Efficacy of inpatient psychotherapy for major depressive disorder: a meta-analysis of controlled trials

Fragestellung: In dieser Metaanalyse soll die Wirksamkeit stationärer Psychotherapie depressiver Störungen im Vergleich zu Kontrollbedingungen ohne psychotherapeutische Intervention beurteilt werden. Dabei werden Faktoren wie Art der Kontrollbedingung, die Verwendung von Fremd- bzw. Selbstbeurteilungsskalen und die Anzahl an Therapieeinheiten als moderierende Variablen berücksichtigt. Methode: Ein systematische Suche in vier biomedizinsichen Datenbanken (CENTRAL, PsycINFO, MEDLINE, Web of Science) wurde unternommen. Als primärer Endpunkt galt die Differenz der Depressionsschwere zwischen der Interventions- und Kontrollbedingung ermittelt durch Selbstbeurteilungsskalen, die in einer random effects Metaanalyse zusammengefasst wurden. In Subgruppenanalysen wurden Studien mit verschiedenen Arten von Kontrollbedingungen verglichen, wobei unterschieden wurde zwischen a) keine Behandlung (z.B.Warteliste), b) treatment as usual (TAU) - nicht durch die Studie standardisiert und c) TAU - manualisiert, durch die Studie standardisiert. Ferner wurden Studien mit 21 Therapieeinheiten, sowie Ergebnisse von Selbst- und Fremdbeurteilungsmaßen verglichen. Eine Prüfung auf einen Publikationsbias der Metaanalyse und eine Bewertung des Risikos systematischer Verzerrungen innerhalb der einzelnen Studien wurde vorgenommen. Resultate: Es wurden 14 relevante Studien (k = 19 Vergleiche) mit insgesamt 1080 Patienten gefunden. Die Metaanalyse wies eine kleine, statistisch signifikante Überlegenheit der stationären Psychotherapie gegenüber Kontrollbedingungen ohne Psychotherapie aus (g = 0.24, p < 0.001, I^2 = 0%, NNT = 7.4). Die Effekte der Intervention zeigten sich über eine Periode von mindestens 12 Monaten stabil (k = 9, n = 710, g = 0.21, p = 0.04, I^2 = 30%). Im Subgruppenvergleich von stationärer Psychotherapie mit standardisierten Kontrollbedingungen zeigte sich keine Überlegenheit der Psychotherapie. Im Vergleich zu Warteliste oder unstandardisiertem TAU blieb der Effekt bestehen. Eine höhere Anzahl an Therapiesitzungen zeigte tendenziell geringere Effekte. Ergebnisse von Fremd- und Selbstbeurteilungmaßen unterschieden sich marginal. Es fand sich keine Evidenz für einen Publikationsbias. Schlussfolgerung: Ein kleiner jedoch robuster und anhaltender Effekt stationärer Psychotherapie gegenüber einer gewöhnlichen stationäre Krankenhausbehandlung konnte für depressive Störungen gezeigt werden. Der Effekt war in einer Subgruppe von Studien mit stärker standardisierten Kontrollbedingungen nicht mehr nachzuweisen.Objective: This meta-analysis aims to investigate the efficacy of inpatient psychotherapy of depressive disorders compared to control conditions without psychotherapy. As moderating factors, we consider the type of control condition, use of self- vs clnician ratings and number of treatment sessions. Methods: A systematic search of four biomedical databases (CENTRAL, PsycINFO, MEDLINE, Web of Science) was performed. The differences in self-rated depression severity between intervention and control groups served as primary outcomes, which were synthesized in a random effects meta-analysis. In subgroup analyses, studies were compared based on differences in the type of control conditions they applied. We distinguished a) no treatment or waitlist controls, b) treatment as usual (TAU) - not standardized by trial design, c) TAU - standardized by trial design, manualized. Subgroups of trials providing 21 treatment sessions were compared as well as results from self- versus clinician ratings. Results: Fourteen relevant studies (k = 19 comparisons) with a total of 1080 patients were retrieved. The meta-analysis showed a small, statistically significant superiority of inpatient psychotherapy compared to control conditions without psychotherapy (g = 0.24, p < 0.001, I^2 = 0%, NNT = 7.4). The effects of the intervention were stable over a minimum12-months follow-up period (g = 0:21; p = 0:04; I2 = 30%). In subgroup comparisons of inpatient psychotherapy to manualized and standardized control conditions, no superiority of psychotherapy was shown. Compared to waitlist and non-standardized TAU the significant effect remained. A higher number of treatment sessions showed trendwise smaller effects. Results between self- and clnician ratings differed only marginally. There was no evidence of a publication bias. Conclusions: We found evidence for a small but robust and lastig effect of inpatient psychotherapy in patients with depressive disorders when compared to treatment as usual. The effect was not present in a subgroup of studies using more standardized control conditions

Working alliance and its link to guidance in an internet-based intervention for depressive disorders: a secondary analysis of a randomized controlled trial

Background: Guided Internet-based interventions (IBIs) are typically found to be more effective than unguided ones, but the reasons behind this are not well understood. The therapist-client working alliance, crucial in face-to-face psychotherapy, is also increasingly recognized as an important factor in IBIs. This study examines trajectories of the working alliance and its relationship to therapeutic guidance through a secondary analysis of a randomized controlled trial (RCT) on Selfapy, a 12-week IBI based on cognitive behavioral therapy for depressive disorders. The trial compared a therapist-guided version (with weekly calls) to an unguided version (n = 301, mean age 37 years, 83% female, mean BDI-II = 30.09). Methods: Based on an intention-to-treat approach, this study investigates within- and between-group differences in the quality of the working alliance, assessed with the WAI-SR questionnaire at mid- and post-treatment via repeated measures ANOVA. Furthermore, correlations and mediation analyses were conducted to explore the relationship between the working alliance and outcomes, as well as adherence parameters. Results: Findings indicate that the IBI was successful in fostering a robust working alliance in both intervention groups, with similar ratings at mid-treatment but significantly higher ratings in the guided group at post-treatment (Cohen’s d = -0.38). Post-treatment working alliance scores were positively linked to symptom reduction at post-treatment (guided: r = .25, unguided r = .15) and follow-up (guided: r = .25, unguided: r = .17). In the unguided group, the association was primarily driven by the subscale task. Serial mediation analysis indicated that the relationship between guidance and outcomes at follow-up was mediated by working alliance (b = 0.59; 95% CI: 0.14, 1.22) and a link between working alliance and adherence (b = 0.15; 95% CI: 0.04, 0.34). Conclusions: Considering limitations like using a questionnaire developed for face-to-face therapy, findings support the importance of the working alliance in guided IBIs, while also providing new insights into its role and formation in unguided IBIs. The potential benefits of a strong working alliance, notably by improving adherence, may prove crucial for integrating guided as well as unguided IBIs into routine use, indicating the need for additional research in this context. Clinical Trial Registration: https://tinyurl.com/2p9h5hnx, German Clinical Trials Register DRKS00017191

Efficacy and acceptability of third-wave psychotherapies in the treatment of depression: a network meta-analysis of controlled trials

Introduction: In recent decades, various new psychotherapy approaches have been developed in an effort to overcome issues of non-response, referred to as “third-wave psychotherapies.” How third-wave therapies perform in comparison to each other, to classical CBT, or other common comparators in the treatment of depression has not yet been systematically assessed. Methods: We firstly determined the scope of the term “third-wave” by conducting a systematic search. The identified approaches were then used as search terms for the systematic review and network meta-analysis (NMA). We searched MEDLINE, CENTRAL, PsychINFO and Web of Science from inception until 31 July 2022. We assessed randomized controlled trials comparing third-wave psychotherapies to each other, CBT, treatment as usual (TAU), medication management, active control conditions, or waitlist (WL) in adult populations with depressive disorders. The treatments included were acceptance and commitment therapy, behavioral activation, cognitive behavioral analysis system of psychotherapy, dialectical behavioral therapy, mindfulness-based cognitive therapy, meta-cognitive therapy, positive psychotherapy and schema therapy. The primary outcome was depression severity (efficacy) at study endpoint, and the secondary outcome was all-cause discontinuation (acceptability). This review was registered in PROSPERO, identifier CRD42020147535. Results: Of 7,971 search results, 55 trials were included in our NMA (5,827 patients). None of the third-wave therapies were more efficacious than CBT but most were superior to TAU [standardized mean differences (SMD) ranging between 0.42 (95% CI −0.37; 1.19) and 1.25 (0.48; 2.04)]. Meta-cognitive therapy (MCT) was more efficacious than three other third-wave therapy approaches. None of the third-wave treatments were more acceptable than WL or CBT. Twenty-seven percent of the trials were rated as low risk of bias. Confidence in the evidence was largely low according to GRADE. Inconsistency emerged for a small number of comparisons. Interpretations: Third-wave therapies are largely efficacious and acceptable alternatives to CBT when compared to TAU, with few differences between them. The evidence so far does not point toward superiority or inferiority over CBT. Patient-level research may offer possibilities for tailoring individual psychotherapies to the needs of individual patients and future trials should make this data available. The evidence base needs to be broadened by sufficiently powered trials

Efficacy and acceptability of third-wave psychotherapies in the treatment of depression: a network meta-analysis of controlled trials

IntroductionIn recent decades, various new psychotherapy approaches have been developed in an effort to overcome issues of non-response, referred to as “third-wave psychotherapies.” How third-wave therapies perform in comparison to each other, to classical CBT, or other common comparators in the treatment of depression has not yet been systematically assessed.MethodsWe firstly determined the scope of the term “third-wave” by conducting a systematic search. The identified approaches were then used as search terms for the systematic review and network meta-analysis (NMA). We searched MEDLINE, CENTRAL, PsychINFO and Web of Science from inception until 31 July 2022. We assessed randomized controlled trials comparing third-wave psychotherapies to each other, CBT, treatment as usual (TAU), medication management, active control conditions, or waitlist (WL) in adult populations with depressive disorders. The treatments included were acceptance and commitment therapy, behavioral activation, cognitive behavioral analysis system of psychotherapy, dialectical behavioral therapy, mindfulness-based cognitive therapy, meta-cognitive therapy, positive psychotherapy and schema therapy. The primary outcome was depression severity (efficacy) at study endpoint, and the secondary outcome was all-cause discontinuation (acceptability). This review was registered in PROSPERO, identifier CRD42020147535.ResultsOf 7,971 search results, 55 trials were included in our NMA (5,827 patients). None of the third-wave therapies were more efficacious than CBT but most were superior to TAU [standardized mean differences (SMD) ranging between 0.42 (95% CI −0.37; 1.19) and 1.25 (0.48; 2.04)]. Meta-cognitive therapy (MCT) was more efficacious than three other third-wave therapy approaches. None of the third-wave treatments were more acceptable than WL or CBT. Twenty-seven percent of the trials were rated as low risk of bias. Confidence in the evidence was largely low according to GRADE. Inconsistency emerged for a small number of comparisons.InterpretationsThird-wave therapies are largely efficacious and acceptable alternatives to CBT when compared to TAU, with few differences between them. The evidence so far does not point toward superiority or inferiority over CBT. Patient-level research may offer possibilities for tailoring individual psychotherapies to the needs of individual patients and future trials should make this data available. The evidence base needs to be broadened by sufficiently powered trials

Working alliance and its link to guidance in an internet-based intervention for depressive disorders: a secondary analysis of a randomized controlled trial

BackgroundGuided Internet-based interventions (IBIs) are typically found to be more effective than unguided ones, but the reasons behind this are not well understood. The therapist-client working alliance, crucial in face-to-face psychotherapy, is also increasingly recognized as an important factor in IBIs. This study examines trajectories of the working alliance and its relationship to therapeutic guidance through a secondary analysis of a randomized controlled trial (RCT) on Selfapy, a 12-week IBI based on cognitive behavioral therapy for depressive disorders. The trial compared a therapist-guided version (with weekly calls) to an unguided version (n = 301, mean age 37 years, 83% female, mean BDI-II = 30.09).MethodsBased on an intention-to-treat approach, this study investigates within- and between-group differences in the quality of the working alliance, assessed with the WAI-SR questionnaire at mid- and post-treatment via repeated measures ANOVA. Furthermore, correlations and mediation analyses were conducted to explore the relationship between the working alliance and outcomes, as well as adherence parameters.ResultsFindings indicate that the IBI was successful in fostering a robust working alliance in both intervention groups, with similar ratings at mid-treatment but significantly higher ratings in the guided group at post-treatment (Cohen’s d = -0.38). Post-treatment working alliance scores were positively linked to symptom reduction at post-treatment (guided: r = .25, unguided r = .15) and follow-up (guided: r = .25, unguided: r = .17). In the unguided group, the association was primarily driven by the subscale task. Serial mediation analysis indicated that the relationship between guidance and outcomes at follow-up was mediated by working alliance (b = 0.59; 95% CI: 0.14, 1.22) and a link between working alliance and adherence (b = 0.15; 95% CI: 0.04, 0.34).ConclusionsConsidering limitations like using a questionnaire developed for face-to-face therapy, findings support the importance of the working alliance in guided IBIs, while also providing new insights into its role and formation in unguided IBIs. The potential benefits of a strong working alliance, notably by improving adherence, may prove crucial for integrating guided as well as unguided IBIs into routine use, indicating the need for additional research in this context.Clinical Trial Registrationhttps://tinyurl.com/2p9h5hnx, German Clinical Trials Register DRKS00017191

Evaluation of the internet-based intervention “Selfapy” in participants with unipolar depression and the impact on quality of life: a randomized, parallel group study

Purpose: Depressive disorders cause a major burden of disease worldwide and often lead to a loss of social functioning. Patients suffering from depressive disorders report a lower quality of life (QOL) than people without a history of mental health issues. Internet-based interventions (IBIs) based on cognitive behavioral therapy (CBT) are effective in reducing symptom severity but data on their impact on quality of life in clinically depressed patients so far is scarce. Methods:Selfapy is a CBT-based IBI for depressive disorders. 401 participants (332 female, mean age 37 ( SD  = 11) with a diagnosis of major depressive disorder (MDD) or dysthymia were enrolled in a randomized, parallel, three-arm trial comparing a therapist-guided Selfapy intervention with an unguided Selfapy intervention and a waiting list control. QOL was measured using the WHOQOL-BREF at baseline, post-treatment (12 weeks) and at 24-week follow-up. The effects of the interventions on QOL were calculated using linear mixed effects models. Results: At post-treatment (12 weeks) the guided and unguided intervention groups reported an increase in QOL on physical and psychological health domains compared to controls (significant group*time interaction). The gain in QOL was maintained over the follow-up period only for psychological health. QOL decreased in the social relationships and environment domains over the course of treatment and during the follow-up treatment for all participants. There were no differences between the guided and the unguided intervention. Conclusion:Selfapy proved to positively affect psychological and physical QOL in a sample of participants suffering from depressive disorders and can therefore be considered an effective and highly scalable therapeutic tool. The pattern of results might partly be attributable to effects of the COVID-19 pandemic and public health measures that coincided with the trial. Trial registration : German Clinical Trials Register (DRKS): DRKS00017191. Registered June 14th, 2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017191 .Peer Reviewe

Evaluation of the internet-based intervention “Selfapy” in participants with unipolar depression and the impact on quality of life: a randomized, parallel group study

&lt;jats:title&gt;Abstract&lt;/jats:title&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Purpose&lt;/jats:title&gt; &lt;jats:p&gt;Depressive disorders cause a major burden of disease worldwide and often lead to a loss of social functioning. Patients suffering from depressive disorders report a lower quality of life (QOL) than people without a history of mental health issues. Internet-based interventions (IBIs) based on cognitive behavioral therapy (CBT) are effective in reducing symptom severity but data on their impact on quality of life in clinically depressed patients so far is scarce.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Methods&lt;/jats:title&gt; &lt;jats:p&gt;&lt;jats:italic&gt;Selfapy&lt;/jats:italic&gt; is a CBT-based IBI for depressive disorders. 401 participants (332 female, mean age 37 (&lt;jats:italic&gt;SD&lt;/jats:italic&gt; = 11) with a diagnosis of major depressive disorder (MDD) or dysthymia were enrolled in a randomized, parallel, three-arm trial comparing a therapist-guided &lt;jats:italic&gt;Selfapy&lt;/jats:italic&gt; intervention with an unguided &lt;jats:italic&gt;Selfapy&lt;/jats:italic&gt; intervention and a waiting list control. QOL was measured using the WHOQOL-BREF at baseline, post-treatment (12 weeks) and at 24-week follow-up. The effects of the interventions on QOL were calculated using linear mixed effects models.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Results&lt;/jats:title&gt; &lt;jats:p&gt;At post-treatment (12 weeks) the guided and unguided intervention groups reported an increase in QOL on physical and psychological health domains compared to controls (significant group*time interaction). The gain in QOL was maintained over the follow-up period only for psychological health. QOL decreased in the social relationships and environment domains over the course of treatment and during the follow-up treatment for all participants. There were no differences between the guided and the unguided intervention.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Conclusion&lt;/jats:title&gt; &lt;jats:p&gt;&lt;jats:italic&gt;Selfapy&lt;/jats:italic&gt; proved to positively affect psychological and physical QOL in a sample of participants suffering from depressive disorders and can therefore be considered an effective and highly scalable therapeutic tool. The pattern of results might partly be attributable to effects of the COVID-19 pandemic and public health measures that coincided with the trial.&lt;/jats:p&gt; &lt;jats:p&gt;&lt;jats:italic&gt;Trial registration&lt;/jats:italic&gt;: German Clinical Trials Register (DRKS): DRKS00017191. Registered June 14th, 2019, &lt;jats:ext-link xmlns:xlink='http://www.w3.org/1999/xlink' ext-link-type='uri' xlink:href='https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&amp;amp;TRIAL_ID=DRKS00017191'&gt;https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&amp;amp;TRIAL_ID=DRKS00017191&lt;/jats:ext-link&gt;.&lt;/jats:p&gt; &lt;/jats:sec&gt