Cochrane Database of Systematic Reviews (Reviews) || Behavioural therapies versus other...

Behavioural therapies versus other psychological therapies for

depression (Review)

Shinohara K, Honyashiki M, Imai H, Hunot V, Caldwell DM, Davies P, Moore THM,

Furukawa TA, Churchill R

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2013, Issue 10

http://www.thecochranelibrary.com

Behavioural therapies versus other psychological therapies for depression (Review)

Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .

5BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

30ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .

35DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

37AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

37ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

96DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 BT vs all other psychological therapies, Outcome 1 Response. . . . . . . . . . 102

Analysis 1.2. Comparison 1 BT vs all other psychological therapies, Outcome 2 Remission. . . . . . . . . . 104

Analysis 1.3. Comparison 1 BT vs all other psychological therapies, Outcome 3 Depression severity. . . . . . . 106

Analysis 1.4. Comparison 1 BT vs all other psychological therapies, Outcome 4 Dropouts for any reason. . . . . 108

Analysis 1.5. Comparison 1 BT vs all other psychological therapies, Outcome 5 Anxiety. . . . . . . . . . . 110

Analysis 1.6. Comparison 1 BT vs all other psychological therapies, Outcome 6 Social adjustment. . . . . . . . 111

Analysis 2.1. Comparison 2 BT-Lewinsohn vs all other psychological therapies, Outcome 1 Response. . . . . . 112

Analysis 2.2. Comparison 2 BT-Lewinsohn vs all other psychological therapies, Outcome 2 Dropouts for any reason. 113

Analysis 3.1. Comparison 3 BT-Jacobson vs all other psychological therapies, Outcome 1 Response. . . . . . . 114

Analysis 3.2. Comparison 3 BT-Jacobson vs all other psychological therapies, Outcome 2 Dropouts for any reason. . 115

Analysis 4.1. Comparison 4 BT-SST/assertiveness vs all other psychological therapies, Outcome 1 Response. . . . 116

Analysis 4.2. Comparison 4 BT-SST/assertiveness vs all other psychological therapies, Outcome 2 Dropouts for any

reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Analysis 5.1. Comparison 5 BT-Relaxation vs all other psychological therapies, Outcome 1 Response. . . . . . 118

Analysis 5.2. Comparison 5 BT-Relaxation vs all other psychological therapies, Outcome 2 Dropouts for any reason. 119

Analysis 6.1. Comparison 6 BT vs all other psychological therapies (Best/worst case scenario), Outcome 1 Response (best

case scenario). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Analysis 6.2. Comparison 6 BT vs all other psychological therapies (Best/worst case scenario), Outcome 2 Response (worst

case scenario). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Analysis 7.1. Comparison 7 Sensitivity analysis: BT vs all other psychological therapies (treatment fidelity), Outcome 1

Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124


Depression severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125


Dropouts for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Analysis 8.1. Comparison 8 Sensitivity analysis: BT vs all other psychological therapies (excluding imputed data), Outcome

1 Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127


2 Remission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

iBehavioural therapies versus other psychological therapies for depression (Review)



3 Depression severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Analysis 9.1. Comparison 9 Sensitivity analysis: BT vs all other psychological therapies (pharmacotherapy not allowed),

Outcome 1 Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131


Outcome 2 Depression severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . 132


Outcome 3 Dropouts for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Analysis 10.1. Comparison 10 Sensitivity analysis: BT vs all other psychological therapies (excluding other subcategories),

Outcome 1 Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134


Outcome 2 Depression severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . 135


Outcome 3 Dropouts for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Analysis 11.1. Comparison 11 Sensitivity analysis: BT vs all other psychological therapies (major depression only), Outcome

1 Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138




3 Dropouts for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Analysis 12.1. Comparison 12 Sensitivity analysis: BT vs all other psychological therapies (fewer than 13 sessions), Outcome

1 Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141




3 Dropouts for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Analysis 13.1. Comparison 13 Sensitivity analysis: BT vs all other psychological therapies (excluding studies that replaced

dropouts), Outcome 1 Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147


dropouts), Outcome 2 Depression severity. . . . . . . . . . . . . . . . . . . . . . . . . 149


dropouts), Outcome 3 Dropouts for any reason. . . . . . . . . . . . . . . . . . . . . . . 151

Analysis 14.1. Comparison 14 BT vs all other psychological therapies (follow-up within 6 months), Outcome 1

Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Analysis 14.2. Comparison 14 BT vs all other psychological therapies (follow-up within 6 months), Outcome 2

Remission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

Analysis 14.3. Comparison 14 BT vs all other psychological therapies (follow-up within 6 months), Outcome 3 Depression

severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

Analysis 15.1. Comparison 15 BT-Lewinsohn vs CBT-Cognitive therapy, Outcome 1 Response. . . . . . . . 156

Analysis 15.2. Comparison 15 BT-Lewinsohn vs CBT-Cognitive therapy, Outcome 2 Depression severity. . . . . 157

Analysis 15.3. Comparison 15 BT-Lewinsohn vs CBT-Cognitive therapy, Outcome 3 Dropouts for any reason. . . 158

Analysis 16.1. Comparison 16 BT-SST/assertiveness vs CBT-Self-Control, Outcome 1 Response. . . . . . . . 159

Analysis 16.2. Comparison 16 BT-SST/assertiveness vs CBT-Self-Control, Outcome 2 Depression severity. . . . . 159

Analysis 16.3. Comparison 16 BT-SST/assertiveness vs CBT-Self-Control, Outcome 3 Dropouts for any reason. . . 160

160APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

166CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

167DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

167SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iiBehavioural therapies versus other psychological therapies for depression (Review)


[Intervention Review]

Behavioural therapies versus other psychological therapies fordepression

Kiyomi Shinohara1, Mina Honyashiki1 , Hissei Imai2, Vivien Hunot3 , Deborah M Caldwell4, Philippa Davies4, Theresa HM Moore4, Toshi A Furukawa5 , Rachel Churchill3

1Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health,

Kyoto, Japan. 2Department of Field Medicine, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto,

Japan. 3Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Bristol, UK. 4School

of Social and Community Medicine, University of Bristol, Bristol, UK. 5Departments of Health Promotion and Behavior Change and

of Clinical Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan

Contact address: Rachel Churchill, Centre for Academic Mental Health, School of Social and Community Medicine, University of

Bristol, Oakfield House, Oakfield Grove, Bristol, Avon, BS8 2BN, UK. [email protected]. [email protected].

Editorial group: Cochrane Depression, Anxiety and Neurosis Group.

Publication status and date: New, published in Issue 10, 2013.

Review content assessed as up-to-date: 31 July 2013.

Citation: Shinohara K, Honyashiki M, Imai H, Hunot V, Caldwell DM, Davies P, Moore THM, Furukawa TA, Churchill R.

Behavioural therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews 2013, Issue 10. Art.No.: CD008696. DOI: 10.1002/14651858.CD008696.pub2.


A B S T R A C T

Background

Behavioural therapies represent one of several categories of psychological therapies that are currently used in the treatment of depression.

However, the effectiveness and acceptability of behavioural therapies for depression compared with other psychological therapies remain

unclear.

Objectives

1. To examine the effects of all BT approaches compared with all other psychological therapy approaches for acute depression.

2. To examine the effects of different BT approaches (behavioural therapy, behavioural activation, social skills training and relaxation

training) compared with all other psychological therapy approaches for acute depression.

3. To examine the effects of all BT approaches compared with different psychological therapy approaches (CBT, third wave CBT,

psychodynamic, humanistic and integrative psychological therapies) for acute depression.

Search methods

We searched the Cochrane Depression Anxiety and Neurosis Group Trials Specialised Register (CCDANCTR, 31/07/2013), which

includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE, (1974-), MEDLINE (1950-) andPsycINFO (1967-). We also searched CINAHL (May 2010) and PSYNDEX (June 2010) and reference lists of the included studies

and relevant reviews for additional published and unpublished studies.

Selection criteria

Randomised controlled trials that compared behavioural therapies with other psychological therapies for acute depression in adults.

1Behavioural therapies versus other psychological therapies for depression (Review)

mailto:[email protected]:[email protected]

Data collection and analysis

Two or more review authors independently identified studies, assessed trial quality and extracted data. We contacted study authors for

additional information.

Main results

Twenty-five trials involving 955 participants compared behavioural therapies with one or more of five other major categories of

psychological therapies (cognitive-behavioural, third wave cognitive-behavioural, psychodynamic, humanistic and integrative therapies).

Most studies had a small sample size and were assessed as being at unclear or high risk of bias. Compared with all other psychological

therapies together, behavioural therapies showed no significant difference in response rate (18 studies, 690 participants, risk ratio (RR)

0.97, 95% confidence interval (CI) 0.86 to 1.09) or in acceptability (15 studies, 495 participants, RR of total dropout rate 1.02, 95%

CI 0.65 to 1.61). Similarly, in comparison with each of the other classes of psychological therapies, low-quality evidence showed better

response to cognitive-behavioural therapies than to behavioural therapies (15 studies, 544 participants, RR 0.93, 95% CI 0.83 to 1.05)

and low-quality evidence of better response to behavioural therapies over psychodynamic therapies (2 studies, 110 participants, RR

1.24, 95% CI 0.84 to 1.82).

When compared with integrative therapies and humanistic therapies, only one study was included in each comparison, and the analysis

showed no significant difference between behavioural therapies and integrative or humanistic therapies.

Authors conclusions

We found low- to moderate-quality evidence that behavioural therapies and other psychological therapies are equally effective. The

current evidence base that evaluates the relative benefits and harms of behavioural therapies is very weak. This limits our confidence in

both the size of the effect and its precision for our key outcomes related to response and withdrawal. Studies recruiting larger samples

with improved reporting of design and fidelity to treatment would improve the quality of evidence in this review.

P L A I N L A N G U A G E S U M M A R Y

Behavioural therapies versus other psychological therapies for depression

Major depression is one of the common mental illnesses characterised by persistent low mood and loss of interest in pleasurable

activities, accompanied by a range of symptoms, including weight loss, insomnia, fatigue, loss of energy, inappropriate guilt, poor

concentration and morbid thoughts of death. Whilst antidepressants remain the mainstay of treatment for depression in healthcare

settings, psychological therapies are still important alternative or additional interventions for depressive disorders. Nowadays, a diverse

range of psychological therapies are available (such as cognitive-behavioural therapies, behavioural therapies, psychodynamic therapies,

humanistic therapies and integrative therapies). It is very important to know whether one type of psychological therapy is more effective

than another, and to know which psychological therapy is the most effective treatment for depression. In this review, we focused on

one of these-behavioural therapies (BT)-because they are relatively simple to deliver, and interest in them has recently been renewed.

Behavioural therapies are usually based purely on operant and respondent principles, aimed to change the patients depressive mood by

changing his or her behaviour patterns. Whilst a number of BT models have been developed, we categorised the following approaches as

behavioural therapies in this review: behavioural therapy (based on Lewinsohns model, which focused on increasing pleasant activities),

behavioural activation (originated from behavioural component of cognitive-behavioural therapy and based on Jacobsons work in

1996), social skills training/assertiveness training and relaxation therapy.

In this review, we assessed the efficacy and acceptability of behavioural therapies compared with all other psychological therapies in the

treatment of acute phase depression (neither long-term nor treatment-resistant depression) in adults. Twenty-five randomised controlled

trails were included in this review. The quality of evidence in our review is low because of issues with the design of the studies that

we found and lack of precision in our results. Although we found that behavioural therapies and all other psychological therapies are

equally effective and acceptable, more research is needed to confirm this finding.



S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

BT compared with all other psychological therapies for depression

Participants or population: people with depression

Settings: outpatient

Intervention: BT

Comparison: all other psychological therapies

Outcomes Illustrative comparative risks* (95% CI) Relative effect

(95% CI)

No of participants

(studies)

Quality of the evidence

(GRADE)

Comments

Assumed risk Corresponding risk

All other psychological

therapies

BT

Response 584 per 1000 567 per 1000

(503 to 637)

RR 0.97

(0.86 to 1.09)

690

(18 studies)

lowa,b,cThe confidence interval

crosses no difference

Remission 554 per 1000 504 per 1000

(443 to 576)

RR 0.91

(0.8 to 1.04)

694

(18 studies)

lowa,b,dThe confidence interval


Response at follow-up

Follow-up: 5 to 24 weeks

678 per 1000 522 per 1000

(400 to 685)

RR 0.77

(0.59 to 1.01)

356

(9 studies)

lowa,b,eThe confidence interval


Depression severity Mean depression severity

in the intervention groups

was

0.03 standard deviations

lower

(0.2 lower to 0.15 higher)

656

(18 studies)

moderatea,bSMD -0.03 (-0.2 to 0.15)

. The confidence interval


Dropouts for any reason 119 per 1000 122 per 1000

(78 to 192)

RR 1.02

(0.65 to 1.61)

495

(15 studies)

moderatea,bThe confidence interval


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*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the

assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence.

High quality: Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very low quality: We are very uncertain about the estimate.

aAll studies were at unclear or high risk of bias in sequence generation and allocation concealment.bThe comparison groups were heterogeneous.cOnly one study reported this outcome, and we used imputed data in other studies.dBecause five studies reported this outcome, we used imputed data in other studies.eNo study reported this outcome; we used imputed data.

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B A C K G R O U N D

Description of the condition

Major depression is characterised by persistent low mood and loss

of interest in pleasurable activities, accompanied by a range of

symptoms, including weight loss, insomnia, fatigue, loss of energy,

inappropriate guilt, poor concentration and morbid thoughts of

death (APA 2000). Somatic complaints are also a common fea-

ture of depression, and people with severe depression may develop

psychotic symptoms (APA 2000).

Depression is the third leading cause of disease burden worldwide

and is expected to show a rising trend over the next 20 years (WHO

2004; WHO 2008). A recent European study has estimated the

point prevalence of major depression and dysthymia at 3.9% and

1.1%, respectively (ESEMeD/MHEDEA 2004). As the largest

source of non-fatal disease burden in the world, accounting for

12% of years lived with disability (Ustun 2004), depression is

associated with marked personal, social and economic morbidity

and loss of functioning and productivity, and it creates significant

demands on service providers in terms of workload (NICE 2009).

Depression is also associated with a significantly increased risk of

mortality (Cuijpers 2002). The strength of this association, even

when confounders such as physical impairment, health-related

behaviours and socio-economic factors are taken into account, has

been shown to be comparable with, or greater than, the strength of

the association between smoking and mortality (Mykletun 2009).

Description of the intervention

Clinical guidelines recommend pharmacological and psycholog-

ical interventions, alone or in combination, in the treatment of

moderate to severe depression (NICE 2009). The prescribing of

antidepressants has increased dramatically in many Western coun-

tries over the past 20 years, mainly with the advent of selective

serotonin reuptake inhibitors and other agents such as serotonin-

noradrenaline reuptake inhibitors (SNRIs) and noradrenalinergic

and specific serotonergic antidepressants (NaSSAs). Antidepres-

sants remain the mainstay of treatment for depression in health-

care settings (Ellis 2004; NICE 2009).

Whilst antidepressants are of proven efficacy for the acute treat-

ment of depression (Cipriani 2005; Guaiana 2007; Arroll 2009;

Cipriani 2009; Cipriani 2009a; Cipriani 2009b), adherence rates

remain very low (Hunot 2007; van Geffen 2009), in part because

of patients concerns about side effects and possible dependency

(Hunot 2007). Furthermore, surveys consistently demonstrate pa-

tients preference for psychological therapies over treatment with

antidepressants (Churchill 2000; Riedel-Heller 2005). Therefore,

psychological therapies offer an important alternative or adjunc-

tive intervention for depressive disorders.

A diverse range of psychological therapies are now available for

the treatment of common mental disorders (Pilgrim 2002). Psy-

chological therapies may be broadly categorised into four sepa-

rate philosophical and theoretical schools, comprising psychoana-

lytic/dynamic (Freud 1949; Klein 1960; Jung 1963), behavioural

(Watson 1924; Skinner 1953; Wolpe 1958), humanistic (Maslow

1943; Rogers 1951; May 1961) and cognitive approaches (Lazarus

1971; Beck 1979). Each of these four schools incorporates several

different and overlapping psychotherapeutic approaches. Some

psychotherapeutic approaches, such as cognitive-analytic therapy

(CAT) (Ryle 1990), explicitly integrate components from several

theoretical schools. Other approaches, such as interpersonal ther-

apy (IPT) for depression (Klerman 1984), have been developed to

address characteristics considered specific to the disorder of inter-

est.

Behaviour therapy (BT) became a dominant force in the 1950s,

drawing from the work of Skinner 1953, Wolpe 1958 and Eysenck

1960. BT emphasises the role of environmental cues in influencing

the acquisition and maintenance of behaviours (Nelson-Jones

1990) and, in contrast with psychoanalysis, was developed through

experimentally derived principles of learning (Rachman 1997).

Several BT models have been developed for the treatment of

depression, including Lewinsohns behavioural therapy approach

(Lewinsohn 1974), behavioural activation (BA) (Jacobson 1996)

and social skills training (Bellack 1980). Some models initially

developed as behavioural treatments, including problem-solving

therapy (Nezu 1986), self-control therapy (Fuchs 1977; Rehm

1977) and the Coping with Depression programme (Lewinsohn

1984), have, over time, integrated cognitive techniques (Jacobson

2001) (see Types of interventions section for a description of these

approaches).

How the intervention might work

Skinner 1953 proposed that depression was associated with an

interruption in established sequences of healthy behaviour that

were previously positively reinforced by the social environment

and were based on operant conditioning principles (in which

behaviour patterns are learnt, rather than instinctive). In subse-

quent expansions of this model, reduction of positively reinforced

healthy behaviour has also been attributed to a decrease in the

number and range of reinforcing stimuli available to the individ-

ual, lack of skill in obtaining positive reinforcement (Lewinsohn

1974) and/or increased frequency of punishment (Lewinsohn

1984).

Conventional BT models for depression focus attention on facil-

itating access to pleasant events and positive reinforcers and de-

creasing the intensity and frequency of events and consequences

deemed to be unpleasant/negative (Lewinsohn 1972), through

monitoring of pleasant events, activity scheduling, social skills

development, assertiveness training, relaxation therapy and time

management training (Hopko 2003a).



Why it is important to do this review

With the advent of cognitive therapy in the 1970s, BT approaches

based purely on operant and respondent principles became re-

garded as insufficient. However, over the past 10 to 15 years, inter-

est in the feasibility of behavioural treatments for depression has

been renewed (Hopko 2003a; Dimidjian 2011). Jacobson 1996

showed that the behavioural component of cognitive-behavioural

therapy (CBT) was as effective as the full package of CBT, and

investigators developed a new and more comprehensive model of

behavioural activation that would be amenable to dissemination

(Jacobson 2001). According to the updated clinical guidelines pro-

duced by the National Institute for Health and Clinical Excellence,

behavioural activation (BA) is one of the recommended treatment

options for moderate to major depressive disorder, along with cog-

nitive-behavioural therapy and IPT, although the guidelines ac-

knowledge that evidence for BA is currently less robust (NICE

2009). In this and other recent systematic reviews, inclusion of

a heterogeneous group of studies and studies using an extended

behavioural activation approach (eBA, regarded as a third wave

CBT intervention) limits interpretation of the findings (Cuijpers

2007; Ekers 2008).

A recent meta-analysis of 17 randomised controlled trials (RCTs)

comparing BT against controls or other psychological therapies

suggested superior outcomes compared with supportive coun-

selling and brief psychological therapy and equivalence between

CBT and BT, in terms of depression recovery rates, symptom lev-

els and participant dropout (Ekers 2008). However, inclusion of

studies using eBA, together with inclusion of minimal contact

computerised interventions, limits interpretation of these find-

ings. An earlier meta-analysis of 16 studies conducted by Cuijpers

2007 comprised a heterogeneous group of studies that included

individuals with dementia and inpatient populations; this again

makes interpretation of the findings difficult. Another systematic

review of brief psychological therapies for depression (Churchill

2001) is now out of date.

As described in Description of the intervention, patients still pre-

fer psychological therapies for the treatment of depression, and

many different types of psychological therapies are available. Thus

it is very important for clinicians to know whether any difference

has been noted between psychological therapies in terms of effi-

cacy or acceptability. Given the resurgence of interest in the use

of BT as a cost-effective intervention for depression that is poten-

tially simpler to deliver (Kanter 2010) and easier to implement

than other psychological therapy models, a comprehensive review

of the comparative effectiveness and acceptability of BT interven-

tions for depression is now timely to inform and update clinical

practice and future clinical guideline development. This review

forms part of a programme of 12 reviews covering BT, CBT, third

wave CBT, psychodynamic therapies, humanistic therapies and

integrative therapies, all compared with control conditions or with

one another.

O B J E C T I V E S

1. To examine the effects of all BT approaches compared with

all other psychological therapy approaches for acute depression.

2. To examine the effects of different BT approaches

(behavioural therapy, behavioural activation, social skills training

and relaxation training) compared with all other psychological

therapy approaches for acute depression.

3. To examine the effects of all BT approaches compared with

different psychological therapy approaches (CBT, third wave

CBT, psychodynamic, humanistic and integrative psychological

therapies) for acute depression.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Methods used in our review were set out in a published protocol

(Churchill 2010). Minor changes from this original protocol have

been deemed necessary and implemented; their details are listed in

the Differences between protocol and review subsection below.

Randomised controlled trials (RCTs) were eligible for inclusion

in this review. Trials employing a cross-over design were included

in the review (whilst it is acknowledged that this design is rarely

used in psychological therapy trials), but only data from the first

active treatment phase were used. Cluster RCTs were also eligible

for inclusion.

Quasi-randomised controlled trials, in which treatment assign-

ment is decided through methods such as alternate days of the

week, were not eligible for inclusion. Trials that replaced dropouts

without randomisation were included only when the proportion

of replaced participants was less than 20%.

Types of participants

Participant characteristics

Studies of men and women aged 18 years were included. A

Cochrane review on psychotherapy for depression in children and

adolescents (< 18 years) has been undertaken (Watanabe 2004).

The increasing prevalence of memory decline (Ivnik 1992), cog-

nitive impairment (Rait 2005) and multiple comorbid physical

disorders/polypharmacy (Chen 2001) in individuals over 74 years

may differentially influence the process and effect of psychological

therapy interventions. Therefore, to ensure that older participants

are appropriately represented in the review (Bayer 2000; McMurdo



2005), an upper age cut-off of < 75 years was used (when a study

may have included individuals 75, we included it so long as the

average age was < 75). A previously published Cochrane review on

psychotherapeutic treatments for older depressed people (Wilson

2008) is being updated concurrently by the review authors.

Setting

Studies could be conducted in a primary, secondary or community

setting and included volunteers. Studies involving inpatients were

excluded. Studies that focused on specific populations-nurses, care

givers, depressed participants at a specific workplace-were included

if all participants met the criteria for depression.

Diagnosis

We included all studies that focused on acute phase treatment of

clinically diagnosed depression.

1. Studies adopting any standardised diagnostic criteria to

define participants suffering from an acute phase unipolar

depressive disorder were included. Accepted diagnostic criteria

included Feighner criteria, Research Diagnostic Criteria and

criteria of the Diagnostic and Statistical Manual of MentalDisorders, Third Edition (DSM-III) (APA 1980), DSM-III-Revised (R) (APA 1987),DSM-Fourth Edition (IV) (APA 1994),DSM-IV-Text Revision (TR) (APA 2000) and InternationalClassification of Diseases, Tenth Edition (ICD)-10 (WHO 1992).Earlier studies may have used ICD-Ninth Edition (9) (WHO1978), but ICD-9 is not based on operationalised criteria, so

studies using ICD-9 were excluded from this category.

2. Mild, moderate and severe depressive disorders are all

included in primary care (Mitchell 2009; Rait 2009; Roca

2009). To fully represent the broad spectrum of severity of

depressive symptoms encountered by healthcare professionals in

primary care, studies that used non-operationalised diagnostic

criteria or a validated clinician or self-report depression symptom

questionnaire, such as the Hamilton Rating Scale for Depression

(Hamilton 1960) or the Beck Depression Inventory (Beck

1961), to identify depression caseness as based on a recognised

threshold, were included. However, it was planned to examine

the influence of including this category of studies in a sensitivity

analysis.

Accepted strategies for classifying mild, moderate and severe de-

pression on the basis of criteria used in the evidence syntheses un-

derpinning the NICE 2009 guidelines for depression were used

when possible. NICE 2009 defines severity of depression in ac-

cordance with DSM-IV as follows: mild depression: few, if any,symptoms in excess of the five required to make the diagnosis, with

symptoms resulting in only minor functional impairment. Mod-

erate depression: symptoms of functional impairment between

mild and severe. Severe depression: most symptoms, and marked

interference of the symptoms with functioning. Can occur with

or without psychotic symptoms.

Studies focusing on chronic depression or treatment-resistant de-

pression (i.e. studies that list these conditions as inclusion criteria)

were excluded from the review. Studies in which participants were

receiving treatment to prevent relapse after a depressive episode

(i.e. where participants were not depressed at study entry) were

also excluded. Treatments for chronic depression and treatment-

resistant depression will be covered in separate Cochrane reviews.

Studies of people described as at risk of suicide or with dysthymia

or other affective disorders such as panic disorder were included

if participants met the criteria for depression as stated above, but

otherwise were excluded.

We did not include subgroup analyses of people with depression

selected from people with mixed diagnoses because such studies

would be susceptible to publication bias (the study authors re-

ported such subgroup studies because the results were interest-

ing). In other words, we included these studies only if the inclu-

sion criteria for the entire study satisfied our eligibility criteria.

Comorbidity

Studies involving participants with comorbid physical or com-

mon mental disorders were eligible for inclusion as long as the

comorbidity was not the focus of the study. In other words, we

excluded studies that focused on depression among individuals

with Parkinsons disease or after acute myocardial infarction but

accepted studies that may have included some participants with

Parkinsons disease or with acute myocardial infarction.

Types of interventions

Experimental interventions

We created the categories of BTs and the comparator on the basis

of both treatment approach (e.g. their theoretical background and

the manuals they used) and content (what therapeutic techniques

they mainly used or what was their area of focus). BT approaches

eligible for inclusion were grouped into four main subcategories,

according to the specific therapeutic principles and techniques de-

scribed by trial authors, as follows: behavioural therapy (based on

the Lewinsohn model, which focuses on increasing pleasant activi-

ties), behavioural activation (originated from the behavioural com-

ponent of cognitive-behavioural therapy), social skills training/as-

sertiveness training and relaxation therapy (see also Appendix 1).

Behavioural therapy (Lewinsohn)

Lewinsohn 1974 proposed that depressed individuals have low

rates of pleasant activities and obtained pleasure, that their mood

covaries with rates of pleasant and aversive activities, that their

mood improves with increases in pleasant activities and that

they lack social skills during the depressed phase. Therefore, be-

havioural therapy based on the approach developed by Lewin-

sohn and colleagues involves helping individuals increase their fre-



quency and quality of pleasant activities, producing correspond-

ing improvement in mood and overall quality of life (Lewinsohn

1974).

Behavioural activation (original model) (Jacobson)

The original model of behavioural activation (BA) developed by

Jacobson 1996 was defined primarily by the proscription of cog-

nitive interventions (Dimidjian 2006) and was tested in a dis-

mantling study in which the behavioural activation component of

cognitive therapy for depression was isolated (Beck 1979). On the

basis of its original design, BA model components include increas-

ing access to pleasant events and consequences, activity schedul-

ing and developing social skills, thereby helping people to make

contact with potentially reinforcing experiences (Jacobson 2001).

No attempt is made to directly restructure cognitions.

Social skills training/assertiveness training

The social skills training model (SST) proposes that depressed peo-

ple may have difficulty initiating, maintaining and ending con-

versations (Jackson 1985). Because of these deficits, the individ-

ual is unable to elicit mutually reinforcing behaviour from other

people in his or her environment. SST subsumes assertion and

conversational skills, together with more specialised subskills such

as dating and job interview skills. Four social contexts of interact-

ing with strangers- friends, family members and people at work

and school-are targeted (Bellack 1980), and interventions such as

instruction, modelling, rehearsal, feedback and reinforcement are

used to enable the development of new responses (Jackson 1985).

As assertiveness training represents a key component of SST, it was

included in the SST category.

Relaxation therapy

Relaxation training is a behavioural stress management technique

that induces a relaxation response, helping to switch off the fight/

flight response and causing levels of stress hormones in the blood-

stream to fall. A variety of techniques may be used to induce relax-

ation, the most common of which is Jacobsons progressive muscle

relaxation training (Bernstein 1973).

Other behavioural therapies

For studies evaluating a behavioural therapy intervention not listed

above, a post hoc decision was made about their inclusion in the

review. The impact of their inclusion was examined in a sensitivity

analysis (see Methods section).

Format of psychological therapies

Psychological therapies that were provided wholly by telephone or

over the Internet were not eligible for inclusion. Interventions in

which face-to-face therapy was augmented by telephone- or Inter-

net-based support but in which most psychotherapy sessions were

provided through face-to-face interviews were included in the re-

view. On the other hand, guided self-help, in which the practi-

tioner provided only brief face-to-face non-therapeutic support to

participants who were using a self-help psychological therapy in-

tervention, was excluded, as were bibliotherapy and writing ther-

apies.

Psychological therapies conducted on an individual or group basis

were eligible for inclusion.

The number of sessions was not limited, and we accepted psycho-

logical therapies delivered in only one session.

Comparators

The comparator intervention consisted of all other types of psy-

chological therapies, categorised as CBT, third wave CBT, psycho-

dynamic, humanistic and integrative approaches. We categorised

each type of psychological therapy into several subcategories, ac-

cording to the specific therapeutic principles and techniques ap-

plied, but here we have listed only the names of these subcategories

within each category. Details of classification of subcategories will

be described in upcoming companion reviews (see also Appendix

1).

Cognitive-behavioural therapies (CBTs)

In cognitive-behavioural therapy, therapists aim to work collabora-

tively with patients to understand the link between thoughts, feel-

ings and behaviours, and to identify and modify unhelpful think-

ing patterns, underlying assumptions and idiosyncratic cognitive

schemata about the self, others and the world (Beck 1979). Cog-

nitive change methods for depression are targeted at the automatic

thought level in the first instance and include thought catching,

reality testing and task assigning as well as generating alternative

strategies (Williams 1997). Behavioural experiments are then used

to re-evaluate underlying beliefs and assumptions (Bennett-Levy

2004). We categorised these therapies into six subcategories: cog-

nitive therapy, rational emotive behaviour therapy, problem-solv-

ing therapy, self-control therapy, a coping with depression course

and other cognitive-behavioural therapies.

Third wave cognitive and behavioural therapies (third wave

CBTs)

Third wave CBT approaches conceptualise cognitive thought pro-

cesses as a form of private behaviour (Hayes 2006; Hofmann

2008). Third wave CBTs target the individuals relationship with

cognitions and emotions, focusing primarily on the function of

cognitions, such as thought suppression or experiential avoidance

(an attempt or desire to suppress unwanted internal experiences,

such as emotions, thoughts and bodily sensations) (Hofmann



2008). A range of strategies, including mindfulness exercises, ac-

ceptance of unwanted thoughts and feelings and cognitive dif-

fusion (stepping back and seeing thoughts as just thoughts), are

used to bring about change in the thinking process. Drawing from

psychodynamic and humanistic principles, third wave CBT ap-

proaches place great emphasis on use of the therapeutic relation-

ship. We categorised these therapies into eight subcategories: ac-

ceptance and commitment therapy, compassionate mind training,

functional analytic psychotherapy, extended behavioural activa-

tion, metacognitive therapy, mindfulness-based cognitive therapy,

dialectical behaviour therapy and other third wave CBTs.

Psychodynamic therapies

Grounded in psychoanalytic theory (Freud 1949), psychodynamic

therapy (PD) uses the therapeutic relationship to explore and re-

solve unconscious conflict through transference and interpreta-

tion, with development of insight and circumscribed character

change as therapeutic goals, and relief of symptoms as an indirect

outcome. Brief therapy models have been devised by Malan 1963,

Mann 1973 and Strupp 1984. We categorised these therapies

into four subcategories: drive/structural model (Freud), relational

model (Strupp, Luborsky), integrative analytic model (Mann) and

other psychodynamic therapies.

Humanistic therapies

Contemporary models of humanistic therapies differ from one

another somewhat in clinical approach, but all focus attention

on the therapeutic relationship (Cain 2002), within which thera-

pist core conditions of empathy, genuineness and unconditional

positive regard (Rogers 1951) are regarded as cornerstones for fa-

cilitating client insight and change. We categorised these thera-

pies into seven subcategories: person-centred therapy (Rogerian),

gestalt therapy, experiential therapies, transactional analysis, exis-

tential therapy, non-directive/supportive therapies and other hu-

manistic therapies.

Interpersonal, cognitive analytic and other integrative

therapies

Integrative therapies are approaches that combine components of

different psychological therapy models. Integrative therapy mod-

els include interpersonal therapy (IPT) (Klerman 1984), cognitive

analytic therapy (CAT) (Ryle 1990) and Hobsons conversational

model (Hobson 1985), manualised as psychodynamic interper-

sonal therapy (Shapiro 1990). With its focus on the interpersonal

context, IPT was developed to specify what was thought to be

a set of helpful procedures commonly used in psychotherapy for

depressed outpatients (Weissman 2007), drawing in part from at-

tachment theory (Bowlby 1980) and cognitive-behavioural ther-

apy (isIPT [ND]) within a time-limited framework. CAT, also

devised as a time-limited psychotherapy, integrates components

from cognitive and psychodynamic approaches. The conversa-

tional model integrates psychodynamic, interpersonal and person-

centred model components.

Counselling interventions traditionally draw from a wide range

of psychological therapy models, including person-centred, psy-

chodynamic and cognitive-behavioural approaches, applied inte-

gratively, according to the theoretical orientation of practitioners

(Stiles 2008). Therefore, studies of counselling usually will be in-

cluded in the integrative therapies reviews. However, if the coun-

selling intervention consists of a single discrete psychological ther-

apy approach, it will be categorised as such, even if the intervention

is referred to as counselling. If the intervention is manualised, this

will inform our classification. We categorised these therapies into

seven subcategories: interpersonal therapy, cognitive-analytic ther-

apy, psychodynamic-interpersonal therapy, cognitive-behavioural

analysis system of psychotherapy, counselling, motivational inter-

viewing and other integrative therapy approaches.

Excluded interventions

The behavioural activation approach has been extended (Jacobson

2001; Martell 2001) by the introduction of contextual and id-

iosyncratic functional analysis into the assessment and treatment of

depression. The extended behavioural activation approach (eBA)

is regarded as a third wave CBT; therefore, for the purposes of

this review, eBA was categorised as a comparator third wave CBT

intervention (Hunot 2010).

Studies of long-term, continuation or maintenance therapy in-

terventions designed to prevent relapse of depression or to treat

chronic depressive disorders were excluded from the review. Simi-

larly, studies of interventions designed to prevent a future episode

of depression were excluded.

Studies of dual modality treatments, in which participants are

randomly assigned to receive a combination of psychological and

pharmacological treatments concurrently, were included in the

review only if the study of interest compared two psychological

models and both groups were prescribed the same concomitant

pharmacological/placebo intervention. Otherwise, these studies

were excluded from the current review and will be examined in

a separate programme of reviews on combination treatments for

depression.

Component or dismantling studies, in which the effectiveness

of individual components of a behavioural therapeutic approach

were investigated, were not included. Only such arms as were con-

structed as stand-alone treatments were eligible for the present re-

view.

Psychological therapy models based on social constructionist prin-

ciples (that focus on the ways in which individuals and groups par-

ticipate in the construction of their perceived social reality), includ-

ing couples therapy, family therapy, solution-focused therapy (de

Shazer 1988), narrative therapy, personal construct therapy, neuro-

linguistic programming and brief problem solving (Watzlavick

1974), were excluded. These therapies work with patterns and



dynamics of relating within and between family, social and cul-

tural systems to create a socially constructed framework of ideas

(OConnell 2007), rather than focusing on an individuals real-

ity. Previously published Cochrane reviews on couples therapy

for depression (Barbato 2006) and family therapy for depression

(Henken 2007) will be updated concurrently.

When the description of a suggested intervention did not meet the

inclusion criteria for an active psychological therapy approach, that

study/study arm was excluded from the review. If the intervention

involved significant time spent with participants, the review team

made a post hoc decision about whether it should be included as a

psychological or an attentional placebo control in a linked review

on BT versus control conditions for depression.

Types of outcome measures

Primary outcomes

1. Treatment efficacy: the number of participants who responded

to treatment, as determined by changes in Beck Depression Inven-

tory (BDI) (Beck 1961), Hamilton Rating Scale for Depression

(HAM-D) (Hamilton 1960) or Montgomery-Asberg Depression

Rating Scale (MADRS) (Montgomery 1979) scores, or in scores

from any other validated depression scale. Many studies define re-

sponse as 50% or greater reduction on BDI, HAM-D, etc., with

some studies defining response using Jacobsons Reliable Change

Index; we accepted the study authors original definition. If the

original authors reported several outcomes corresponding with our

definition of response, we gave preference for BDI as a self-rating

scale and for HAM-D as an observer-rating scale.

2. Treatment acceptability: the number of participants who

dropped out of psychological therapy for any reason.

Secondary outcomes

3. The number of participants who remitted while receiving

treatment, based on the endpoint absolute status of participants,

as measured by the Beck Depression Inventory (BDI) (Beck

1961), the Hamilton Rating Scale for Depression (HAM-D)

(Hamilton 1960), the Montgomery-Asberg Depression Rating

Scale (MADRS) (Montgomery 1979) or any other validated de-

pression scale. Examples of definitions of remission include 10 or

less on BDI, 7 or less on HAM-D and 10 or less on MADRS; we

accepted the study authors original definition. If the original au-

thors reported several outcomes that corresponded with our defi-

nition of response, we gave preference to BDI as a self-rating scale

and to HAM-D as an observer-rating scale.

4. Improvement in depression symptoms, based on a continuous

outcome of group mean scores at the end of treatment using BDI,

HAM-D, MADRS or any other validated depression scale.

5. Improvement in overall symptoms, as determined by using the

Clinical Global Impressions scale (CGI) (Guy 1976).

6. Improvement in anxiety symptoms, as measured using a vali-

dated continuous scale, either assessor-rated, such as the Hamilton

Anxiety Scale (HAM-A) (Hamilton 1959), or self-report, includ-

ing the Trait subscale of the Spielberger State-Trait Anxiety Inven-

tory (STAI-T) (Spielberger 1983) and the Beck Anxiety Inventory

(BAI) (Beck 1988).

7. Adverse effects, such as completed suicides, attempted suicides

and worsening of symptoms, when reported, were summarised in

narrative form.

8. Social adjustment and social functioning, including Global As-

sessment of Function (Luborsky 1962) scores, when reported, were

summarised in narrative form.

9. Quality of life, as assessed with the use of validated measures

such as Short Form (SF)-36 (Ware 1993), Health of the Nation

Outcome Scales (HoNOS) (Wing 1994) and World Health Or-

ganization Quality of Life (WHOQOL) (WHO 1998), when re-

ported, was summarised in narrative form.

10. Economic outcomes (e.g. days of work absence/ability to re-

turn to work, number of appointments with primary care physi-

cian, number of referrals to secondary services, use of additional

treatments), when reported, were summarised in narrative form.

Search methods for identification of studies

This review is one in a programme of 12 reviews. We ran one

search (detailed below) to identify studies relevant to all 12 linked

reviews. From these search results three reviewers (RC,VH and

TAF) then allocated studies to the individual reviews.

No language restrictions were applied.

Electronic searches

The Cochrane, Depression, Anxiety and Neurosis Review

Groups Specialised Register (CCDANCTR)

We searched two clinical trials registers created and main-

tained by the Cochrane Depression, Anxiety and Neurosis

Group (CCDAN)-the CCDANCTR-Studies Register and the

CCDANCTR-References Register-in June 2010, and updated

searches were carried out in April 2011 and February 2012 (Regis-

ter up to date as of January 2012), using an extensive list of search

terms for a programme of reviews on all psychological therapies for

depression. An updated search restricting to search terms relevant

to behavioural therapies was conducted in July 2013 (Appendix

2).

References to trials for inclusion in the Groups registers were col-

lated from routine (weekly) searches of MEDLINE, EMBASE and

PsycINFO and quarterly searches of the Cochrane Central Reg-

ister of Controlled Trials (CENTRAL). These searches employed

generic terms for depression, anxiety and neuroses, together with

sensitive (database-specific) RCT filters. Details of CCDANs

generic search strategies can be found on the Groups website.


http://ccdan.cochrane.org/search-strategies-identification-studieshttp://ccdan.cochrane.org/search-strategies-identification-studieshttp://ccdan.cochrane.org/search-strategies-identification-studieshttp://ccdan.cochrane.org/search-strategies-identification-studies

CCDANCTR-Studies Register

The CCDANCTR-Studies Register contains more than 11,000

trials for the treatment or prevention of depression, anxiety and

neurosis. Each trial has been coded using the EU-Psi coding man-

ual (as a guide) and includes information on intervention, condi-

tion, comorbidities, age, treatment setting, etc.

The studies register was searched using the following search terms:

Condition = (depress* or dysthymi*) and Intervention = (*therap*

or training)

CCDANCTR-References Register

The CCDANCTR-References Register contains bibliographic

records of reports of trials coded in the CCDANCTR-Studies Reg-

ister, together with several other uncoded references (total number

of records > 31,500). This register was searched using a compre-

hensive list of terms for psychotherapies, as indicated in Appendix

3. Records already retrieved from the search of the CCDANCTR-

Studies Register were de-duplicated.

CINAHL and PSYNDEX

In addition to CCDANCTR, we searched CINAHL May 2010

and PSYNDEX in June 2010 as indicated in Appendix 4;

Appendix 5.

No restriction on date, language or publication status was applied

to the searches.

ClinicalTrials.gov

ClinicalTrials.gov was searched (July 2013) using advanced search

and Age = Adults (18-65) or Senior (66+); Study Type = Inter-

ventional; Condition = (depression or depressive or depressed or

MDD); and Intervention = (behavior or behaviour or behavioral

or behavioural).

Searching other resources

Reference lists

The references of all selected studies were searched for more pub-

lished reports and citations of unpublished studies. Relevant re-

view papers were checked.

Personal communication

Subject experts were contacted to check that all relevant studies,

published and unpublished, had been considered for inclusion.

Data collection and analysis

Selection of studies

Two review authors (RC, VH) examined the abstracts of all pub-

lications obtained through the search strategy. Full articles of all

studies identified by either of the review authors were then ob-

tained and inspected by the same two review authors to identify

trials meeting the following criteria.

1. Randomised controlled trial.

2. Participants had depression diagnosed by operationalised

criteria.

3. Any BT approach (behavioural therapy, behavioural

activation, social skills training and relaxation training)

compared with any other psychological therapy approach.

Conflicts of opinion regarding eligibility of a study were discussed

with a third review author after the full paper had been retrieved

and consultation with the study authors sought, if necessary, until

consensus was reached. External subject or methodological experts

were consulted as necessary.

Data extraction and management

Data from each study were extracted independently by at least

three review authors. Any disagreement was discussed with an

additional review author, and, when necessary, the authors of the

studies were contacted for further information.

Information related to study population, sample size, interven-

tions, comparators, potential biases in the conduct of the trial, out-

comes including adverse events, follow-up and methods of statis-

tical analysis was abstracted from the original reports into specially

designed paper forms and then was entered onto a spreadsheet.

Management of time points

We had planned to summarise and categorise post-treatment out-

comes and outcomes at each reported follow-up point as follows:

short term (up to 6 months post-treatment), medium term (7 to 12

months post-treatment) and long term (longer than 12 months).

However, because no study adequately reported follow-up out-

comes at longer than six months post-treatment, we performed

analyses only for short-term outcomes.

Assessment of risk of bias in included studies

Risk of bias was assessed for each included study using The

Cochrane Collaborations Risk of bias tool (Higgins 2008). The

following five domains were considered.

1. Sequence generation: Was the allocation sequence

adequately generated?

2. Allocation concealment: Was allocation adequately

concealed, or was it based on a validated rating scale?


http://psitri.stakes.fi/NR/rdonlyres/36A8E972-32E6-4E04-9ABD-7D5CC42E162E/0/EUchar "A8penalty z@ PSIchar "A8penalty z@ codingchar "A8penalty z@ manual.pdfhttp://psitri.stakes.fi/NR/rdonlyres/36A8E972-32E6-4E04-9ABD-7D5CC42E162E/0/EUchar "A8penalty z@ PSIchar "A8penalty z@ codingchar "A8penalty z@ manual.pdfhttp://psitri.stakes.fi/NR/rdonlyres/36A8E972-32E6-4E04-9ABD-7D5CC42E162E/0/EUchar "A8penalty z@ PSIchar "A8penalty z@ codingchar "A8penalty z@ manual.pdf

3. Blinding of participants, personnel and outcome assessors

for each main outcome or class of outcomes: Was knowledge of

the allocated treatment adequately prevented during the study?

4. Incomplete outcome data for each main outcome or class of

outcomes: Were incomplete outcome data adequately addressed?

5. Selective outcome reporting: Are reports of the study free of

any suggestion of selective outcome reporting?

In addition, the following risks of bias specific to psychological

therapy trials were systematically appraised.

1. Therapist qualification/training: Are the therapists qualified

to deliver psychological therapy, and have they received specialist

training for the intervention they are providing?

2. Treatment fidelity: Was the therapy monitored against a

manual or a scale through audiotapes or videotapes?

3. Researcher allegiance/Conflict of interest: Did the

researcher have a vested interest for or against the therapies under

examination?

4. Therapist allegiance/Conflict of interest: Did the therapist

have a vested interest for or against the therapies provided?

5. Other sources of bias: Was the study apparently free of

other problems that could put it at high risk of bias?

A description of what was reported to have happened in each study

was recorded, and a judgement on the risk of bias was made for

each domain within and across studies, based on the following

three categories.

1. Low risk of bias.

2. Unclear risk of bias.

3. High risk of bias.

Two review authors independently assessed the risk of bias in se-

lected studies. Any disagreement was discussed with a third review

author. Where necessary, study authors were contacted for further

information. All risk of bias data were presented graphically and

described in the text. Allocation concealment was used as a marker

of trial quality for the purpose of undertaking sensitivity analyses.

Measures of treatment effect

Continuous outcomes

Where studies used the same outcome measure for comparison,

data were pooled by calculating the mean difference (MD). When

different measures were used to assess the same outcome, data

were pooled with standardised mean difference (SMD) and 95%

confidence intervals (95% CIs) calculated.

Dichotomous outcomes

These outcomes were analysed by calculating a pooled odds ratio

(OR) and 95% CIs for each comparison. Because ORs can be

difficult to interpret, these pooled ORs were converted to risk

ratios (RRs) using the formula provided in the Cochrane Handbookfor Systematic Reviews of Interventions (Higgins 2008a) and werepresented in this form for ease of interpretation.

Unit of analysis issues

Cluster-randomised trials

Cluster-randomised trials were to be included as long as proper

adjustment for the intracluster correlation could be conducted in

accordance with the Cochrane Handbook for Systematic Reviews ofInterventions (Higgins 2008).

Cross-over trials

Trials employing a cross-over design were to be included in the

review, but only data from the first active treatment phase were

used.

Studies with multiple treatment groups

Multiple-arm studies (those with greater than two intervention

arms) can pose analytical problems in pair-wise meta-analysis. For

studies with more than two relevant active treatment arms, data

were managed in this review as follows.

Continuous data

Means, SDs and numbers of participants for all active treatment

groups were pooled across treatment arms as a function of the

number of participants in each arm to be compared against the

control group (Law 2003; Higgins 2008;Higgins 2008a).

Dichotomous data

Data from relevant active intervention arms were collapsed into a

single arm for comparison, or data from relevant active interven-

tion arms were split equally between comparator arms.

Dealing with missing data

Missing dichotomous data were managed through intention-to-

treat (ITT) analysis, in which it was assumed that participants

who dropped out after randomisation had a negative outcome.

It was also planned to conduct best/worse case scenarios for the

clinical response outcome, in which it would be assumed that

dropouts in the active treatment group had positive outcomes

and those in the control group had negative outcomes (best case

scenario), and that dropouts in the active treatment group had

negative outcomes and those in the control group had positive

outcomes (worst case scenario), thus providing boundaries for the

observed treatment effect. If a large amount of information was

missing, these best/worst case scenarios were to be given greater

emphasis in the presentation of results.

Missing continuous data were analysed on an endpoint basis, in-

cluding only participants with a final assessment, or were analysed

by using the last observation carried forward to the final assessment

(LOCF), if LOCF data were reported by the trial authors. When



standard deviations (SDs) were missing, attempts were made to

obtain these data by contacting trial authors. When SDs were not

available from trial authors, they were calculated from P values,

t-values, confidence intervals or standard errors, if these were re-

ported in the articles (Deeks 1997). When SDs were missing, at-

tempts were made to obtain these data by contacting trial authors.

When a vast majority of actual SDs were available and only a

minority of SDs were unavailable or unobtainable, it was planned

to use a method for imputing SDs and calculating percentage

responders; the method devised by Furukawa and colleagues (

Furukawa 2005; Furukawa 2006; da Costa 2012) was used. If this

method was employed, data would be interpreted with caution and

the degree of observed heterogeneity would be taken into account.

A sensitivity analysis would also be undertaken to examine the

effect of the decision to use imputed data.

When additional figures were not available or obtainable and it was

not deemed appropriate to use the Furukawa method as described

above, the study data were not included in the comparison of

interest.

Assessment of heterogeneity

Statistical heterogeneity was formally tested using the Chi2 test,

which provides evidence of variation in effect estimates beyond

that of chance. Because the Chi2 test has low power to assess het-

erogeneity when a small number of participants or trials are in-

cluded, the P value was conservatively set at 0.1. Heterogeneity was

also quantified using the I2 statistic, which calculated the percent-

age of variability due to heterogeneity rather than to chance. We

expected, a priori, that considerable clinical heterogeneity would

be noted between studies, and so I2 values in the range of 50%

to 90% were considered to represent substantial statistical hetero-

geneity and were to be explored further. However, the importance

of the observed I2 depended on the magnitude and direction of

treatment effects and the strength of evidence for heterogeneity

(Higgins 2003; Deeks 2008). Forest plots generated in RevMan

5 now provide an estimate of tau2, the between-study variance in

a random-effects meta-analysis. To provide an indication of the

spread of true intervention effects, we also used the tau2 estimate

to determine an approximate range of intervention effects using

the method outlined in Section 9.5.4 of the Cochrane Handbookfor Systematic Reviews of Interventions (Deeks 2008). This was tobe done only for the primary outcomes.

Assessment of reporting biases

As far as possible, the impact of reporting biases was minimised

by undertaking comprehensive searches of multiple sources (in-

cluding trial registries), increasing efforts to identify unpublished

material and including non-English language publications.

We also tried to identify outcome reporting bias in trials by record-

ing all trial outcomes, planned and reported, and noting where

outcomes were missing. When we found evidence of missing out-

comes, we attempted to obtain any available data directly from

the authors.

When sufficient numbers of trials allowed for a meaningful anal-

ysis, funnel plots were constructed to establish the potential influ-

ence of reporting biases and small-study effects.

Data synthesis

Given the potential heterogeneity of psychological therapy ap-

proaches for inclusion, together with the likelihood of differing

secondary comorbid mental disorders in the population of inter-

est, a random-effects model was used in all analyses.

Subgroup analysis and investigation of heterogeneity

Clinical heterogeneity

We had planned to conduct the following subgroup analyses, but

we could not perform some of them because of lack of data.

1. Baseline depression severity: The severity of depression on

entry into the trial was expected to have an impact on outcomes.

We had planned to categorise baseline severity as mild, moderate

or severe. However, we did not conduct this analysis because

baseline depression severity was categorised as moderate in most

of the studies, and this analysis was not meaningful.

2. Number of sessions: Differences in the numbers of therapy

sessions received were likely, and this was expected to affect

treatment outcomes. We had planned subgroup analysis

according to the numbers of therapy sessions (1 to 7, 8 to 12, 13

to 20, more than 20). However, because included studies were

too few, we conducted sensitivity analysis only by excluding

studies in which the number of sessions was greater than 12.

3. Type of comparison: The type of comparator used was

likely to influence the observed effectiveness of the intervention.

We had planned subgroup analyses about subtype comparisons.

However, only two subtype comparisons included more than one

study (BT-Lewinsohn vs CBT-Cogntive therapy and BT-SST/

assertion vs CBT-Self-control).

4. Strength of therapeutic alliance/perceived therapist

empathy based on validated measures such as the Barrett-

Lennard Relationship Inventory (Barrett-Lennard 1986) or the

Working Alliance Inventory (Horvath 1986): We did not

conduct this analysis because of lack of available data.

Sensitivity analysis

1. Fidelity to treatment: Studies that did not assess fidelity to

the psychological therapy model(s) under evaluation through

assessment of audiotapes or videotapes of therapy sessions were

excluded.

2. Study quality: Allocation concealment was to be used as a

marker of trial quality. We planned to conduct sensitivity

analysis excluding studies that did not use allocation



concealment. However, we did not do so because no study

reported how allocation concealment was ensured.

3. Trials for which missing data were imputed were excluded.

4. Trials that included the use of antidepressant treatment

(naturalistic use; combination treatment used in both

psychological therapy arms) were excluded.

5. Trials included in the review after post hoc decisions were

made about their eligibility as behavioural therapeutic

approaches were excluded.

6. Trials in which dropouts were replaced without

randomisation were excluded.

R E S U L T S

Description of studies

Results of the search

See Figure 1. We conducted a search for all psychological therapies

in January 2012. After removing duplicates, we identified 6710

records relevant to this review or to the reviews of all psychologi-

cal therapies for treating depression in adults. We excluded 6524

records on the basis of titles and abstracts and read 186 full text

studies to assess for eligibility. A total of 122 studies were judged

eligible for inclusion in this review or the reviews of all psycholog-

ical therapies. Of those 122 studies, 30 studies had BT arms, but

5 studies were not included in this review because they compared

BT with control conditions only. Finally 25 studies were included

in this review.



Figure 1. Study flow diagram.



In July 2013 we updated the searches while restricting to search

terms relevant to behavioural therapies only (CCDANCTR to 31/

07/13). A total of 632 new references were identified. On the basis

of the information provided in abstracts, four potentially relevant

studies were noted; however, on retrieving the full text papers, we

found none of the studies to be eligible.

In July 2013 we also searched ClinicalTrials.gov. A total of 186

references were identified, of which five were potentially relevant

studies; however, on retrieving the full text papers, we found none

of the studies to be eligible.

We tried to contact 13 trial authors for missing information;

seven responded, three of whom provided the desired information

(Gardner 1981; Rehm 1979; Taylor 1977).

Included studies

Design

We had planned to include randomised controlled trials (RCTs),

cluster RCTs and cross-over design trials.

Twenty-two of the included 25 studies had a parallel-group, in-

dividually randomised design. One study (Lapointe 1980) had

a parallel-group cluster-randomised design. But these studies did

not adequately report outcomes. One study (Rude 1986) had a

cluster-randomised cross-over design, and one study (Kelly 1983)

had an individually randomised cross-over design; in this case,

only data from the first half of the trial were used. Two studies

(Breckenridge 1985; Wilson 1982) replaced the dropouts.

Sample size

The sample sizes per arm were small in the great majority of the

studies. Of 25 included studies, six studies did not report the

numbers of participants randomly assigned at baseline. In all, 11

studies recruited fewer than 10 participants per arm, and six studies

recruited 10 to 20 participants per arm. Only two studies recruited

30 or more participants to each arm (Bellack 1981; Rehm 1984).

Setting

In seven studies, the setting was unclear. In 13 studies, non-medical

university settings such as university departments of psychology

were reported. In five studies, the setting was a secondary/tertiary

care or other medical setting.

Eighteen of 25 studies were carried out in the USA. Other studies

were carried out in Australia (three), Spain (two), Greece (one)

and Canada (one).

Participants

Proportion of women

Three studies did not report the number of female participants.

Seven studies recruited only women. The proportion of females

among all participants ranged between 56% and 80% in the re-

maining 15 studies.

Age

Seven studies did not provide the mean age of participants. The

mean age was in the twenties in three studies, in the thirties in 11

studies, and in the forties in two studies. The remaining two studies

(Breckenridge 1985; Gallagher 1979) recruited elderly individuals

only, whose average age was in the sixties.

Diagnosis

In eight studies, investigators stated that they used one of the fol-

lowing operationalised criteria: Research Diagnostic Criteria in

four studies, DSM-III in two studies, DSM-III-R in one study andFeighner criteria in one study. In most of the other studies, a de-

pression symptom questionnaire was used to identify depression.

Eight studies reported that they enrolled only participants with a

diagnosis of major depressive disorder. Other studies reported that

they recruited participants with dysthymia or depressive disorder

not otherwise specified, in addition to major depression, or they

just stated that participants had a diagnosis of depression.

Baseline severity of depression was reported on the basis of BDI in

21 studies, the Zung Self-Rating Scale in two studies and the Min-

nesota Multiphasic Personality Inventory (MMPI) in one study.

One study did not report baseline severity. Of 21 studies that used

BDI, the severity of depression was classified as mild in one study,

moderate in 16 studies and severe in four studies, in accordance

with the following rules of thumb for interpretation of BDI: scores

0 to 13 minimal, 14 to 19 mild, 20 to 28 moderate and 29 to 63

severe (Beck 1996; Steer RA 2001).

Intervention

As described in the Methods section, we classified BT into five

subcategories. The subcategories of BT in the included studies

were as follows: behavioural therapy (Lewinsohn) in 11 stud-

ies (Breckenridge 1985; Comas-Diaz 1981; Gallagher 1979;

Kelly 1982; Kelly 1983; McNamara 1986; Padfield 1975; Shaw

1977; Skinner 1983; Taylor 1977; Wilson 1983), behavioural

activation (Jacobson) in one study (Jacobson 1996), SST/asser-

tion in eight studies (Bellack 1981; Lapointe 1980; Maldonado



1982; Maldonado 1984; Rehm 1979; Rude 1986; Sanchez 1980;

Schmitt 1988), relaxation in two studies (Pace 1977; Wetzel 1992)

and other behavioural therapies in two studies (Gardner 1981;

Rehm 1984). The remaining study included both behavioural

therapy (Lewinsohn) and SST/assertion (Zeiss 1979).

In slightly less than half of the included studies (10 of 25), the

participants received group therapy, and in nearly half of the stud-

ies (12 of 25), they received individual therapy. Two studies did

not report whether the therapy provided was group or individual

treatment. One study compared group BT with individual hu-

manistic therapy (Bellack 1981).

The duration of intervention ranged form 3.5 to 16 weeks, most

often between one and three months.

The number of sessions varied among studies and ranged from 5

to 20: 1 to 7 sessions in 11 studies, 8 to 12 sessions in 10 studies

and 13 to 20 sessions in 3 studies. One study did not report the

number of sessions.

Eighteen studies provided follow-up assessment, but some did not

report the outcomes. The timing of follow-up assessment varied

among the studies (five weeks to 10 months)

Comparisons

Three studies compared BT with two comparator psycholog-

ical therapies: two studies compared BT with CBT and psy-

chodynamic therapies (Breckenridge 1985; Lapointe 1980), and

one study compared BT with CBT and humanistic therapies

(McNamara 1986).

A total of 22 studies compared BT with a single comparator psy-

chological therapy: 17 studies compared BT with CBT, two stud-

ies compared BT with psychodynamic therapies, two studies com-

pared BT with humanistic therapies and one study compared BT

with integrative therapies. No study compared BT with third wave

CBT.

Scale used to measure outcomes

BDI was the scale most frequently used to measure depressive

symptoms; it was used in 22 studies. The second most often used

scale was the Hamilton Rating Scale for Depression (HAM-D),

which was used in 12 studies. In almost half of the studies, investi-

gators did not use a validated assessor-rated scale. Only one study

(Wetzel 1992) reported response as outcome based on the use

of a validated scale.

Although five studies reported remission using the authors def-

inition, this definition was heterogeneous among studies. For ex-

ample, the definition was no major depressive disorder at posttest

and BDI scores less than eight in Jacobson 1996, and a score of

11 or less on BDI in Rehm 1979.

Excluded studies

We excluded 64 studies from this review and from the other reviews

of all psychological therapies for depression, and 10 of those 64

studies had BT arms.

The reasons for exclusion of 10 studies were as follows: 5 studies did

not randomise participants adequately (Bowers 1990; Gallagher

1982; Mclean 1979; Rokke 1999; Turner 1979), 3 studies re-

cruited inpatients (Brand 1992; Hopko 2003b; Snarski 2011) and

2 studies appeared to include participants who did not have a diag-

nosis of depression (Losada 2011; Reynolds 2011). We excluded

five studies because they compared BT only with control condi-

tions (Barrera 1979; Broota 1990; Cullen 2002; Hayman 1980;

Wilson 1982).

No studies for this review are awaiting classification or are ongoing.

Risk of bias in included studies

Please see Figure 2 for the Risk of bias summary.



Figure 2. Risk of bia

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