Hostname: page-component-8448b6f56d-c4f8m Total loading time: 0 Render date: 2024-04-19T12:12:17.058Z Has data issue: false hasContentIssue false
  • English
  • Français

Cognitive behaviour therapy for depression in primary care: systematic review and meta-analysis

Published online by Cambridge University Press:  28 January 2019

Fredrik Santoft Open the ORCID record for Fredrik Santoft [Opens in a new window] ,
Erland Axelsson Open the ORCID record for Erland Axelsson [Opens in a new window] ,
Lars-Göran Öst Open the ORCID record for Lars-Göran Öst [Opens in a new window] ,
Maria Hedman-Lagerlöf Open the ORCID record for Maria Hedman-Lagerlöf [Opens in a new window] ,
Jens Fust Open the ORCID record for Jens Fust [Opens in a new window]  and
Erik Hedman-Lagerlöf Open the ORCID record for Erik Hedman-Lagerlöf [Opens in a new window]
Fredrik Santoft
Affiliation:
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Erland Axelsson*
Affiliation:
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Lars-Göran Öst
Affiliation:
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Department of Psychology, Stockholm University, Stockholm, Sweden
Maria Hedman-Lagerlöf
Affiliation:
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Jens Fust
Affiliation:
Neuro, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Erik Hedman-Lagerlöf
Affiliation:
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
*
Author for correspondence: Erland Axelsson, E-mail: erland.axelsson@ki.se
Get access Rights & Permissions [Opens in a new window]

Abstract

Depression is common in primary care, and most patients prefer psychological treatment over pharmacotherapy. Cognitive behaviour therapy (CBT) is an effective treatment, but there are gaps in current knowledge about CBT in the primary care context, especially with regard to long-term effects and the efficacy of specific delivery formats. This is an obstacle to the integration of primary care and specialist psychiatry. We conducted a systematic review and meta-analysis of randomised controlled trials of CBT for primary care patients with depression to investigate the effect of CBT for patients with depression in primary care. A total of 34 studies, with 2543 patients in CBT and 2815 patients in control conditions, were included. CBT was more effective than the control conditions [g = 0.22 (95% confidence interval (CI) 0.15–0.30)], and the effect was sustained at follow-up [g = 0.17 (95% CI 0.10–0.24)]. CBT also led to a higher response rate [odds ratio (OR) = 2.47 (95% CI 1.60–3.80)] and remission rate [OR = 1.56 (95% CI 1.15–2.14)] than the control conditions. Heterogeneity was moderate. The controlled effect of CBT was significant regardless of whether patients met diagnostic criteria for depression, scored above a validated cut-off for depression, or merely had depressive symptoms. CBT also had a controlled effect regardless of whether the treatment was delivered as individual therapy, group therapy or therapist-guided self-help. We conclude that CBT appears to be effective for patients with depression in primary care, and recommend that patients with mild to moderate depression be offered CBT in primary care.

Keywords

Cognitive behaviour therapydepressionmajor depressionmeta-analysisprimary carepsychological treatmentpsychotherapysystematic review
Type
Review Article
Information
Psychological Medicine , Volume 49 , Issue 8 , June 2019 , pp. 1266 - 1274
Copyright
Copyright © Cambridge University Press 2019 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

*

Joint first authorship.

References

Casañas, R, Catalán, R, del Val, JL, Real, J, Valero, S and Casas, M (2012) Effectiveness of a psycho-educational group program for major depression in primary care: a randomized controlled trial. BMC Psychiatry 12, 230.Google Scholar
Chowdhary, N, Anand, A, Dimidjian, S, Shinde, S, Weobong, B, Balaji, M, Hollon, SD, Rahman, A, Wilson, G, Verdeli, H, Araya, R, King, M, Jordans, MJ, Fairburn, C, Kirkwood, B and Patel, V (2016) The healthy activity program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation. British Journal of Psychiatry 208, 381–388.Google Scholar
Cohen, J (1988) Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates.Google Scholar
Cramer, H, Salisbury, C, Conrad, J, Eldred, J and Araya, R (2011) Group cognitive behavioural therapy for women with depression: pilot and feasibility study for a randomised controlled trial using mixed methods. BMC Psychiatry 11, 82.Google Scholar
Cuijpers, P (1997) Bibliotherapy in unipolar depression: a meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry 28, 139–147.Google Scholar
Cuijpers, P, Smit, F, Oostenbrink, J, de Graaf, R, Ten Have, M and Beekman, A (2007) Economic costs of minor depression: a population-based study. Acta Psychiatrica Scandinavica 115, 229–236.Google Scholar
Cuijpers, P, van Straten, A, van Schaik, A and Andersson, G (2009) Psychological treatment of depression in primary care: a meta-analysis. British Journal of General Practice 59, e51–e60.Google Scholar
Cuijpers, P, Berking, M, Andersson, G, Quigley, L, Kleiboer, A and Dobson, KS (2013) A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry 58, 376–385.Google Scholar
Cuijpers, P, Karyotaki, E, Weitz, E, Andersson, G, Hollon, SD and van Straten, A (2014) The effects of psychotherapies for major depression in adults on remission, recovery and improvement: a meta-analysis. Journal of Affective Disorders 159, 118–126.Google Scholar
Cummings, P (2009) The relative merits of risk ratios and odds ratios. Archives of Pediatrics and Adolescent Medicine 163, 438–445.Google Scholar
Dalgard, OS (2006) A randomized controlled trial of a psychoeducational group program for unipolar depression in adults in Norway (NCT00319540). Clinical Practice & Epidemiology in Mental Health 2, 15.Google Scholar
Duval, S and Tweedie, R (2000) Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455–463.Google Scholar
Dwight-Johnson, M, Aisenberg, E, Golinelli, D, Hong, S, O'Brien, M and Ludman, E (2011) Telephone-based cognitive-behavioral therapy for Latino patients living in rural areas: a randomized pilot study. Psychiatric Services 62, 936–942.Google Scholar
Egger, M, Davey Smith, G, Schneider, M and Minder, C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315, 629–634.Google Scholar
Ekers, D, Richards, D, McMillan, D, Bland, J and Gilbody, S (2011) Behavioural activation delivered by the nonspecialist: phase II randomised controlled trial. British Journal of Psychiatry 198, 66–72.Google Scholar
ESEMeD⁄MHEDEA 2000 investigators (2004) Use of mental health services in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica 109, 47–54.Google Scholar
Gilbody, S, Littlewood, E, Hewitt, C, Brierley, G, Tharmanathan, P, Araya, R, Barkham, M, Bower, P, Cooper, C, Gask, L, Kessler, D, Lester, H, Lovell, K, Parry, G, Richards, DA, Andersen, P, Brabyn, S, Knowles, S, Shepherd, C, Tallon, D and White, D (2015) Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ 351, h5627.Google Scholar
Gilbody, S, Lewis, H, Adamson, J, Atherton, K, Bailey, D, Birtwistle, J, Bosanquet, K, Clare, E, Delgadillo, J, Ekers, D, Foster, D, Gabe, R, Gascoyne, S, Haley, L, Hamilton, J, Hargate, R, Hewitt, C, Holmes, J, Keding, A, Lilley-Kelly, A, Meer, S, Mitchell, N, Overend, K, Pasterfield, M, Pervin, J, Richards, DA, Spilsbury, K, Traviss-Turner, G, Trepel, D, Woodhouse, R, Ziegler, F and McMillan, D (2017) Effect of collaborative care vs usual care on depressive symptoms in older adults with subthreshold depression: the CASPER randomized clinical trial. JAMA 317, 728–737.Google Scholar
González González, S, Fernández Rodríguez, C, Pérez Rodríguez, J and Amigo, I (2007) Secondary prevention of depression in primary care. Psychology in Spain 11, 24–32.Google Scholar
Hedges, LV (1981) Distribution theory for Glass's estimator of effect size and related estimators. Journal of Educational and Behavioral Statistics 6, 107–128.Google Scholar
Hedman, E, Ljótsson, B and Lindefors, N (2012) Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost-effectiveness. Expert Review of Pharmacoeconomics & Outcomes Research 12, 745–764.Google Scholar
Hegerl, U, Hautzinger, M, Mergl, R, Kohnen, R, Schutze, M, Scheunemann, W, Allgaier, A-K, Coyne, J and Henkel, V (2010) Effects of pharmacotherapy and psychotherapy in depressed primary-care patients: a randomized, controlled trial including a patients’ choice arm. International Journal of Neuropsychopharmacology 13, 31–44.Google Scholar
Higgins, JP, Thompson, SG, Deeks, JJ and Altman, DG (2003) Measuring inconsistency in meta-analyses. BMJ 327, 557–560.Google Scholar
Higgins, JP, Altman, DG, Gotzsche, PC, Juni, P, Moher, D, Oxman, AD, Savovic, J, Schulz, KF, Weeks, L, Sterne, JA, Cochrane Bias Methods Group and Cochrane Statistical Methods Group (2011) The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 343, d5928.Google Scholar
Husain, N, Chaudhry, N, Fatima, B, Husain, M, Amin, R, Chaudhry, IB, Ur Rahman, R, Tomenson, B, Jafri, F, Naeem, F and Creed, F (2014) Antidepressant and group psychosocial treatment for depression: a rater blind exploratory RCT from a low income country. Behavioural and Cognitive Psychotherapy 42, 693–705.Google Scholar
Joling, KJ, van Hout, HP, van't Veer-Tazelaar, PJ, van der Horst, HE, Cuijpers, P, van de Ven, PM and van Marwijk, HW (2011) How effective is bibliotherapy for very old adults with subthreshold depression? A randomized controlled trial. American Journal of Geriatric Psychiatry 19, 256–265.Google Scholar
Kanter, JW, Santiago-Rivera, AL, Santos, MM, Nagy, G, Lopez, M, Hurtado, GD and West, P (2015) A randomized hybrid efficacy and effectiveness trial of behavioral activation for Latinos with depression. Behavior Therapy 46, 177–192.Google Scholar
Kessler, D, Lewis, G, Kaur, S, Wiles, N, King, M, Weich, S, Sharp, DJ, Araya, R, Hollinghurst, S and Peters, TJ (2009) Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial. The Lancet 374, 628–634.Google Scholar
Kivi, M, Eriksson, MC, Hange, D, Petersson, EL, Vernmark, K, Johansson, B and Björkelund, C (2014) Internet-based therapy for mild to moderate depression in Swedish primary care: short term results from the PRIM-NET randomized controlled trial. Cognitive Behaviour Therapy 43, 289–298.Google Scholar
Laidlaw, K, Davidson, K, Toner, H, Jackson, G, Clark, S, Law, J, Howley, M, Bowie, G, Connery, H and Cross, S (2008) A randomised controlled trial of cognitive behaviour therapy vs treatment as usual in the treatment of mild to moderate late life depression. International Journal of Geriatric Psychiatry 23, 843–850.Google Scholar
Levin, W, Campbell, DR, McGovern, KB, Gau, JM, Kosty, DB, Seeley, JR and Lewinsohn, PM (2011) A computer-assisted depression intervention in primary care. Psychological Medicine 41, 1373–1383.Google Scholar
Linde, K, Sigterman, K, Kriston, L, Rucker, G, Jamil, S, Meissner, K and Schneider, A (2015) Effectiveness of psychological treatments for depressive disorders in primary care: systematic review and meta-analysis. Annals of Family Medicine 13, 56–68.Google Scholar
Lipsey, MW and Wilson, DB (2001) Practical Meta-Analysis. Thousand Oaks, CA: Sage Publications, Inc.Google Scholar
Lovell, K, Bower, P, Richards, D, Barkham, M, Sibbald, B, Roberts, C, Davies, L, Rogers, A, Gellatly, J and Hennessy, S (2008) Developing guided self-help for depression using the Medical Research Council complex interventions framework: a description of the modelling phase and results of an exploratory randomised controlled trial. BMC Psychiatry 8, 91.Google Scholar
McHugh, RK, Whitton, SW, Peckham, AD, Welge, JA and Otto, MW (2013) Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. Journal of Clinical Psychiatry 74, 595–602.Google Scholar
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339, b2535.Google Scholar
Moussavi, S, Chatterji, S, Verdes, E, Tandon, A, Patel, V and Üstün, B (2007) Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet 370, 851–858.Google Scholar
National Collaborating Centre for Mental Health (2010) Depression: The Treatment and Management of Depression in Adults (Update). Leicester and London: The British Psychological Society and the Royal College of Psychiatrists.Google Scholar
Naylor, EV, Antonuccio, DO, Litt, M, Johnson, GE, Spogen, DR, Williams, R, McCarthy, C, Lu, MM, Fiore, DC and Higgins, DL (2010) Bibliotherapy as a treatment for depression in primary care. Journal of Clinical Psychology in Medical Settings 17, 258–271.Google Scholar
Ormel, J, Petukhova, M, Chatterji, S, Aguilar-Gaxiola, S, Alonso, J, Angermeyer, MC, Bromet, EJ, Burger, H, Demyttenaere, K, de Girolamo, G, Haro, JM, Hwang, I, Karam, E, Kawakami, N, Lepine, JP, Medina-Mora, ME, Posada-Villa, J, Sampson, N, Scott, K, Ustun, TB, Von Korff, M, Williams, DR, Zhang, M and Kessler, RC (2008) Disability and treatment of specific mental and physical disorders across the world. British Journal of Psychiatry 192, 368–375.Google Scholar
Power, MJ and Freeman, C (2012) A randomized controlled trial of IPT versus CBT in primary care: with some cautionary notes about handling missing values in clinical trials. Clinical Psychology & Psychotherapy 19, 159–169.Google Scholar
R Core Team (2016) R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing.Google Scholar
Ross, M and Scott, M (1985) An evaluation of the effectiveness of individual and group cognitive therapy in the treatment of depressed patients in an inner city health centre. Journal of the Royal College of General Practitioners 35, 239–242.Google Scholar
Schulz, KF, Altman, DG, Moher, D and Group, C (2010) CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMC Medicine 8, 18.Google Scholar
Scott, AI and Freeman, CP (1992) Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks. BMJ 304, 883–887.Google Scholar
Scott, C, Tacchi, MJ, Jones, R and Scott, J (1997) Acute and one-year outcome of a randomised controlled trial of brief cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry 171, 131–134.Google Scholar
Serfaty, MA, Haworth, D, Blanchard, M, Buszewicz, M, Murad, S and King, M (2009) Clinical effectiveness of individual cognitive behavioral therapy for depressed older people in primary care: a randomized controlled trial. Archives of General Psychiatry 66, 1332–1340.Google Scholar
Smit, A, Kluiter, H, Conradi, HJ, van der Meer, K, Tiemens, BG, Jenner, JA, van Os, TW and Ormel, J (2006) Short-term effects of enhanced treatment for depression in primary care: results from a randomized controlled trial. Psychological Medicine 36, 15–26.Google Scholar
Sørensen Høifødt, R, Lillevoll, KR, Griffiths, KM, Wilsgaard, T, Eisemann, M, Waterloo, K and Kolstrup, N (2013) The clinical effectiveness of web-based cognitive behavioral therapy with face-to-face therapist support for depressed primary care patients: randomized controlled trial. Journal of Medical Internet Research 15, 301–322.Google Scholar
Spek, V, Nyklicek, I, Smits, N, Cuijpers, P, Riper, H, Keyzer, J and Pop, V (2007) Internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years old: a random controlled clinical trial. Psychological Medicine 37, 1797–1806.Google Scholar
Teasdale, JD, Fennell, MJ, Hibbert, GA and Amies, PL (1984) Cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry 144, 400–406.Google Scholar
Thornicroft, G, Chatterji, S, Evans-Lacko, S, Gruber, M, Sampson, N, Aguilar-Gaxiola, S, Al-Hamzawi, A, Alonso, J, Andrade, L, Borges, G, Bruffaerts, R, Bunting, B, de Almeida, JM, Florescu, S, de Girolamo, G, Gureje, O, Haro, JM, He, Y, Hinkov, H, Karam, E, Kawakami, N, Lee, S, Navarro-Mateu, F, Piazza, M, Posada-Villa, J, de Galvis, YT and Kessler, RC (2017) Undertreatment of people with major depressive disorder in 21 countries. British Journal of Psychiatry 210, 119–124.Google Scholar
Twomey, C, O'Reilly, G and Byrne, M (2015) Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis. Family Practice 32, 3–15.Google Scholar
Viechtbauer, W (2010) Conducting meta-analyses in R with the metafor package. Journal of Statistical Software 36, 1–48.Google Scholar
Wahl, I, Löwe, B, Bjorner, JB, Fischer, F, Langs, G, Voderholzer, U, Aita, SA, Bergemann, N, Brähler, E and Rose, M (2014) Standardization of depression measurement: a common metric was developed for 11 self-report depression measures. Journal of Clinical Epidemiology 67, 73–86.Google Scholar
Ward, E, King, M, Lloyd, M, Bower, P, Sibbald, B, Farrelly, S, Gabbay, M, Tarrier, N and Addington-Hall, J (2000) Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: clinical effectiveness. BMJ 321, 1383–1388.Google Scholar
Watson, JC, Gordon, LB, Stermac, L, Kalogerakos, F and Steckley, P (2003) Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology 71, 773–781.Google Scholar
Watts, SE, Turnell, A, Kladnitski, N, Newby, JM and Andrews, G (2015) Treatment-as-usual (TAU) is anything but usual: a meta-analysis of CBT versus TAU for anxiety and depression. Journal of Affective Disorders 175, 152–167.Google Scholar
Wiles, N, Hollinghurst, S, Mason, V, Musa, M, Burt, V, Hyde, J, Jerrom, B, Lewis, G and Kessler, D (2008) A randomized controlled trial of cognitive behavioural therapy as an adjunct to pharmacotherapy in primary care based patients with treatment resistant depression: a pilot study. Behavioural and Cognitive Psychotherapy 36, 21–33.Google Scholar
Wiles, N, Thomas, L, Abel, A, Ridgway, N, Turner, N, Campbell, J, Garland, A, Hollinghurst, S, Jerrom, B, Kessler, D, Kuyken, W, Morrison, J, Turner, K, Williams, C, Peters, T and Lewis, G (2013) Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial. The Lancet 381, 375–384.Google Scholar
Willemse, GR, Smit, F, Cuijpers, P and Tiemens, BG (2004) Minimal-contact psychotherapy for sub-threshold depression in primary care. British Journal of Psychiatry 185, 416–421.Google Scholar
Williams, C, Wilson, P, Morrison, J, McMahon, A, Walker, A, Allan, L, McConnachie, A, McNeill, Y and Tansey, L (2013) Guided self-help cognitive behavioural therapy for depression in primary care: a randomised controlled trial. PLoS ONE 8, e52735.Google Scholar
World Health Organization (2008) The Global Burden of Disease: 2004 Update. Geneva, Switzerland: World Health Organization.Google Scholar
Supplementary material: PDF

Santoft et al. supplementary material

Online Supplement

Download Santoft et al. supplementary material(PDF)
PDF 1.1 MB