supply and demand in LMICs. Nevertheless, more studies are needed to draw firm conclusions regarding the magnitude of the effects of digital interventions.
Previous meta-analyses on psychotherapy for adult depression have found a larger treatment effect in non-Western trials compared to Western trials (i.e. North America, Europe, and Australia). However, factors contributing to this difference remain unclear. This study investigated different study characteristics between Western and non-Western trials and examined their association with effect size estimates. We systematically searched PubMed, PsycINFO, Embase, and Cochrane Library (01–09–2022). We included randomized-controlled trials (RCTs) that compared psychotherapy with a control condition. The validity of included RCTs was assessed by the Cochrane risk of bias assessment tool (RoB 1). Effect sizes were pooled using the random-effects model. Subgroup analyses and meta-regressions were also conducted. We identified 405 eligible trials, among which 105 trials (117 comparisons, 16 304 participants) were from non-Western countries. We confirmed that non-Western trials had a larger treatment effect (g = 1.10, 95% CI 0.90–1.31) than Western trials (g = 0.57, 95% CI 0.52–0.62). Trials from non-Western countries also had more usual care controls, higher risk of bias, larger sample sizes, lower mean ages, younger adults, more group-based interventions, and other recruitment methods (e.g. systematic screening; p < 0.05). The larger effect sizes found in non-Western trials were related to the presence of wait-list controls, high risk of bias, cognitive-behavioral therapy, and clinician-diagnosed depression (p < 0.05). The larger treatment effects observed in non-Western trials may result from the high heterogeneous study design and relatively low validity. Further research on long-term effects, adolescent groups, and individual-level data are still needed.
It is not clear if there is an interaction between psychotherapy and pharmacotherapy. First, there may be no interaction at all, meaning that the effects of both are independent of each other. Second, antidepressants may reduce the effects of psychotherapy, and third, antidepressants may increase the effects of psychotherapy. We examined which of the three is correct.
We conducted random effects meta-analyses of randomized trials comparing psychotherapies for adult depression with control conditions. The proportion of users of antidepressants was used as a predictor of the effect size in a series of meta-regression analyses, while adjusting for relevant moderators, such as type of control group and baseline severity.
We included 300 randomized controlled trials (353 comparisons between treatment and control; 32,852 participants). The main effect size of psychotherapy was g = 0.71 (95% CI: 0.64; 0.79) with high heterogeneity (I2 = 82; 95% CI: 80; 84). We found no significant association between the proportion of antidepressants users and effect size (p = .07). We did find a significant association with some other predictors, including the type of control group and risk of bias. The use of antidepressants was associated with higher response rates within the control conditions, but not with the relative effects of the treatments compared to the control groups.
We found support for the independent effects of psychotherapy and pharmacotherapy, which is good news from a clinical perspective. Apparently, patients can start with psychotherapy and do not have to be afraid that this will reduce the effects of the therapy.
It is crucial to optimize global mental health research to address the high burden of mental health challenges and mental illness for individuals and societies. Data sharing and reuse have demonstrated value for advancing science and accelerating knowledge development. The FAIR (Findable, Accessible, Interoperable, and Reusable) Guiding Principles for scientific data provide a framework to improve the transparency, efficiency, and impact of research. In this review, we describe ethical and equity considerations in data sharing and reuse, delineate the FAIR principles as they apply to mental health research, and consider the current state of FAIR data practices in global mental health research, identifying challenges and opportunities. We describe noteworthy examples of collaborative efforts, often across disciplinary and national boundaries, to improve Findability and Accessibility of global mental health data, as well as efforts to create integrated data resources and tools that improve Interoperability and Reusability. Based on this review, we suggest a vision for the future of FAIR global mental health research and suggest practical steps for researchers with regard to study planning, data preservation and indexing, machine-actionable metadata, data reuse to advance science and improve equity, metrics and recognition.
In the past 10 years an increasing number of randomised trials have examined the effects of transdiagnostic treatments of patients with depression or anxiety. We conducted the first comprehensive meta-analysis of the outcomes of this emerging field.
We used the searches in PubMed, PsychINFO, Embase and the Cochrane library of an existing database of randomised trials of psychological interventions for depression to identify studies comparing a transdiagnostic treatment of patients with depression or anxiety with a control group (deadline 1 January 2022). We conducted random-effects meta-analyses and examined the effects on depression and anxiety at the short and longer term.
We included 45 randomised controlled trials with 51 comparisons between a psychotherapy and a control group and 5530 participants. Thirty-five (78%) studies were conducted in the last 10 years. The overall effect size was g = 0.54 (95% CI 0.40–0.69; NNT = 5.87), with high heterogeneity (I2 = 78; 95% CI 71–83), and a broad PI (−0.31–1.39). The effects remained significant in a series of sensitivity analyses, including exclusion of outliers, adjustment for publication bias, for studies with low risk of bias, and in multilevel analyses. The results were comparable for depression and anxiety separately. At 6 months after randomisation the main effects were still significant, but not at 12 months, although the number of studies was small.
Transdiagnostic treatments of patients with depression or anxiety are increasingly examined and are probably effective at the short term.
Climate change may affect mental health. We conducted an umbrella review of meta-analyses examining the association between mental health and climate events related to climate change, pollution and green spaces. We searched major bibliographic databases and included meta-analyses with at least five primary studies. Results were summarized narratively. We included 24 meta-analyses on mental health and climate events (n = 13), pollution (n = 11), and green spaces (n = 2) (two meta-analyses provided data on two categories). The quality was suboptimal. According to AMSTAR-2, the overall confidence in the results was high for none of the studies, for three it was moderate, and for the other studies the confidence was low to critically low. The meta-analyses on climate events suggested an increased prevalence of symptoms of post-traumatic stress, depression, and anxiety associated with the exposure to various types of climate events, although the effect sizes differed considerably across study and not all were significant. The meta-analyses on pollution suggested that there may be a small but significant association between PM2.5, PM10, NO2, SO2, CO and mental health, especially depression and suicide, as well as autism spectrum disorders after exposure during pregnancy, but the resulting effect sizes varied considerably. Serious methodological flaws make it difficult to draw credible conclusions. We found reasonable evidence for an association between climate events and mental health and some evidence for an association between pollution and mental disorders. More high-quality research is needed to verify these associations.
Several in-person and remote delivery formats of cognitive-behavioural therapy (CBT) for panic disorder are available, but up-to-date and comprehensive evidence on their comparative efficacy and acceptability is lacking. Our aim was to evaluate the comparative efficacy and acceptability of all CBT delivery formats to treat panic disorder. To answer our question we performed a systematic review and network meta-analysis of randomised controlled trials. We searched MEDLINE, Embase, PsycINFO, and CENTRAL, from inception to 1st January 2022. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO. We found a total of 74 trials with 6699 participants. Evidence suggests that face-to-face group [standardised mean differences (s.m.d.) −0.47, 95% confidence interval (CI) −0.87 to −0.07; CINeMA = moderate], face-to-face individual (s.m.d. −0.43, 95% CI −0.70 to −0.15; CINeMA = Moderate), and guided self-help (SMD −0.42, 95% CI −0.77 to −0.07; CINeMA = low), are superior to treatment as usual in terms of efficacy, whilst unguided self-help is not (SMD −0.21, 95% CI −0.58 to −0.16; CINeMA = low). In terms of acceptability (i.e. all-cause discontinuation from the trial) CBT delivery formats did not differ significantly from each other. Our findings are clear in that there are no efficacy differences between CBT delivered as guided self-help, or in the face-to-face individual or group format in the treatment of panic disorder. No CBT delivery format provided high confidence in the evidence at the CINeMA evaluation.
Although psychological treatments have been found to be effective for depression in adults, many individuals with depression do not actively seek help. It is currently unclear whether psychological treatments are effective among those not actively seeking help. Besides, little is known about the proportion of patients who completed a screening questionnaire who end up in a clinical trial. Therefore, we conducted a meta-analysis of 52 randomized trials comparing psychotherapies for adults with a diagnosis or elevated symptoms of depression against control conditions (care-as-usual, waiting list, and other inactive treatment). Only studies recruiting participants who do not actively seek help (participants who have been recruited through screening instead of advertisements and clinical referrals) were included. To obtain an overall effect estimate of psychotherapy, we pooled all post-test differences with a random-effects model. We found that psychological treatments had a moderate to high effect on reducing depressive symptoms compared to control groups [g = 0.55; 95% confidence interval (CI) 0.41–0.69]. Heterogeneity was high (I2 = 75%; 95% CI 68–80). At 12 months' follow-up, the effects were small but significant (6–8 months: g = 0.33; 95% CI 0.14–0.52; 9–12 months: g = 0.24; 95% CI 0.11–0.37). As a secondary outcome, we found that 13% of patients who completed a screening questionnaire met the inclusion criteria for depression and agreed to be randomized in the trial. Based on the current evidence, psychological treatments for depression might be effective for depressed patients who are not actively seeking help.
Studies have identified high rates of mental disorders in refugees, but most used self-report measures of psychiatric symptoms. In this study, we examined the percentages of adult refugees and asylum seekers meeting diagnostic criteria for major depressive disorder (MDD), post-traumatic stress disorder, bipolar disorder (BPD), and psychosis.
A systematic literature search in three databases was conducted. We included studies examining the prevalence of MDD, post-traumatic stress disorder, BPD, and psychosis in adult refugees according to a clinical diagnosis. To estimate the pooled prevalence rates, we performed a meta-analysis using the Meta-prop package in Stata (PROSPERO: CRD42018111778).
We identified 7048 records and 40 studies (11 053 participants) were included. The estimated pooled prevalence rates were 32% (95% CI 26–39%; I2= 99%) for MDD, 31% (95% CI 25–38%; I2= 99.5%) for post-traumatic stress disorder, 5% (95% CI 2–9%; I2 = 97.7%) for BPD, and 1% (95% CI 1–2%; I2= 0.00%) for psychosis. Subgroup analyses showed significantly higher prevalence rates of MDD in studies conducted in low-middle income countries (47%; 95% CI 38–57%, p = 0.001) than high-income countries studies (28%; 95% CI 22–33%), and in studies which used the Mini-International Neuropsychiatric Interview (37%; 95% CI 28–46% p = 0.05) compared to other diagnostic interviews (26%; 95% CI 20–33%). Studies among convenience samples reported significant (p = 0.001) higher prevalence rates of MDD (35%; 95% CI 23–46%) and PTSD (34%; 95% CI 22–47%) than studies among probability-based samples (MDD: 30%; 95% CI 21–39%; PTSD: 28%; 95% 19–37%).
This meta-analysis has shown a markedly high prevalence of mental disorders among refugees. Our results underline the devastating effects of war and violence, and the necessity to provide mental health intervention to address mental disorders among refugees. The results should be cautiously interpreted due to the high heterogeneity.
The treatment of depression in patients with somatic disorders is crucial, given its negative impact on quality of life (QoL), functioning, and even on the somatic disease prognosis. We aimed to examine the most updated evidence on the effects of psychotherapy in patients with depression and somatic disorders, including HIV, oncological, cardiometabolic, and neurological disorders.
We conducted a meta-analysis of 75 randomized trials (8209 participants) of psychotherapy for adults with somatic disorders and a diagnosis or elevated symptoms of depression. Outcomes included depression, QoL, somatic health-related outcomes, and mortality.
Psychotherapy significantly reduced the severity of depression at post-treatment across all categories of somatic disorders (Hedges'g = 0.65; 95% CI 0.52–0.79), with sustained effects at 6–11 months (g = 0.38; 95% CI 0.22–0.53) and at 12 months follow-up or longer (g = 0.13; 95% CI 0.04–0.21). Psychotherapy also showed significant effects on QoL (g = 0.26; 95% CI 0.17–0.35), maintained up to 11 months follow-up (g = 0.25; 95% CI 0.16–0.34). No significant effects were observed on the most frequently reported somatic health-related outcomes (glycemic control, pain), and neither on mortality. Heterogeneity in most analyses was very high, and only 29 (38%) trials were rated at low risk of bias (RoB).
Psychotherapy may be an effective treatment option for patients with depression and somatic disorders, with long-term effects on depression severity and QoL. However, these results should be interpreted with caution due to heterogeneity and RoB.
Depression during pregnancy and after the birth of a child is highly prevalent and an important public health problem. Psychological interventions are the first-line treatment and, although a considerable number of randomized trials have been conducted, no recent comprehensive meta-analysis has evaluated treatment effects.
We used an existing database of randomized controlled trials of psychotherapies for adult depression and included studies aimed at perinatal depression. Random effects models were used in all analyses. We examined the effects of the interventions in the short and long term, and also examined secondary outcomes.
Forty-three studies with 49 comparisons and 6270 participants between an intervention and control group were included. The overall effect size was g = 0.67 [95% confidence interval (CI) 0.45~0.89; numbers needed-to-be-treated = 4.39] with high heterogeneity (I2 = 80%; 95% CI 75~85). This effect size remained largely unchanged and significant in a series of sensitivity analyses, although some publication bias was found. The effects remained significant at 6–12 months follow-up. Significant effects were also found for social support, anxiety, functional limitations, parental stress and marital stress, although the number of studies for each outcome was low. All results should be considered with caution because of the high levels of heterogeneity in most analyses.
Psychological interventions are probably effective in the treatment of perinatal depression, with effects that last at least up to 6–12 months and probably also have effects on social support, anxiety, functional impairment, parental stress, and marital stress.
Psychotherapies are the treatment of choice for panic disorder, but which should be considered as first-line treatment is yet to be substantiated by evidence.
To examine the most effective and accepted psychotherapy for the acute phase of panic disorder with or without agoraphobia via a network meta-analysis.
We conducted a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the most effective and accepted psychotherapy for the acute phase of panic disorder. We searched MEDLINE, Embase, PsycInfo and CENTRAL, from inception to 1 Jan 2021 for RCTs. Cochrane and PRISMA guidelines were used. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO (CRD42020206258).
We included 136 RCTs in the systematic review. Taking into consideration efficacy (7352 participants), acceptability (6862 participants) and the CINeMA confidence in evidence appraisal, the best interventions in comparison with treatment as usual (TAU) were cognitive–behavioural therapy (CBT) (for efficacy: standardised mean differences s.m.d. = −0.67, 95% CI −0.95 to −0.39; CINeMA: moderate; for acceptability: relative risk RR = 1.21, 95% CI −0.94 to 1.56; CINeMA: moderate) and short-term psychodynamic therapy (for efficacy: s.m.d. = −0.61, 95% CI −1.15 to −0.07; CINeMA: low; for acceptability: RR = 0.92, 95% CI 0.54–1.54; CINeMA: moderate). After removing RCTs at high risk of bias only CBT remained more efficacious than TAU.
CBT and short-term psychodynamic therapy are reasonable first-line choices. Studies with high risk of bias tend to inflate the overall efficacy of treatments. Results from this systematic review and network meta-analysis should inform clinicians and guidelines.
Digital interventions for anxiety disorders are a promising solution to address barriers to evidence-based treatment access. Precise and powerful estimates of digital intervention effectiveness for anxiety disorders are necessary for further adoption in practice. The present systematic review and meta-analysis examined the effectiveness of digital interventions across all anxiety disorders and specific to each disorder v. wait-list and care-as-usual controls.
A systematic search of bibliographic databases identified 15 030 abstracts from inception to 1 January 2020. Forty-seven randomized controlled trials (53 comparisons; 4958 participants) contributed to the meta-analysis. Subgroup analyses were conducted by an anxiety disorder, risk of bias, treatment support, recruitment, location and treatment adherence.
A large, pooled effect size of g = 0.80 [95% Confidence Interval: 0.68–0.93] was found in favor of digital interventions. Moderate to large pooled effect sizes favoring digital interventions were found for generalized anxiety disorder (g = 0.62), mixed anxiety samples (g = 0.68), panic disorder with or without agoraphobia (g = 1.08) and social anxiety disorder (g = 0.76) subgroups. No subgroups were significantly different or related to the pooled effect size. Notably, the effects of guided interventions (g = 0.84) and unguided interventions (g = 0.64) were not significantly different. Supplemental analysis comparing digital and face-to-face interventions (9 comparisons; 683 participants) found no significant difference in effect [g = 0.14 favoring digital interventions; Confidence Interval: −0.01 to 0.30].
The precise and powerful estimates found further justify the application of digital interventions for anxiety disorders in place of wait-list or usual care.
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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