Author's Accepted Manuscript
Effectiveness of psychological interventions in preventing recurrence of depressive disorder: Meta-analysis and meta-regression Karolien E.M. Biesheuvel-Leliefeld, Gemma D. Kok, Claudi L.H. Bockting, Pim Cuijpers, Steven D. Hollon, Harm W.J. van Marwijk, Filip Smit
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PII: DOI: Reference:
S0165-0327(14)00802-7 http://dx.doi.org/10.1016/j.jad.2014.12.016 JAD7168
To appear in:
Journal of Affective Disorders
Received date: 4 July 2014 Revised date: 2 December 2014 Accepted date: 4 December 2014 Cite this article as: Karolien E.M. Biesheuvel-Leliefeld, Gemma D. Kok, Claudi L. H. Bockting, Pim Cuijpers, Steven D. Hollon, Harm W.J. van Marwijk, Filip Smit, Effectiveness of psychological interventions in preventing recurrence of depressive disorder: Meta-analysis and meta-regression, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.12.016 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Journal of Affective Disorders Words abstract: 250 Words main text: 4,652 No tables: 3 (separate files) No figures: 3 (separate files) No Supplemental Information, SI: 5 (separate files)
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26
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Schulberg, H.C., Block, M.R., Madonia, M.J., Scott, C.P., Rodriguez, E., Imber, S.D., Perel, J., Lave, J., Houck, P.R., Coulehan, J.L., 1996. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch. Gen. Psychiatry 53, 913-919.
Raskin, A., Schulterbrandt, J., Reatig, N., McKeon, J.J., 1969. Replication of factors of psychopathology in interview, ward behavior and self-report ratings of hospitalized depressives. J Nerv. Ment. Dis. 148, 87-98.
Perlis, R.H., Nierenberg, A.A., Alpert, J.E., Pava, J., Matthews, J.D., Buchin, J., Sickinger, A.H., Fava, M., 2002. Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder. J. Clin. Psychopharmacol. 22, 474-480.
Paykel, E.S., Scott, J., Cornwall, P.L., Abbott, R., Crane, C., Pope, M., Johnson, A.L., 2005. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol. Med. 35, 59-68.
Ma, S.H., Teasdale, J.D., 2004. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin. Psychol. 72, 31-40.
Kuyken, W., Byford, S., Taylor, R.S., Watkins, E., Holden, E., White, K., Barrett, B., Byng, R., Evans, A., Mullan, E., Teasdale, J.D., 2008. Mindfulnessbased cognitive therapy to prevent relapse in recurrent depression. J Consult Clin. Psychol. 76, 966-978.
Klerman, G.L., Dimascio, A., Weissman, M., Prusoff, B., Paykel, E.S., 1974. Treatment of depression by drugs and psychotherapy. Am J Psychiatry 131, 186-191.
Klein, D.N., Santiago, N.J., Vivian, D., Blalock, J.A., Kocsis, J.H., Markowitz, J.C., McCullough Jr, J.P., Rush, A.J., Trivedi, M.H., Arnow, B.A., Dunner, D.L., Manber, R., Rothbaum, B., Thase, M.E., Keitner, G.I., Miller, I.W., Keller, M.B., 2004. Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression. J. Consult Clin. Psychol. 72, 681-688.
Jarrett, R.B., Minhajuddin, A., Gershenfeld, H., Friedman, E.S., Thase, M.E., 2013. Preventing depressive relapse and recurrence in higher-risk cognitive therapy responders: a randomized trial of continuation phase cognitive therapy, fluoxetine, or matched pill placebo. JAMA Psychiatry 70, 1152-1160.
Jarrett, R.B., Kraft, D., Schaffer, M., Witt-Browder, A., Risser, R., Atkins, D.H., Doyle, J., 2000. Reducing relapse in depressed outpatients with atypical features: a pilot study. Psychother. Psychosom. 69, 232-239.
Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., Silver, P.C., 2001. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Arch. Gen. Psychiatry 58, 381-388.
Hollon, S.D., DeRubeis, R.J., Shelton, R.C., Amsterdam, J.D., Salomon, R.M., O'Reardon, J.P., Lovett, M.L., Young, P.R., Haman, K.L., Freeman, B.B., Gallop, R., 2005. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch. Gen. Psychiatry 62, 417-422.
Hollandare, F., Johnsson, S., Randestad, M., Tillfors, M., Carlbring, P., Andersson, G., Engstrom, I., 2011. Randomized trial of Internet-based relapse prevention for partially remitted depression. Acta Psychiatr. Scand. 124, 285-294.
28
Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., 1979. Cognitive therapy of depression. De Jonghe F., 2013. Kort en Krachtig (Brief and Potent). Short Psychodynamic Supportive Psychotherapy. De Jonghe F., Rijnierse, P., Janssen, R., 1994. Psychoanalytic supportive psychotherapy. J Am Psychoanal. Assoc. 42, 421-446. Hawton, K., Salkovskis, P., Kirk, J., Clark, D., 1989. Problem-solving; Cognitive behaviour therapy for psychiatric problems. 406-426. Klerman, G.L., Budman, S., Berwick, D., Weissman, M.M., Damico-White, J., Demby, A., Feldstein, M., 1987. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care 25, 1078-1088. Segal, Z., Williams, J.M., Teasdale, J.D., 2002. Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Watzke, B., Rueddel, H., Koch, U., Rudolph, M., Schulz, H., 2008. Comparison of therapeutic action, style and content in cognitive-behavioural and psychodynamic group therapy under clinically representative conditions. Clin Psychol. Psychother. 15, 404-417. Weissman, M., Markowitz, J.C., Klerman, G.L., 2007. Clinician's Quick Guide to Interpersonal Psychotherapy. New York: Oxford University Press; 2007. Baker, A.L., Wilson, P.H., 1985. Cognitive-behavior therapy for depression: The effects of booster sessions on relapse. Behav. Ther. 16, 335-344. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for measuring depression. Arch. Gen. Psychiatry 4, 561-571. Blackburn, I.M., Eunson, K.M., Bishop, S., 1986. A two-year naturalistic follow-up of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. J Affect. Disord. 10, 67-75. Blackburn, I.M., Moore, R.G., 1997. Controlled acute and follow-up trial of cognitive therapy and pharmacotherapy in out-patients with recurrent depression. Br. J Psychiatry 171, 328-334. Bockting, C.L.H., Spinhoven, P., Wouters, L.F., Koeter, M.W.J., Schene, A.H., 2009. Long-term effects of preventive cognitive therapy in recurrent depression: a 5.5-year follow-up study. J Clin. Psychiatry 70, 1621-1628. Bondolfi, G., Jermann, F., der Linden, M.V., Gex-Fabry, M., Bizzini, L., Rouget, B.W., Myers-Arrazola, L., Gonzalez, C., Segal, Z., Aubry, J.M., Bertschy, G., 2010. Depression relapse prophylaxis with Mindfulness-Based Cognitive Therapy: replication and extension in the Swiss health care system. J Affect. Disord. 122, 224-231. Conradi, H.J., de Jonge, P., Kluiter, H., Smit, A., van der Meer, K., Jenner, J.A., van Os, T.W.D.P., Emmelkamp, P.M.G., Ormel, J., 2007. Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy. Psychol. Med. 37, 849-862. Fava, G.A., Rafanelli, C., Grandi, S., Canestrari, R., Morphy, M.A., 1998. Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. Am J Psychiatry 155, 1443-1445. Fava, G.A., Ruini, C., Rafanelli, C., Grandi, S., 2002. Cognitive behavior approach to loss of clinical effect during long-term antidepressant treatment: a pilot study. Am J Psychiatry 159, 2094-2095. Fava, G.A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., Grandi, S., 2004. Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. Am J Psychiatry 161, 1872-1876. First, M.B., Gibbon, M., Spitzer, R.L., Williams, J.B.W., 1996. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV).
Teasdale, J.D., Segal, Z.V., Williams, J.M., Ridgeway, V.A., Soulsby, J.M., Lau, M.A., 2000. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J. Consult Clin. Psychol. 68, 615-623.
Segal, Z.V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., Levitan, R.D., 2010. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch. Gen. Psychiatry 67, 12561264.
29 Frank, E., Kupfer, D.J., Perel, J.M., Cornes, C., Jarrett, D.B., Mallinger, A.G., Thase, M.E., McEachran, A.B., Grochocinski, V.J., 1990. Three-year outcomes for maintenance therapies in recurrent depression. Arch. Gen. Psychiatry 47, 1093-1099. Godfrin, K.A., van, H.C., 2010. The effects of mindfulness-based cognitive therapy on recurrence of depressive episodes, mental health and quality of life: A randomized controlled study. Behav. Res. Ther. 48, 738-746. Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23, 56-62. Hollandare, F., Johnsson, S., Randestad, M., Tillfors, M., Carlbring, P., Andersson, G., Engstrom, I., 2011. Randomized trial of Internet-based relapse prevention for partially remitted depression. Acta Psychiatr. Scand. 124, 285-294. Hollon, S.D., DeRubeis, R.J., Shelton, R.C., Amsterdam, J.D., Salomon, R.M., O'Reardon, J.P., Lovett, M.L., Young, P.R., Haman, K.L., Freeman, B.B., Gallop, R., 2005. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch. Gen. Psychiatry 62, 417-422. Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., Silver, P.C., 2001. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Arch. Gen. Psychiatry 58, 381-388. Jarrett, R.B., Kraft, D., Schaffer, M., Witt-Browder, A., Risser, R., Atkins, D.H., Doyle, J., 2000. Reducing relapse in depressed outpatients with atypical features: a pilot study. Psychother. Psychosom. 69, 232-239. Jarrett, R.B., Minhajuddin, A., Gershenfeld, H., Friedman, E.S., Thase, M.E., 2013. Preventing depressive relapse and recurrence in higher-risk cognitive therapy responders: a randomized trial of continuation phase cognitive therapy, fluoxetine, or matched pill placebo. JAMA Psychiatry 70, 1152-1160. Klein, D.N., Santiago, N.J., Vivian, D., Blalock, J.A., Kocsis, J.H., Markowitz, J.C., McCullough Jr, J.P., Rush, A.J., Trivedi, M.H., Arnow, B.A., Dunner, D.L., Manber, R., Rothbaum, B., Thase, M.E., Keitner, G.I., Miller, I.W., Keller, M.B., 2004. Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression. J. Consult Clin. Psychol. 72, 681-688. Klerman, G.L., Dimascio, A., Weissman, M., Prusoff, B., Paykel, E.S., 1974. Treatment of depression by drugs and psychotherapy. Am J Psychiatry 131, 186-191. Kuyken, W., Byford, S., Taylor, R.S., Watkins, E., Holden, E., White, K., Barrett, B., Byng, R., Evans, A., Mullan, E., Teasdale, J.D., 2008. Mindfulnessbased cognitive therapy to prevent relapse in recurrent depression. J Consult Clin. Psychol. 76, 966-978. Ma, S.H., Teasdale, J.D., 2004. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin. Psychol. 72, 31-40. Paykel, E.S., Scott, J., Cornwall, P.L., Abbott, R., Crane, C., Pope, M., Johnson, A.L., 2005. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol. Med. 35, 59-68. Perlis,R.H., Nierenberg, A.A., Alpert, J.E., Pava, J., Matthews, J.D., Buchin, J., Sickinger, A.H., Fava, M., 2002. Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder. J. Clin. Psychopharmacol. 22, 474-480. Raskin, A., Schulterbrandt, J., Reatig, N., McKeon, J.J., 1969. Replication of factors of psychopathology in interview, ward behavior and self-report ratings of hospitalized depressives. J Nerv. Ment. Dis. 148, 87-98. Schulberg, H.C., Block, M.R., Madonia, M.J., Scott, C.P., Rodriguez, E., Imber, S.D., Perel, J., Lave, J., Houck, P.R., Coulehan, J.L., 1996. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch. Gen. Psychiatry 53, 913-919. Segal, Z.V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., Levitan, R.D., 2010. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch. Gen. Psychiatry 67, 12561264. Teasdale, J.D., Segal, Z.V., Williams, J.M., Ridgeway, V.A., Soulsby, J.M., Lau, M.A., 2000. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J. Consult Clin. Psychol. 68, 615-623.
Table 2 Selected characteristics of 25 included studies a.
30 Fig. 1 PRISMA Flow chart of the literature search. Fig. 2 Forest plot of risk ratios and 95% confidence-intervals for psychological interventions versus treatment-as-usuala, a Abbreviations: CI, confidence interval. Fig. 3 Forest plot of risk ratios and 95% confidence-intervals for psychological interventions versus antidepressant medicationa, a Abbreviations: CI, confidence interval. Table 1 Psychological interventions included in the meta-analysis. Name therapy Approach Cognitive (behavioural) therapy (CT) Negative automatic thoughts, maladaptive information processing, and avoidance behaviour play a key role in the development and recurrence of depression (Beck et al., 1979) Mindfulness based cognitive therapy Protocol-led, group-based skills training program designed to teach recovered depressed patients how to (MCT) disengage from automatic, cognitive processing patterns linked to relapse (Segal et al., 2002). Interpersonal therapy (IPT) Originates from interpersonal theory by Klerman et al. (1987). It links stressful life events and insufficient social support to the development and recurrence of depressive symptoms (Weissman et al., 2007). Problem solving therapy (PST) Brief treatment focused on strengthening practical problem-solving skills. The goal is to stimulate an active attitude towards everyday problems and, hereby, to achieve a reduction in mental health problems (Hawton et al., 1989) Psychodynamic therapy (PDT) Focuses on the affective, behavioural and cognitive aspects of relationships from a psychodynamic point of view (De Jonghe F. et al., 1994; De Jonghe F., 2013). It comprises intervention methods such as clarification, interpretation and confrontation each addressing intra-psychic conflict and resistance (Watzke et al., 2008).
44
46
44
47
40
200 7
199 8
200 2
200 4
199 0
Conradi et al. (2007) Fava et al. (1998) Fava et al. (2002) Fava et al. (2004) Frank et al. a
48
45
200 9
201 0
40
4
199 7
198 6
Mea Yea n r age 198 40 5
Bondolfi et al. (2010)
Blackbur n et al. (1997) Bockting et al. (2009)
Baker et al. (1985) Blackbur n et al. (1986)
Author
77
60
60
68
61
72
73
59
84
7
4
4
not clear
not clear
4
4
3
2
no previo % us Femal episod e es 74 n/a
ADM
ADM
ADM
n/a
n/a
n/a
ADM
ADM
Previo us comparatorb Group CBT
ADM+ ADM+ IPT IPT
ADM
ADM
ADM
n/a
n/a
n/a
CT
CT
Previo us intervention b Group CBT
TAU
ADM
ADM
Current comparat or TAU
IPT
CT
CT+AD M
CT
CBT
TAU
TAU
ADM
TAU
TAU
MCT+TA TAU U
CT+TAU
CT
CT
Current interventi on CBT
156
332
60
332
156
60
286
52
104
Follo w-up (wks) 22
MDE (RDC defined) MDE (RDC defined) MDE (RDC defined) MDE (RDC
MDE (CIDI)
MDE according to SCID
MDE according to SCID
HRSD8 and BDI9 or retreatmen t HRSD14
Definition recurrence BDI17
unknown
156
secondary 20 care
secondary 6 care
secondary 20 care
communit 8 y, primary and secondary care communit 8 y, primary and secondary care primary 156 care
secondary 104 care
primary 26 and secondary care
Length of interventi Setting on (wks) communit 12 y
1/26
8/20
1/4
10/20
21/38
9/27
69/88
4/17
3/13
Risk rate interventi on 6/10
1/23
18/20
4/4
15/20
39/62
10/28
73/84
4/13
7/9
Risk rate 31 comparat or 7/9
200 0
200 0
200 1
201
Jarrett et al. b (2000)
Jarrett et al. (2001)
Jarrett et
40
200 5
Jarrett et al. a (2000)
45
201 1
Hollanda re et al. (2011) Hollon et al. (2005)
43
43
41
41
46
201 0
Godfrin et al. (2010)
40
199 0
Frank et al. b (1990)
(1990)
67
73
84
84
59
85
81
77
4
3
2
2
2
6
not clear
7
CT
CT
CT
CT
CT
n/a
n/a
n/a
CT
ADM
TAU
ADM
n/a
n/a
ADM+ ADM+ IPT IPT
ADM
CT
CT
CT
CT
CT
CBT (internet)
ADM
TAU
ADM
TAU
ADM
TAU
MCT+TA TAU U
IPT
140
104
104
104
104
26
56
156
MDD
defined)+ HSRD15 +Raskin 7 MDE (RDC defined)+ HSRD15 +Raskin 7 MDE according to DSMIV MDD according to SCID MDE or HRSD14 , at least 2 weeks MDE (RDC defined) or retreatmen t MDE (RDC defined) or retreatmen t MDD (DSM defined) 156
communit 36 y, primary and secondary care secondary 34
secondary 10 care
secondary 10 care
secondary 52 care
communit 10 y
secondary 8 care
unknown
11/25
15/41
3/7
3/7
5/20
4/38
12/40
1/26
12/28
22/43
4/7
6/7
7/14
14/37
32/47
0/28
32
200 2
199 6
Perlis et al. (2002)
Schulber g et al. a (1996)
38
40
4
45
200 4
200 5
49
200 8
Paykel et al. (2005)
not 100 clear
197 4
83
55
49
76
77
not 100 clear
197 4
Klerman et al. a (1974) Klerman et al. b (1974) Kuyken et al. (2008) Ma et al. (2004)
67
200 4
Klein et al. (2004)
45
3
(2013)
not clear
5
2
3
6
not clear
not clear
2
IPT
ADM
n/a
n/a
n/a
ADM
ADM
CBAS P (CBT)
TAU
ADM
n/a
n/a
n/a
ADM
ADM
CBAS P (CBT)
ADM
TAU
TAU
IPT
CT+AD M
CBT+AD M
TAU
ADM
ADM
MCT+TA TAU U
MCT+TA ADM U
IPT
IPT
CBASP (CBT)
17
28
275
60
65
35
35
52
MDD >4 weeks or HAMD1 3, at least 8 weeks MDE at any visit, HRSD15 at two consecutiv e visits symptoma tic (HRSD1 3)
MDE according to SCID MDE (DSM-IV defined)
not clear
(DSM defined, LIFE PSR=5 or 6, 2 cons weeks) MDD and HRSD16 for 2 visits not clear
52
primary care
18
secondary 26 care
primary 36 care and communit y secondary 32 care
primary care
secondary 36 care
secondary 36 care
care secondary care secondary 52 care
17/91
4/66
48/80
14/36
29/61
4/25
4/25
1/42
44/92
5/66
51/78
23/37
37/62
3/25
9/25
8/40
33
201 0
201 0
200 0
Segal et al. a (2010)
Segal et al. b (2010)
Teasdale et al. (2000)
41
45
43
38
71
61
59
83
5
5
5
not clear
n/a
ADM
ADM
IPT
n/a
ADM
ADM
ADM
ADM
TAU
ADM
MCT+TA TAU U
MCT
MCT
IPT
60
78
78
17
symptoma tic (HRSD1 3) HRSD16 2 consecutiv e weeks+M DE on SCID HRSD16 2 consecutiv e weeks+M DE on SCID recovery or remission, HRSD-17 ; 9:?7
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aAbbreviations: ADM, anti-depressant medication; CT, Cognitive (Behaviour) Therapy; CI, confidence interval; I2, heterogeneity; IPT, Interpersonal Therapy; K, number of contrasts; MCT, Mindfulness-based Cognitive Therapy; NNT, number-needed-to-treat; RD, risk difference; RR D-L, random-effects according to DerSimonian and Laird; TAU, treatment-as-usual.
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Figure 1
Identification
Screening
Eligibility
Included
Studies included in meta-analysis (n = 25 )
Full-text articles assessed for eligibility (n = 69)
Records screened by abstract and title (n = 3,537)
Records excluded (n =3,468)
No relapse rates, 11 Follow up after acute-phase, 8 No RCT, 11 No psychological treatment, 2 No recovered participants, 2 Other, 10
Full-text articles excluded, with reasons (n = 44)
Additional records identified through other sources (n = 2)
Number of duplicates removed (n = 2,162)
Records identified through database searching Medline (2,384) Psychinfo (855) CINAHL (206) Embase (1,330) Cochrane (922) (n = 5,697)
Figure 2
a
0.771 0.902 0.933 0.879 0.667 0.444 0.885 0.441 0.278 0.500 0.715 0.119 0.444 0.626 0.391 0.641 0.758 0.638
0.417 0.786 0.450 0.623 0.402 0.255 0.059 0.264 0.101 0.202 0.435 0.016 0.157 0.387 0.242 0.364 0.542 0.533
1.427 1.035 1.935 1.239 1.106 0.775 13.354 0.735 0.767 1.239 1.176 0.909 1.256 1.012 0.631 1.130 1.061 0.764
-0.827 -1.466 -0.185 -0.738 -1.570 -2.857 -0.089 -3.136 -2.471 -1.497 -1.321 -2.052 -1.529 -1.913 -3.848 -1.537 -1.615 -4.887
0.408 0.143 0.853 0.461 0.116 0.004 0.929 0.002 0.013 0.134 0.187 0.040 0.126 0.056 0.000 0.124 0.106 0.000
a
0.01
0.1
1
100 Favours control
10
Risk ratio and 95% CI
Favours intervention
Risk Lower Upper ratio limit limit Z-Value p-Value
Statistics for each study
a Abbreviations; CI, confidence interval; a, study contrast versus treatment-as-usual CI, confidence interval
Baker,1985 Bockting,2009 Bondolfi,2010 Conradi,2007 Fava,1998 Fava,2004 Frank,1990 Godfrin,2010 Hollandare,2011 Jarrett,2000 Jarrett,2001 Klein,2004 Klerman,1974 Ma,2004 Schulberg,1996 Segal,2010 Teasdale,2000
Study name
Figure 2. Forest of risk ratios and 95% confidence-intervals Figure 2. Forest plotplot of risk ratios and 95% confidence-intervals forfor psychological psychological interventions versus treatment-as-usuala interventions versus treatment-as-usual
Figure 3
a
Statistics for each study
0.297 0.765 0.333 3.222 0.500 0.750 1.027 1.333 0.797 0.918 0.800 0.739 0.828 0.825
0.104 0.850 0.234 2.496 0.085 1.312 0.137 75.752 0.199 1.258 0.257 2.185 0.555 1.899 0.332 5.356 0.571 1.112 0.721 1.168 0.225 2.848 0.424 1.288 0.442 1.553 0.704 0.966
-2.263 -0.444 -1.571 0.726 -1.473 -0.527 0.084 0.405 -1.335 -0.699 -0.344 -1.067 -0.587 -2.391
0.024 0.657 0.116 0.468 0.141 0.598 0.933 0.685 0.182 0.485 0.731 0.286 0.557 0.017
Risk Lower Upper ratio limit limit Z-Value p-Value
CI, confidence interval
Blackburn,1986 Blackburn,1997 Fava,2002 Frank,1990 Hollon,2005 Jarrett,2000 Jarrett. 2013 Klerman,1974 Kuyken,2008 Paykel,2005 Perlis,2002 Schulberg,1996 Segal,2010
Study name
1 Favours intervention
0.01 0.1
100
a
Favours control
10
Risk ratio and 95% CI
Figure 3. Forest plot of risk ratios and 95% confidence-intervals for psychological interventions versus anti-depressant medication
Effectiveness of psychological interventions in preventing recurrence of depressive disorder: Meta-analysis and meta-regression Karolien E.M. Biesheuvel-Leliefeld, Gemma D. Kok, Claudi L.H. Bockting, Pim Cuijpers, Steven D. Hollon, Harm W.J. van Marwijk, Filip Smit
www.elsevier.com/locate/jad
PII: DOI: Reference:
S0165-0327(14)00802-7 http://dx.doi.org/10.1016/j.jad.2014.12.016 JAD7168
To appear in:
Journal of Affective Disorders
Received date: 4 July 2014 Revised date: 2 December 2014 Accepted date: 4 December 2014 Cite this article as: Karolien E.M. Biesheuvel-Leliefeld, Gemma D. Kok, Claudi L. H. Bockting, Pim Cuijpers, Steven D. Hollon, Harm W.J. van Marwijk, Filip Smit, Effectiveness of psychological interventions in preventing recurrence of depressive disorder: Meta-analysis and meta-regression, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.12.016 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Journal of Affective Disorders Words abstract: 250 Words main text: 4,652 No tables: 3 (separate files) No figures: 3 (separate files) No Supplemental Information, SI: 5 (separate files)
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26
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Perlis, R.H., Nierenberg, A.A., Alpert, J.E., Pava, J., Matthews, J.D., Buchin, J., Sickinger, A.H., Fava, M., 2002. Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder. J. Clin. Psychopharmacol. 22, 474-480.
Paykel, E.S., Scott, J., Cornwall, P.L., Abbott, R., Crane, C., Pope, M., Johnson, A.L., 2005. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol. Med. 35, 59-68.
Ma, S.H., Teasdale, J.D., 2004. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin. Psychol. 72, 31-40.
Kuyken, W., Byford, S., Taylor, R.S., Watkins, E., Holden, E., White, K., Barrett, B., Byng, R., Evans, A., Mullan, E., Teasdale, J.D., 2008. Mindfulnessbased cognitive therapy to prevent relapse in recurrent depression. J Consult Clin. Psychol. 76, 966-978.
Klerman, G.L., Dimascio, A., Weissman, M., Prusoff, B., Paykel, E.S., 1974. Treatment of depression by drugs and psychotherapy. Am J Psychiatry 131, 186-191.
Klein, D.N., Santiago, N.J., Vivian, D., Blalock, J.A., Kocsis, J.H., Markowitz, J.C., McCullough Jr, J.P., Rush, A.J., Trivedi, M.H., Arnow, B.A., Dunner, D.L., Manber, R., Rothbaum, B., Thase, M.E., Keitner, G.I., Miller, I.W., Keller, M.B., 2004. Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression. J. Consult Clin. Psychol. 72, 681-688.
Jarrett, R.B., Minhajuddin, A., Gershenfeld, H., Friedman, E.S., Thase, M.E., 2013. Preventing depressive relapse and recurrence in higher-risk cognitive therapy responders: a randomized trial of continuation phase cognitive therapy, fluoxetine, or matched pill placebo. JAMA Psychiatry 70, 1152-1160.
Jarrett, R.B., Kraft, D., Schaffer, M., Witt-Browder, A., Risser, R., Atkins, D.H., Doyle, J., 2000. Reducing relapse in depressed outpatients with atypical features: a pilot study. Psychother. Psychosom. 69, 232-239.
Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., Silver, P.C., 2001. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Arch. Gen. Psychiatry 58, 381-388.
Hollon, S.D., DeRubeis, R.J., Shelton, R.C., Amsterdam, J.D., Salomon, R.M., O'Reardon, J.P., Lovett, M.L., Young, P.R., Haman, K.L., Freeman, B.B., Gallop, R., 2005. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch. Gen. Psychiatry 62, 417-422.
Hollandare, F., Johnsson, S., Randestad, M., Tillfors, M., Carlbring, P., Andersson, G., Engstrom, I., 2011. Randomized trial of Internet-based relapse prevention for partially remitted depression. Acta Psychiatr. Scand. 124, 285-294.
28
Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., 1979. Cognitive therapy of depression. De Jonghe F., 2013. Kort en Krachtig (Brief and Potent). Short Psychodynamic Supportive Psychotherapy. De Jonghe F., Rijnierse, P., Janssen, R., 1994. Psychoanalytic supportive psychotherapy. J Am Psychoanal. Assoc. 42, 421-446. Hawton, K., Salkovskis, P., Kirk, J., Clark, D., 1989. Problem-solving; Cognitive behaviour therapy for psychiatric problems. 406-426. Klerman, G.L., Budman, S., Berwick, D., Weissman, M.M., Damico-White, J., Demby, A., Feldstein, M., 1987. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care 25, 1078-1088. Segal, Z., Williams, J.M., Teasdale, J.D., 2002. Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Watzke, B., Rueddel, H., Koch, U., Rudolph, M., Schulz, H., 2008. Comparison of therapeutic action, style and content in cognitive-behavioural and psychodynamic group therapy under clinically representative conditions. Clin Psychol. Psychother. 15, 404-417. Weissman, M., Markowitz, J.C., Klerman, G.L., 2007. Clinician's Quick Guide to Interpersonal Psychotherapy. New York: Oxford University Press; 2007. Baker, A.L., Wilson, P.H., 1985. Cognitive-behavior therapy for depression: The effects of booster sessions on relapse. Behav. Ther. 16, 335-344. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for measuring depression. Arch. Gen. Psychiatry 4, 561-571. Blackburn, I.M., Eunson, K.M., Bishop, S., 1986. A two-year naturalistic follow-up of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. J Affect. Disord. 10, 67-75. Blackburn, I.M., Moore, R.G., 1997. Controlled acute and follow-up trial of cognitive therapy and pharmacotherapy in out-patients with recurrent depression. Br. J Psychiatry 171, 328-334. Bockting, C.L.H., Spinhoven, P., Wouters, L.F., Koeter, M.W.J., Schene, A.H., 2009. Long-term effects of preventive cognitive therapy in recurrent depression: a 5.5-year follow-up study. J Clin. Psychiatry 70, 1621-1628. Bondolfi, G., Jermann, F., der Linden, M.V., Gex-Fabry, M., Bizzini, L., Rouget, B.W., Myers-Arrazola, L., Gonzalez, C., Segal, Z., Aubry, J.M., Bertschy, G., 2010. Depression relapse prophylaxis with Mindfulness-Based Cognitive Therapy: replication and extension in the Swiss health care system. J Affect. Disord. 122, 224-231. Conradi, H.J., de Jonge, P., Kluiter, H., Smit, A., van der Meer, K., Jenner, J.A., van Os, T.W.D.P., Emmelkamp, P.M.G., Ormel, J., 2007. Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy. Psychol. Med. 37, 849-862. Fava, G.A., Rafanelli, C., Grandi, S., Canestrari, R., Morphy, M.A., 1998. Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. Am J Psychiatry 155, 1443-1445. Fava, G.A., Ruini, C., Rafanelli, C., Grandi, S., 2002. Cognitive behavior approach to loss of clinical effect during long-term antidepressant treatment: a pilot study. Am J Psychiatry 159, 2094-2095. Fava, G.A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., Grandi, S., 2004. Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. Am J Psychiatry 161, 1872-1876. First, M.B., Gibbon, M., Spitzer, R.L., Williams, J.B.W., 1996. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV).
Teasdale, J.D., Segal, Z.V., Williams, J.M., Ridgeway, V.A., Soulsby, J.M., Lau, M.A., 2000. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J. Consult Clin. Psychol. 68, 615-623.
Segal, Z.V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., Levitan, R.D., 2010. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch. Gen. Psychiatry 67, 12561264.
29 Frank, E., Kupfer, D.J., Perel, J.M., Cornes, C., Jarrett, D.B., Mallinger, A.G., Thase, M.E., McEachran, A.B., Grochocinski, V.J., 1990. Three-year outcomes for maintenance therapies in recurrent depression. Arch. Gen. Psychiatry 47, 1093-1099. Godfrin, K.A., van, H.C., 2010. The effects of mindfulness-based cognitive therapy on recurrence of depressive episodes, mental health and quality of life: A randomized controlled study. Behav. Res. Ther. 48, 738-746. Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23, 56-62. Hollandare, F., Johnsson, S., Randestad, M., Tillfors, M., Carlbring, P., Andersson, G., Engstrom, I., 2011. Randomized trial of Internet-based relapse prevention for partially remitted depression. Acta Psychiatr. Scand. 124, 285-294. Hollon, S.D., DeRubeis, R.J., Shelton, R.C., Amsterdam, J.D., Salomon, R.M., O'Reardon, J.P., Lovett, M.L., Young, P.R., Haman, K.L., Freeman, B.B., Gallop, R., 2005. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch. Gen. Psychiatry 62, 417-422. Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., Silver, P.C., 2001. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Arch. Gen. Psychiatry 58, 381-388. Jarrett, R.B., Kraft, D., Schaffer, M., Witt-Browder, A., Risser, R., Atkins, D.H., Doyle, J., 2000. Reducing relapse in depressed outpatients with atypical features: a pilot study. Psychother. Psychosom. 69, 232-239. Jarrett, R.B., Minhajuddin, A., Gershenfeld, H., Friedman, E.S., Thase, M.E., 2013. Preventing depressive relapse and recurrence in higher-risk cognitive therapy responders: a randomized trial of continuation phase cognitive therapy, fluoxetine, or matched pill placebo. JAMA Psychiatry 70, 1152-1160. Klein, D.N., Santiago, N.J., Vivian, D., Blalock, J.A., Kocsis, J.H., Markowitz, J.C., McCullough Jr, J.P., Rush, A.J., Trivedi, M.H., Arnow, B.A., Dunner, D.L., Manber, R., Rothbaum, B., Thase, M.E., Keitner, G.I., Miller, I.W., Keller, M.B., 2004. Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression. J. Consult Clin. Psychol. 72, 681-688. Klerman, G.L., Dimascio, A., Weissman, M., Prusoff, B., Paykel, E.S., 1974. Treatment of depression by drugs and psychotherapy. Am J Psychiatry 131, 186-191. Kuyken, W., Byford, S., Taylor, R.S., Watkins, E., Holden, E., White, K., Barrett, B., Byng, R., Evans, A., Mullan, E., Teasdale, J.D., 2008. Mindfulnessbased cognitive therapy to prevent relapse in recurrent depression. J Consult Clin. Psychol. 76, 966-978. Ma, S.H., Teasdale, J.D., 2004. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin. Psychol. 72, 31-40. Paykel, E.S., Scott, J., Cornwall, P.L., Abbott, R., Crane, C., Pope, M., Johnson, A.L., 2005. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol. Med. 35, 59-68. Perlis,R.H., Nierenberg, A.A., Alpert, J.E., Pava, J., Matthews, J.D., Buchin, J., Sickinger, A.H., Fava, M., 2002. Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder. J. Clin. Psychopharmacol. 22, 474-480. Raskin, A., Schulterbrandt, J., Reatig, N., McKeon, J.J., 1969. Replication of factors of psychopathology in interview, ward behavior and self-report ratings of hospitalized depressives. J Nerv. Ment. Dis. 148, 87-98. Schulberg, H.C., Block, M.R., Madonia, M.J., Scott, C.P., Rodriguez, E., Imber, S.D., Perel, J., Lave, J., Houck, P.R., Coulehan, J.L., 1996. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch. Gen. Psychiatry 53, 913-919. Segal, Z.V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., Levitan, R.D., 2010. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch. Gen. Psychiatry 67, 12561264. Teasdale, J.D., Segal, Z.V., Williams, J.M., Ridgeway, V.A., Soulsby, J.M., Lau, M.A., 2000. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J. Consult Clin. Psychol. 68, 615-623.
Table 2 Selected characteristics of 25 included studies a.
30 Fig. 1 PRISMA Flow chart of the literature search. Fig. 2 Forest plot of risk ratios and 95% confidence-intervals for psychological interventions versus treatment-as-usuala, a Abbreviations: CI, confidence interval. Fig. 3 Forest plot of risk ratios and 95% confidence-intervals for psychological interventions versus antidepressant medicationa, a Abbreviations: CI, confidence interval. Table 1 Psychological interventions included in the meta-analysis. Name therapy Approach Cognitive (behavioural) therapy (CT) Negative automatic thoughts, maladaptive information processing, and avoidance behaviour play a key role in the development and recurrence of depression (Beck et al., 1979) Mindfulness based cognitive therapy Protocol-led, group-based skills training program designed to teach recovered depressed patients how to (MCT) disengage from automatic, cognitive processing patterns linked to relapse (Segal et al., 2002). Interpersonal therapy (IPT) Originates from interpersonal theory by Klerman et al. (1987). It links stressful life events and insufficient social support to the development and recurrence of depressive symptoms (Weissman et al., 2007). Problem solving therapy (PST) Brief treatment focused on strengthening practical problem-solving skills. The goal is to stimulate an active attitude towards everyday problems and, hereby, to achieve a reduction in mental health problems (Hawton et al., 1989) Psychodynamic therapy (PDT) Focuses on the affective, behavioural and cognitive aspects of relationships from a psychodynamic point of view (De Jonghe F. et al., 1994; De Jonghe F., 2013). It comprises intervention methods such as clarification, interpretation and confrontation each addressing intra-psychic conflict and resistance (Watzke et al., 2008).
44
46
44
47
40
200 7
199 8
200 2
200 4
199 0
Conradi et al. (2007) Fava et al. (1998) Fava et al. (2002) Fava et al. (2004) Frank et al. a
48
45
200 9
201 0
40
4
199 7
198 6
Mea Yea n r age 198 40 5
Bondolfi et al. (2010)
Blackbur n et al. (1997) Bockting et al. (2009)
Baker et al. (1985) Blackbur n et al. (1986)
Author
77
60
60
68
61
72
73
59
84
7
4
4
not clear
not clear
4
4
3
2
no previo % us Femal episod e es 74 n/a
ADM
ADM
ADM
n/a
n/a
n/a
ADM
ADM
Previo us comparatorb Group CBT
ADM+ ADM+ IPT IPT
ADM
ADM
ADM
n/a
n/a
n/a
CT
CT
Previo us intervention b Group CBT
TAU
ADM
ADM
Current comparat or TAU
IPT
CT
CT+AD M
CT
CBT
TAU
TAU
ADM
TAU
TAU
MCT+TA TAU U
CT+TAU
CT
CT
Current interventi on CBT
156
332
60
332
156
60
286
52
104
Follo w-up (wks) 22
MDE (RDC defined) MDE (RDC defined) MDE (RDC defined) MDE (RDC
MDE (CIDI)
MDE according to SCID
MDE according to SCID
HRSD8 and BDI9 or retreatmen t HRSD14
Definition recurrence BDI17
unknown
156
secondary 20 care
secondary 6 care
secondary 20 care
communit 8 y, primary and secondary care communit 8 y, primary and secondary care primary 156 care
secondary 104 care
primary 26 and secondary care
Length of interventi Setting on (wks) communit 12 y
1/26
8/20
1/4
10/20
21/38
9/27
69/88
4/17
3/13
Risk rate interventi on 6/10
1/23
18/20
4/4
15/20
39/62
10/28
73/84
4/13
7/9
Risk rate 31 comparat or 7/9
200 0
200 0
200 1
201
Jarrett et al. b (2000)
Jarrett et al. (2001)
Jarrett et
40
200 5
Jarrett et al. a (2000)
45
201 1
Hollanda re et al. (2011) Hollon et al. (2005)
43
43
41
41
46
201 0
Godfrin et al. (2010)
40
199 0
Frank et al. b (1990)
(1990)
67
73
84
84
59
85
81
77
4
3
2
2
2
6
not clear
7
CT
CT
CT
CT
CT
n/a
n/a
n/a
CT
ADM
TAU
ADM
n/a
n/a
ADM+ ADM+ IPT IPT
ADM
CT
CT
CT
CT
CT
CBT (internet)
ADM
TAU
ADM
TAU
ADM
TAU
MCT+TA TAU U
IPT
140
104
104
104
104
26
56
156
MDD
defined)+ HSRD15 +Raskin 7 MDE (RDC defined)+ HSRD15 +Raskin 7 MDE according to DSMIV MDD according to SCID MDE or HRSD14 , at least 2 weeks MDE (RDC defined) or retreatmen t MDE (RDC defined) or retreatmen t MDD (DSM defined) 156
communit 36 y, primary and secondary care secondary 34
secondary 10 care
secondary 10 care
secondary 52 care
communit 10 y
secondary 8 care
unknown
11/25
15/41
3/7
3/7
5/20
4/38
12/40
1/26
12/28
22/43
4/7
6/7
7/14
14/37
32/47
0/28
32
200 2
199 6
Perlis et al. (2002)
Schulber g et al. a (1996)
38
40
4
45
200 4
200 5
49
200 8
Paykel et al. (2005)
not 100 clear
197 4
83
55
49
76
77
not 100 clear
197 4
Klerman et al. a (1974) Klerman et al. b (1974) Kuyken et al. (2008) Ma et al. (2004)
67
200 4
Klein et al. (2004)
45
3
(2013)
not clear
5
2
3
6
not clear
not clear
2
IPT
ADM
n/a
n/a
n/a
ADM
ADM
CBAS P (CBT)
TAU
ADM
n/a
n/a
n/a
ADM
ADM
CBAS P (CBT)
ADM
TAU
TAU
IPT
CT+AD M
CBT+AD M
TAU
ADM
ADM
MCT+TA TAU U
MCT+TA ADM U
IPT
IPT
CBASP (CBT)
17
28
275
60
65
35
35
52
MDD >4 weeks or HAMD1 3, at least 8 weeks MDE at any visit, HRSD15 at two consecutiv e visits symptoma tic (HRSD1 3)
MDE according to SCID MDE (DSM-IV defined)
not clear
(DSM defined, LIFE PSR=5 or 6, 2 cons weeks) MDD and HRSD16 for 2 visits not clear
52
primary care
18
secondary 26 care
primary 36 care and communit y secondary 32 care
primary care
secondary 36 care
secondary 36 care
care secondary care secondary 52 care
17/91
4/66
48/80
14/36
29/61
4/25
4/25
1/42
44/92
5/66
51/78
23/37
37/62
3/25
9/25
8/40
33
201 0
201 0
200 0
Segal et al. a (2010)
Segal et al. b (2010)
Teasdale et al. (2000)
41
45
43
38
71
61
59
83
5
5
5
not clear
n/a
ADM
ADM
IPT
n/a
ADM
ADM
ADM
ADM
TAU
ADM
MCT+TA TAU U
MCT
MCT
IPT
60
78
78
17
symptoma tic (HRSD1 3) HRSD16 2 consecutiv e weeks+M DE on SCID HRSD16 2 consecutiv e weeks+M DE on SCID recovery or remission, HRSD-17 ; 9:?7
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Figure 1
Identification
Screening
Eligibility
Included
Studies included in meta-analysis (n = 25 )
Full-text articles assessed for eligibility (n = 69)
Records screened by abstract and title (n = 3,537)
Records excluded (n =3,468)
No relapse rates, 11 Follow up after acute-phase, 8 No RCT, 11 No psychological treatment, 2 No recovered participants, 2 Other, 10
Full-text articles excluded, with reasons (n = 44)
Additional records identified through other sources (n = 2)
Number of duplicates removed (n = 2,162)
Records identified through database searching Medline (2,384) Psychinfo (855) CINAHL (206) Embase (1,330) Cochrane (922) (n = 5,697)
Figure 2
a
0.771 0.902 0.933 0.879 0.667 0.444 0.885 0.441 0.278 0.500 0.715 0.119 0.444 0.626 0.391 0.641 0.758 0.638
0.417 0.786 0.450 0.623 0.402 0.255 0.059 0.264 0.101 0.202 0.435 0.016 0.157 0.387 0.242 0.364 0.542 0.533
1.427 1.035 1.935 1.239 1.106 0.775 13.354 0.735 0.767 1.239 1.176 0.909 1.256 1.012 0.631 1.130 1.061 0.764
-0.827 -1.466 -0.185 -0.738 -1.570 -2.857 -0.089 -3.136 -2.471 -1.497 -1.321 -2.052 -1.529 -1.913 -3.848 -1.537 -1.615 -4.887
0.408 0.143 0.853 0.461 0.116 0.004 0.929 0.002 0.013 0.134 0.187 0.040 0.126 0.056 0.000 0.124 0.106 0.000
a
0.01
0.1
1
100 Favours control
10
Risk ratio and 95% CI
Favours intervention
Risk Lower Upper ratio limit limit Z-Value p-Value
Statistics for each study
a Abbreviations; CI, confidence interval; a, study contrast versus treatment-as-usual CI, confidence interval
Baker,1985 Bockting,2009 Bondolfi,2010 Conradi,2007 Fava,1998 Fava,2004 Frank,1990 Godfrin,2010 Hollandare,2011 Jarrett,2000 Jarrett,2001 Klein,2004 Klerman,1974 Ma,2004 Schulberg,1996 Segal,2010 Teasdale,2000
Study name
Figure 2. Forest of risk ratios and 95% confidence-intervals Figure 2. Forest plotplot of risk ratios and 95% confidence-intervals forfor psychological psychological interventions versus treatment-as-usuala interventions versus treatment-as-usual
Figure 3
a
Statistics for each study
0.297 0.765 0.333 3.222 0.500 0.750 1.027 1.333 0.797 0.918 0.800 0.739 0.828 0.825
0.104 0.850 0.234 2.496 0.085 1.312 0.137 75.752 0.199 1.258 0.257 2.185 0.555 1.899 0.332 5.356 0.571 1.112 0.721 1.168 0.225 2.848 0.424 1.288 0.442 1.553 0.704 0.966
-2.263 -0.444 -1.571 0.726 -1.473 -0.527 0.084 0.405 -1.335 -0.699 -0.344 -1.067 -0.587 -2.391
0.024 0.657 0.116 0.468 0.141 0.598 0.933 0.685 0.182 0.485 0.731 0.286 0.557 0.017
Risk Lower Upper ratio limit limit Z-Value p-Value
CI, confidence interval
Blackburn,1986 Blackburn,1997 Fava,2002 Frank,1990 Hollon,2005 Jarrett,2000 Jarrett. 2013 Klerman,1974 Kuyken,2008 Paykel,2005 Perlis,2002 Schulberg,1996 Segal,2010
Study name
1 Favours intervention
0.01 0.1
100
a
Favours control
10
Risk ratio and 95% CI
Figure 3. Forest plot of risk ratios and 95% confidence-intervals for psychological interventions versus anti-depressant medication
