Comparative effectiveness of psychological treatments for depressive disorders in primary care: network meta-analysis.
BACKGROUND
A variety of psychological interventions to treat depressive disorders have been developed and are used in primary care. In a systematic review, we compared the effectiveness of psychological treatments grouped by theoretical background, intensity of contact with the health care professional, and delivery mode for depressed patients in this setting.


METHODS
Randomized trials comparing a psychological treatment with usual care, placebo, another psychological treatment, pharmacotherapy, or a combination treatment in adult depressed primary care patients were identified by database searches up to December 2013. We performed both conventional pairwise meta-analysis and network meta-analysis combining direct and indirect evidence. Outcome measures were response to treatment (primary outcome), remission of symptoms, post-treatment depression scores and study discontinuation.


RESULTS
A total of 37 studies with 7,024 patients met the inclusion criteria. Among the psychological treatments investigated in at least 150 patients face-to-face cognitive behavioral therapy (CBT; OR 1.80; 95 % credible interval 1.35-2.39), face-to-face counselling and psychoeducation (1.65; 1.27-2.13), remote therapist lead CBT (1.87; 1.38-2.53), guided self-help CBT (1.68; 1.22-2.30) and no/minimal contact CBT (1.53; 1.07-2.17) were superior to usual care or placebo, but not face-to-face problem-solving therapy and face-to-face interpersonal therapy. There were no statistical differences between psychological treatments apart from face-to-face interpersonal psychotherapy being inferior to remote therapist-lead CBT (0.60; 0.37-0.95). Remote therapist-led (0.86; 0.21-3.67), guided self-help (0.93; 0.62-1.41) and no/minimal contact CBT (0.85; 0.54-1.36) had similar effects as face-to-face CBT.


CONCLUSIONS
The limited available evidence precludes a sufficiently reliable assessment of the comparative effectiveness of psychological treatments in depressed primary care patients. Findings suggest that psychological interventions with a cognitive behavioral approach are promising, and primarily indirect evidence indicates that it applies also when they are delivered with a reduced number of therapist contacts or remotely.


BACKGROUND
01KG1012 at http://www.gesundheitsforschung-bmbf.de/de/2852.php.
Institute of General Practice, Technische Universität München, Orleansstr 47, D-81667, Munich, Germany. Klaus.Linde@tum.de.
Klaus
K
Linde
Institute for Medical Biometry and Statistics, Medical Center - University of Freiburg, Stefan-Meier-Str. 26, D-79104, Freiburg, Germany. ruecker@imbi.uni-freiburg.de#
Gerta
G
Rücker
Institute of General Practice, Technische Universität München, Orleansstr 47, D-81667, Munich, Germany. kirsten@sigterman.nl.
Kirsten
K
Sigterman
Institute of General Practice, Technische Universität München, Orleansstr 47, D-81667, Munich, Germany. susanneohnsmann@gmx.de.
Susanne
S
Jamil
Institute of General Practice, Technische Universität München, Orleansstr 47, D-81667, Munich, Germany. Karin.Meissner@med.uni-muenchen.de.|Institute of Medical Psychology, Ludwig-Maximilians-University Munich, Goethestr 31, D-80336, Munich, Germany. Karin.Meissner@med.uni-muenchen.de.
Karin
K
Meissner
Institute of General Practice, Technische Universität München, Orleansstr 47, D-81667, Munich, Germany. antonius.schneider@tum.de.
Antonius
A
Schneider
Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr 52, D-20246, Hamburg, Germany. l.kriston@uke.uni-hamburg.de.
Levente
L
Kriston
D000928:Antidepressive Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003866:Depressive Disorder / Q000628:therapy*; D006801:Humans; D015233:Models, Statistical; D011320:Primary Health Care / Q000379:methods*; D011613:Psychotherapy / Q000379:methods*; D016896:Treatment Outcome
D000928:Antidepressive Agents