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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 Library 2013, 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.

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  • 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

    Analysis 7.2. Comparison 7 Sensitivity analysis: BT vs all other psychological therapies (treatment fidelity), Outcome 2

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

    Analysis 7.3. Comparison 7 Sensitivity analysis: BT vs all other psychological therapies (treatment fidelity), Outcome 3

    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

    Analysis 8.2. Comparison 8 Sensitivity analysis: BT vs all other psychological therapies (excluding imputed data), Outcome

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

    iBehavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • Analysis 8.3. Comparison 8 Sensitivity analysis: BT vs all other psychological therapies (excluding imputed data), Outcome

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

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

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

    Analysis 9.2. Comparison 9 Sensitivity analysis: BT vs all other psychological therapies (pharmacotherapy not allowed),

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

    Analysis 9.3. Comparison 9 Sensitivity analysis: BT vs all other psychological therapies (pharmacotherapy not allowed),

    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

    Analysis 10.2. Comparison 10 Sensitivity analysis: BT vs all other psychological therapies (excluding other subcategories),

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

    Analysis 10.3. Comparison 10 Sensitivity analysis: BT vs all other psychological therapies (excluding other subcategories),

    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

    Analysis 11.2. Comparison 11 Sensitivity analysis: BT vs all other psychological therapies (major depression only), Outcome

    2 Depression severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

    Analysis 11.3. Comparison 11 Sensitivity analysis: BT vs all other psychological therapies (major depression only), Outcome

    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

    Analysis 12.2. Comparison 12 Sensitivity analysis: BT vs all other psychological therapies (fewer than 13 sessions), Outcome

    2 Depression severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

    Analysis 12.3. Comparison 12 Sensitivity analysis: BT vs all other psychological therapies (fewer than 13 sessions), Outcome

    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

    Analysis 13.2. Comparison 13 Sensitivity analysis: BT vs all other psychological therapies (excluding studies that replaced

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

    Analysis 13.3. Comparison 13 Sensitivity analysis: BT vs all other psychological therapies (excluding studies that replaced

    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)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • [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.

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

    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)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

    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.

    2Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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

    crosses no difference

    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

    crosses no difference

    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

    crosses no difference

    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

    crosses no difference

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    http://www.thecochranelibrary.com/view/0/SummaryFindings.html
  • *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).

    5Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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

    6Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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-

    7Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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

    8Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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

    9Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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.

    10Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

    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?

    11Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

    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

    12Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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

    13Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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.

    14Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • Figure 1. Study flow diagram.

    15Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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

    16Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • 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.

    17Behavioural therapies versus other psychological therapies for depression (Review)

    Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

  • Figure 2. Risk of bia