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Meerwijk, E.L., Parekh, A., Oquendo, M.A., Allen, I.E., Franck, L.S., & Lee, K.A. (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. Lancet Psychiatry.

The World Health Organization reports that more than 800,000 people die of suicide per year around the world. However suicide prevention efforts over the past decade have fallen short of targets. In fact, the prevalence rates of suicide in the US have risen steadily since 2000 to about 1.3% of the population in 2014. Many who kill themselves have a mental disorder like depression, anxiety disorders, substance abuse, psychoses, or personality disorders. Best practices suggest that directly addressing suicidal thoughts and behaviors during treatment, rather than only addressing symptoms like depression and hopelessness, are most effective in reducing suicide. However, there are no meta analyses of randomized controlled trials that specifically assess the relative utility of direct versus indirect psychological interventions. In their meta analysis, Meerwijk and colleagues looked at psychosocial interventions aimed to prevent suicide or to treat mental illness associated with suicide. They included 31 studies representing over 13,000 participants. Interventions included cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), case management, social skills training, and supportive telephone calls. Depending on the target problem, the interventions either directly addressed suicidal behavior or they indirectly addressed suicidal behavior. Mean duration of treatment was over 11 months. Studies that looked at direct or indirect interventions were each compared to control groups that received some form of usual care in the community, or psychiatric management, or general practitioner care. Individuals who received usual care were 1.5 times more likely to die of or attempt suicide compared to those receiving direct or indirect psychological interventions. There was a 35% lower odds of suicide and attempts with direct interventions compared to usual care; and an 18% lower odds of suicide and attempts with indirect interventions compared to usual care. The difference between the effectiveness of direct versus indirect interventions was large (d = .77), suggesting that direct interventions were more effective than indirect interventions at reducing suicide and suicide attempts.

Practice Implications

This is the largest meta analysis of its kind. Most direct interventions to prevent suicide and suicidal behaviors were based on CBT and DBT. Indirectly addressing suicide by focusing on depressive symptoms, anxiety, and hopelessness was somewhat effective compared to usual care. However, direct interventions that included talking about the patient’s suicidal thoughts and behaviors and how best to cope were most effective.

Weitz, E.S., Hollon, S.D., Twisk, J., van Straten, A., Huibers, M.J.H., David, D., …. Cuijpers, P. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: An individual patient data meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.1516.

The American Psychiatric Association guidelines for the treatment of depression indicates that although psychotherapy is adequate for mild to moderate depression, anti-depressant medications are indicated for the treatment of severe depression in major depressive disorder. These recommendations are mainly based on the findings of the National Institute of Mental Health Treatment of Depression Collaborative Research Program that was published in the mid 1990s. Several authors since then have disputed this claim, but no meta-analyses have been done on the studies of head-to-head patient-level comparisons of psychotherapy vs antidepressant medications for the purpose of evaluating their relative efficacy for severity of depression. In this meta analysis, Weitz and colleagues look at medications vs psychotherapy for depression and then evaluate if initial severity of depressive symptoms helped to explain any differences. The authors looked at all studies that compared cognitive behavioral therapy (CBT) against antidepressant medications for depression. They focused on CBT because it was the most often studied of the psychotherapies in this context. A systematic review turned up 24 studies, and they were able to get original patient-level data from the authors of 16 of the 24 studies. This represented over 1,700 participants with major depression. These 16 studies were no different from the 8 studies that did not provide original data. Between 17% and 54% of the 1,700 depressed participants met criteria for severe depression at pre-treatment. There were no significant differences between antidepressant medications and CBT on clinically relevant outcomes in terms of “response” (i.e., improvement) or “remission” (i.e., symptom-free). In total, 63% of patients in the antidepressant medication condition and 58% of patients in the CBT condition responded to treatment, and 51% of patients in the antidepressant medication condition and 47% of patients in the CBT condition met criteria for remission. Most importantly, the effects of CBT and antidepressant medications on response to treatment or remission did not differ based on initial severity of depressive symptoms.

Practice Implications

Patients with severe depression were no more likely to require medication to get better than patients with less severe depression. This meta analysis that included the majority of studies that exist on the topic found no evidence to support the guidelines that severe depression should be treated with antidepressant medications over psychotherapy. The authors conclude that CBT may also be a first-line treatment for severe depression.

Clarke, K., Mayo-Wilson, E., Kenny, J., & Phillig, S. (2015). Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clinical Psychology Review, 39, 58-70.

According to the American Psychiatric Association, the risk for relapse from depression can be as high as 60% for those who had one episode, 70% for those who had two episodes, and 90% for those who had three previous episodes. Intervening after recovery from an episode of depression might prevent relapse. A relapse is defined as any significant deterioration in depression following a period of clear improvement. We know that relapse after discontinuing antidepressant treatment is greater than relapse after discontinuing psychotherapy, likely because psychotherapy and not medications result in the patient acquiring new coping skills and strengths. Clarke and colleagues conducted a meta analysis of psychological interventions that were designed or adapted in order to reduce relapse after the acute phase depression. These include mindfulness based therapy (MBT) which helps individuals process experience without judgment by using mindfulness techniques; cognitive behavioral therapy (CBT) which helps to modify thoughts and behaviors key to depression; and interpersonal psychotherapy (IPT) which focuses on helping to deal with interpersonal and social role problems related to depression. Clarke and colleagues reviewed 29 studies that included 4216 participants who had at least one episode of depression, had recovered after treatment, and who received either MBT, CBT, or IPT to prevent relapse. These were compared to control conditions that included wait-lists, treatment as usual, or some other active intervention. Compared to all of the controls, MBT, CBT, and IPT reduced relapse rates from 21% to 25% among patients one year post acute treatment. The effects for CBT were maintained up to two years post treatment. There were no differences between psychotherapies and control conditions in drop out rates.

Practice Implications

Psychotherapies (e.g., MBT, CBT, and IPT) reduce relapse from depression by about 22%. up to one year post recovery. Practitioners should consider offering MBT, CBT, or IPT as a form of booster sessions to reduce the likelihood of relapse from a previous episode of depression. Such interventions are important given the increasing relapse rates for each subsequent episode of depression.

Johnsen, T. J., & Friborg, O. (2015, May 11). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015

Depression is a highly debilitating disorder and ranked third in terms of disease burden in the world. Cognitive behavioral therapy (CBT) is an effective treatment for depression that was introduced over 40 years ago. In part, CBT sees depression as caused by maladaptive thoughts that maintain emotional distress and dysfunctional behavior. Reducing depression is achieved by eliminating the impact of or chancing maladaptive thoughts. CBT is the most researched psychological treatment for depression, and the research goes back several decades. A number of technical variations and new additions have been made over the years to CBT to improve patient outcomes. The volume of research and its history provides a unique opportunity to assess time trends in the effects of CBT. In this meta analysis, Johnsen and Friborg asked: “have the effects of CBT changed over time”? They also looked at whether client factors (e.g., demographics, symptom severity), therapist factors (e.g., age, experience, training), common factors (e.g., therapeutic alliance, client expectancies), and technique factors (e.g., fidelity to a treatment manual) can explain these trends. Johnsen and Friborg reported on 70 studies of 2,426 patients conducted from 1977 to 2014. Males accounted for 30.9% of patients, 43% had comorbid psychiatric conditions, and the average patient was at least moderately depressed. The average effect of CBT in reducing depression was large (g = 1.46 after accounting for publication bias). Women had better outcomes, studies with poorer methodological quality showed larger effects, and patients of more experienced therapists had better outcomes. There were too few studies measuring therapeutic alliance to assess the effect of common factors on outcomes. Most interesting was a significant relationship between effect sizes and year of publication. That is, the effects of CBT declined significantly over the years, though the average effect remained large. Surprisingly, there was a steeper decline for studies that used a treatment manual compared to those that did not. No other variables were reliably associated with this decline.

Practice Implications

Women and patients of more experienced therapists appear to benefit most from CBT. Although the effects of CBT declined over time, the treatment remained highly effective. Johnsen and Friborg’s study could not easily explain this decline. The authors suggested that the placebo effect (expectation on the part of patients, researchers, and therapists) is typically stronger for new treatments. However, as time passes the strong initial expectations tend to wane thus reducing the overall effect of the intervention. They also suggested that CBT treatment outcomes may be improved not by technical variations and new additions, but by better ways of integrating common, therapist, and client factors.

Author email: tjj@psykologtromso.no

Cuijpers, P., Koole, S.L., van Dijke, A., Roca, M., Li, J., & Reynolds, C.F. (2014). Psychotherapy for subclinical depression: A meta-analysis. British Journal of Psychiatry, 205, 268-274.

Subclinical depression refers to someone having relevant depressive symptoms but without meeting standard diagnostic criteria for a depressive disorder. Cuijpers and colleagues indicate that subclinical depression can be defined as meeting at least one but not more than four DSM core symptoms for depression. Subclinical depression is highly prevalent. About 50% of individuals with major depression have had a subclinical depressive disorder, and so subclinical depression may be a risk for developing major depression later on. Depression in general is associated with a high level of health and economic burden worldwide (see my June 2014 blog). Antidepressant medications are likely not more effective than a placebo in treating subclinical depression. Cuipers and colleagues examined whether psychotherapy is effective in treating subclinical depression, and whether psychotherapy reduces the subsequent occurrence of major depression. Cuijpers and colleagues report on a meta analysis of 18 studies of psychotherapy for subclinical depression representing 1,913 patients. Most of the studies were based on cognitive behavioral therapy (CBT). In order to compare the effects of psychotherapy for subclinical depression versus psychotherapy for major depression, they also included 56 studies of psychotherapy for major depression. Psychological treatments had a small to moderate effect on subclinical depression (g = .35) that was statistically significant. Psychotherapy significantly reduced the incidence of major depressive episodes by 39% at 6 months follow up, and by 26% at 12 months follow up. The effect of psychotherapy for major depression (g = .63) was significantly larger than the effect of psychotherapy for subclinical depression (g = .35). No differences were found between CBT and other forms of psychotherapy for subclinical depression.

Practice Implications

The results of this meta analysis indicate that psychological treatment of subclinical depression is moderately effective, and may reduce the incidence of major depression in the longer term for some. Effect sizes of psychotherapy for subclinical depression were likely underestimated because the type of control groups used in these studies affected study quality. However, even after controlling for study quality, the effects of psychotherapy for subclinical depression were still smaller than effects for psychotherapy of major depression. Although the number of studies comparing CBT to other therapies is small, the findings are similar to other meta analyses that indicate that several psychotherapies are effective treatment options for depressive symptoms.

Xie, C.L., Wang, X.D., Chen, J., Lin, H.Z., Chen, Y.H., Pan, J.L., & Wang, W.W. (2015). A systematic review and meta-analysis of cognitive behavioral and psychodynamic therapy for depression in Parkinson’s disease patients. Neurological Sciences, 1-11.

Parkinson’s disease (PD) is a neurodegenerative brain disorder that progresses slowly in most people. When dopamine producing cells in the brain are damaged or do not produce enough dopamine, motor symptoms of PD appear. Non-motor symptoms, including depression, apathy, and sleep disorders are also common so that in clinical settings about a 40% of patients with PD may have a depressive disorder. Depression is a top predictor of poor quality of life in patients with PD. Depression in PD is not well understood but may be due to neurobiological vulnerability and to psychological factors. Antidepressant medications are often prescribed for depression in PD but their efficacy is questionable. Xie and colleagues argue that long term use of some antidepressants may lead to worsening of some PD motor symptoms. In this meta analysis, Xie and colleagues examine the efficacy of brief psychological interventions, including cognitive behavioral therapy (CBT) and psychodynamic psychotherapy for depressive symptoms in PD. Twelve eligible studies were included in the meta analysis representing 766 patients with a mean age of 62 years (48% men). As an interesting note, 9 of the 12 studies were conducted in China and 3 were from the US or UK. Six of the studies used CBT for depression, and the remaining used psychodynamic therapy for depression in PD patients. Control conditions were often “treatment as usual”, and varied from antidepressant medication (e.g., Citalopram), nursing care, telephone calls, or no treatment for the depression. The effects of psychological interventions compared to control conditions on depressive symptoms were large, and remained large even after removing outlier studies. Outcomes for psychodynamic psychotherapy were better than for CBT, although both interventions resulted in large effects. There were also significant positive effects of brief psychotherapies on cognitive functioning, but not on quality of life. The authors were concerned that the quality of studies was variable and that many studies demonstrated a risk of bias. Further, most studies did not report outcomes at follow up periods.

Practice Implications

Significant depressive symptoms commonly occur in patients with Parkinson’s disease (PD). As a result, overall quality of life may be reduced in patients with PD. Medications for depression may be complicated by the neurodegenerative nature of PD – that is, effects of medications on depressive symptoms may be small and their neuro-motor side effects may be intolerable for some patients. This meta analysis by Xie and colleagues of 12 studies suggests that better research on psychotherapy for depression in PD needs to be conducted with adequate follow ups. Nevertheless, the findings suggest that brief psychological interventions may represent viable and effective alternatives for patients with PD who have a depressive disorder.