A systematic review of non-pharmacological treatments for depression in people with chronic physical health problems

Authors:
RIZZO Maria, et al
Journal article citation:
Journal of Psychosomatic Research, 71(1), July 2011, pp.18-27.
Publisher:
Elsevier

This systematic review was prompted by the need to update the NICE guidelines on the management of depression in adults to include separate guidance for adults with depression and chronic physical health problems. It aimed to look at whether non-pharmacological treatment is effective for the population in question, compared to usual care and, if so, are there any differences between the different kinds of non-pharmacological interventions. Evidence from 35 studies, including 22 that were subjected to meta-analysis, suggests that some non-pharmacological treatments for depression result in improved outcomes compared to usual treatment in people with chronic physical health problems. The strongest evidence was for individual and group-based cognitive and behavioural interventions. There was not enough evidence to compare the effects of different kinds of non-pharmacological interventions. Interventions aimed specifically at reducing depression, and those in which participants were recruited with diagnosed depression, produced the strongest evidence of a beneficial effect.

Extended abstract:
Author

RIZZO Maria; et al.;

A systematic review of non-pharmacological treatments for depression in people with chronic physical health problems.

Journal citation/publication details

Journal of Psychosomatic Research, 71(1), July 2011, pp.18-27.

Summary

Evidence from 35 studies, including 22 that were subjected to meta-analysis, suggests that some non-pharmacological treatments for depression result in improved outcomes compared to usual treatment in people with chronic physical health problems. The strongest evidence was for individual and group-based cognitive and behavioural interventions. There was not enough evidence to compare the effects of different kinds of non-pharmacological interventions. Interventions aimed specifically at reducing depression, and those in which participants were recruited with diagnosed depression, produced the strongest evidence of a beneficial effect.

Context

This systematic review was prompted by the need to update the NICE guidelines on the management of depression in adults to include separate guidance for adults with depression and chronic physical health problems. The aim was to look at whether non-pharmacological treatment is effective for the population in question, compared to usual care and, if so, are there any differences between the different kinds of non-pharmacological interventions. The evidence from trials including only participants with diagnosed depression was compared with evidence from studies using a broader range of subjects, some with minor depression. Finally, trials that focussed on reducing depression were compared with trials with a broader aim, such as reducing psychosocial stressors and improving health-related quality of life.

Methods

What sources were searched?
The electronic databases CINAHL, CENTRAL, EMBASE, Medline, and PsycINFO were searched from inception to March 2008. The reference lists of retrieved articles, previous reviews, and meta-analyses were manually searched and members of the Guideline Development Group were consulted.

What search terms/strategies were used?
Full details of the search terms used and individual search strategies are reported in full in the online version of the NICE guideline on depression in chronic physical health problems at www.nccmh.org.uk/guidelines_dchp.html.
 
What criteria were used to decide on which studies to include?
Studies were included if participants had a chronic physical health problem and were diagnosed with major depression or dysthymia using DSM or ICD criteria, or; another recognised scale, or; if treatment and control groups had a mean baseline depression score above the cut-off on a recognised scale. Cut-off scores for recognised scales are presented in Table 1. Only randomised controlled trials of psychosocial interventions offered alone, or in combination with a pharmacological intervention if there was a comparison psychosocial intervention only group, were considered. Straight comparisons with pharmacological interventions were excluded as were studies of psychosocial interventions delivered as part of a complex, multi-component intervention.

Who decided on their relevance and quality?
Study eligibility was assessed by the first named author; queries were discussed with a second reviewer. Methodological quality was assessed using the SIGN (Scottish Intercollegiate Guidelines Network) checklist for randomised controlled trials. Studies were assigned with a quality rating of ++, +, or – according to whether ‘all or most’, ‘some’, or ‘few or none’ of the criteria were fulfilled, respectively. The quality of the evidence was also assessed at the outcome level by combining studies in a meta-analysis using the GRADE system using quality ratings of  ‘high’, ‘moderate’, ‘low’, and ‘very low’. Full details are available in Appendix 21 of the online guidelines.

How many studies were included and where were they from?
A total of 51,926 articles was initially retrieved. After screening, 101 papers were examined in full and 35 were included in the systematic review. The final number of studies selected for meta-analysis was 22. The flow of the literature through the selection process is illustrated in Figure 1. There is no indication of the study settings.

How were the study findings combined?
Study details were extracted and entered into a database; outcome data was extracted into Review Manager 4.2.8. and subjected to meta-analysis, as appropriate, using a random effects model. Sub-group analyses were conducted to compare outcomes based on the severity of depression at recruitment, and outcomes for interventions with the sole purpose of reducing depression and those with a broader focus. Full details of the statistical methods used are presented in the text. The results of the studies that were not subjected to meta-analysis are presented in Table 2, and the study characteristics of those that were meta-analysed are presented in Table 3.

Findings of the review

There was moderate evidence from three studies that peer (self-help) support has a small effect on depression. Excluding one study that did not recruit participants for depression revealed a large effect. Three studies comparing guided self-help based on cognitive and behavioural models showed a small but significant reduction in depression; the evidence was again moderate.

Five studies examined individual-based cognitive and behavioural interventions compared with standard care. Meta-analysis revealed a moderate and significant effect on reducing depression. Sub-group analysis revealed a large effect size for interventions aimed specifically at depression and those in which people were identified with depression at baseline. Eight trials comparing group-based cognitive and behavioural interventions with standard care produced similar results and stronger evidence on sub-group analysis. Limited support for the benefit of combining SSRI treatment with a psychosocial intervention was provided by evidence from three studies.

Authors' conclusions

‘Overall, the efficacy of psychosocial interventions for people with depression and chronic health problems is comparable to their efficacy in people with depression in general’ and ‘people who suffer from a chronic physical health condition and depression should be treated for their depression in addition to the usual care that they receive for their physical health’.

Implications for policy or practice

People who suffer from a chronic physical health condition and depression should be treated for depression in addition to the usual care they receive for their physical condition; and the evidence base on effective psychosocial interventions for depression in those without chronic physical health problems can be extrapolated by clinicians to this population - with some adaptations, such as providing examples of maladaptive thoughts related to their specific condition. 

Related references

National Collaborating Centre for Mental Health. (CG91) Depression: the treatment and management of depression in adults with chronic physical health problems. Leicester & London: British Psychological Society and The Royal College of Psychiatrists; 2009.

Subject terms:
long term conditions, psychosocial intervention, psychotherapy, behaviour therapy, depression;
Content type:
systematic review
Link:
Journal home page
ISSN print:
0022-3999

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