The efficacy and acceptability of psychological interventions for depression: where we are now and where we are going

Abstract

Depression is an eminently treatable disorder, although estimates of treatment efficacy have been inflated by publication bias. Patients with less severe depressions respond to even nonspecific interventions, whereas patients with more severe depressions require treatments that mobilize specific mechanisms. The cognitive and behavior therapies can be as efficacious as medications in the treatment of severe depression and have an enduring effect that medications lack. Medications may interfere with those enduring effects when added in combination and may prolong the life of the underlying episode when used alone. Thus the cognitive behavioral interventions might be the optimal first-line treatments for depression. First published online 27 August 2015Key words: Depression, precision medicine, prevention, treatment. Is treatment as efficacious as is currently believed?Several different types of interventions have been established in the treatment of major depressive disorder (MDD), but the efficacy of those interventions has been overestimated in the published literature. This appears to be true with respect to both the antidepressant medications (ADMs) and psychotherapy. Turner et al. (2008) found that only half the studies submitted to the Food and Drug Administration to secure marketing approval found active medication to be superior to pill-placebo and that over 90% of those positive studies ended up being published v. only about a third of those with null findings. Moreover, nearly all of the 'failed' studies that did get published were 'spun' to make it appear that ADM was superior to pill-placebo. Correcting for publication bias reduced the estimated effect of medication by about a third. Cuijpers et al. (2010) found comparable magnitude of publication bias in the psychotherapy literature, although this had to be inferred from a relative deficit of small studies with weak effects. What this means is that someone reading the published literature would come away thinking that both ADM and psychotherapy are more efficacious than they really are. It is not that they do not work; just that they do not work as well as the published literature would lead one to believe. Does treatment have a specific effect for less severe patients?Fournier et al. (2010) plotted treatment outcome as a function of initial severity at the level of the individual patient and found that ADM separated from pillplacebo only among patients with more severe depressions. Patients with less severe depressions (over half of the sample) did about as well on pill-placebo as they did on active medications. This means that they are responding to psychological rather than pharmacological mechanisms. Something similar appears to be the case for the psychosocial interventions. Driessen et al. (2010) found that psychosocial interventions only exceeded non-specific controls among patients with more severe depressions. As for medications, this suggests that non-specific factors account for a large portion of the effects of psychotherapy. Cuijpers e...

The Mortality and Myocardial Effects of Antidepressants Are Moderated by Preexisting Cardiovascular Disease: A Meta-Analysis

“…Put another way, controlling for depressive symptoms that are concurrent with AD use may cause researchers to underestimate the adverse health effects of AD use. One possible explanation is that AD use only leads to a transient reduction in depressive symptoms because they induce an oppositional tolerance (caused by mechanisms in the brain responsible for maintaining homeostasis) that interferes with spontaneous remission and prolongs episodes [19,27,94,95,96]. Under this hypothesis, depressive symptoms under prolonged AD use (i.e., months or longer) are higher than they would be without medication, and partialling out concurrent depression also partials out the negative health effects of ADs that covary with this iatrogenic depression.…”

Evidence‐Based Interventions for Depressed Mothers and Their Young Children

“…The benefits of ADMs are particularly robust for individuals with severe depression (see Hollon, 2016 for a review). ADMs are the most common treatment for depression in child-bearing age women (Ko, Farr, Dietz, & Robbins, 2012).…”

“…Importantly, CBT has enduring effects that last beyond the end of the acute treatment, and are about the same as remaining on ADMs. CBT also is about two and a half times more likely to prevent recurrence as compared to stopping ADMs (see Hollon, 2016 for a review). With regard to perinatal depression in particular, a meta-analytic review (Sockol, 2015) showed that interventions based on CBT resulted in significant reductions in depressive symptoms compared to controls, with even greater reductions in depression in studies that included higher proportions of mothers who were nonwhite, single, and had more than one child.…”

The implementation and adherence to evidence-based protocols for psychotherapy for depression: the perspective of therapists in Dutch specialized mental healthcare

“…Adequate implementation of protocolized, evidence-based psychotherapy such as cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) has been associated with better treatment outcomes [ 1 , 2 ]. Unfortunately, a large number of patients still receives inadequate or suboptimal psychological treatment [ 3 – 9 ].…”