Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis.

Importance: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them. Objective: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information. Data Sources: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019. Study Selection: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization. Data Extraction and Synthesis: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression. Main Outcomes and Measures: Patient Health Questionnaire-9 (PHQ-9) scores. Results: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9. Conclusions and Relevance: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.

Bias through selective inclusion and attrition: Representativeness when comparing provider performance with routine outcome monitoring data.

BACKGROUND: Observational research based on routine outcome monitoring is prone to missing data, and outcomes can be biased due to selective inclusion at baseline or selective attrition at posttest. As patients with complete data may not be representative of all patients of a provider, missing data may bias results, especially when missingness is not random but systematic. METHODS: The present study establishes clinical and demographic patient variables relevant for representativeness of the outcome information. It applies strategies to estimate sample selection bias (weighting by inclusion propensity) and selective attrition bias (multiple imputation based on multilevel regression analysis) and estimates the extent of their impact on an index of provider performance. The association between estimated bias and response rate is also investigated. RESULTS: Provider-based analyses showed that in current practice, the effect of selective inclusion was minimal, but attrition had a more substantial effect, biasing results in both directions: overstating and understating performance. For 22% of the providers, attrition bias was estimated to be in excess of 0.05 ES. Bias was associated with overall response rate (r = .50). When selective inclusion and attrition bring providers' response below 50%, it is more likely that selection bias increased beyond a critical level, and conclusions on the comparative performance of such providers may be misleading. CONCLUSIONS: Estimates of provider performance were biased by selection, especially by missing data at posttest. Results on the extent and direction of bias and minimal requirements for response rates to arrive at unbiased performance indicators are discussed.

Cost effectiveness of guided Internet-based interventions for depression in comparison with control conditions: An individual-participant data meta-analysis.

BACKGROUND: There is limited evidence on the cost effectiveness of Internet-based treatments for depression. The aim was to evaluate the cost effectiveness of guided Internet-based interventions for depression compared to controls. METHODS: Individual-participant data from five randomized controlled trials (RCT), including 1,426 participants, were combined. Cost-effectiveness analyses were conducted at 8 weeks, 6 months, and 12 months follow-up. RESULTS: The guided Internet-based interventions were more costly than the controls, but not statistically significant (12 months mean difference = €406, 95% CI: - 611 to 1,444). The mean differences in clinical effects were not statistically significant (12 months mean difference = 1.75, 95% CI: - .09 to 3.60 in Center for Epidemiologic Studies Depression Scale [CES-D] score, .06, 95% CI: - .02 to .13 in response rate, and .00, 95% CI: - .03 to .03 in quality-adjusted life-years [QALYs]). Cost-effectiveness acceptability curves indicated that high investments are needed to reach an acceptable probability that the intervention is cost effective compared to control for CES-D and response to treatment (e.g., at 12-month follow-up the probability of being cost effective was .95 at a ceiling ratio of 2,000 €/point of improvement in CES-D score). For QALYs, the intervention's probability of being cost effective compared to control was low at the commonly accepted willingness-to-pay threshold (e.g., at 12-month follow-up the probability was .29 and. 31 at a ceiling ratio of 24,000 and 35,000 €/QALY, respectively). CONCLUSIONS: Based on the present findings, guided Internet-based interventions for depression are not considered cost effective compared to controls. However, only a minority of RCTs investigating the clinical effectiveness of guided Internet-based interventions also assessed cost effectiveness and were included in this individual-participant data meta-analysis.

E-health to manage distress in patients with an implantable cardioverter-defibrillator: primary results of the WEBCARE trial.

UNLABELLED: The Web-based distress management program for patients with an implantable cardioverter-defibrillator (ICD; WEBCARE) was developed to mitigate distress and enhance health-related quality of life in ICD patients. This study investigated the treatment effectiveness at 3-month follow-up for generic and disease-specific outcome measures. METHODS: Consecutive patients implanted with a first-time ICD from six hospitals in the Netherlands were randomized to either the "WEBCARE" or the "usual care" group. Patients in the WEBCARE group received a 12-week fixed, six-lesson behavioral treatment based on the problem-solving principles of cognitive behavioral therapy. RESULTS: Two hundred eighty-nine patients (85% response rate) were randomized. The prevalence of anxiety and depression ranged between 11% and 30% and 13% and 21%, respectively. No significant intervention effects were observed for anxiety (ß = 0.35; p = .32), depression (ß = -0.01; p = .98) or health-related quality of life (Mental Component Scale: ß = 0.19; p = .86; Physical Component Scale: ß = 0.58; p = .60) at 3 months, with effect sizes (Cohen d) being small (range, 0.06-0.13). There were also no significant group differences as measured with the disease-specific measures device acceptance (ß = -0.37; p = .82), shock anxiety (ß = 0.21; p = .70), and ICD-related concerns (ß = -0.08; p = .90). No differences between treatment completers and noncompleters were observed on any of the measures. CONCLUSIONS: In this Web-based intervention trial, no significant intervention effects on anxiety, depression, health-related quality of life, device acceptance, shock anxiety, or ICD-related concerns were observed. A more patient tailored approach targeting the needs of different subsets of ICD patients may be warranted. TRIAL REGISTRATION: clinicaltrials.gov. Identifier: NCT00895700.

Activity recognition with smartphone support.

In this paper, the authors describe a method of accurately detecting human activity using a smartphone accelerometer paired with a dedicated chest sensor. The design, implementation, testing and validation of a custom mobility classifier are also presented. Offline analysis was carried out to compare this custom classifier to de-facto machine learning algorithms, including C4.5, CART, SVM, Multi-Layer Perceptrons, and Naïve Bayes. A series of trials were carried out in Ireland, initially involving N=6 individuals to test the feasibility of the system, before a final trial with N=24 subjects took place in the Netherlands. The protocol used and analysis of 1165min of recorded activities from these trials are described in detail in this paper. Analysis of collected data indicate that accelerometers placed in these locations, are capable of recognizing activities including sitting, standing, lying, walking, running and cycling with accuracies as high as 98%.

Predicting outcome of Internet-based treatment for depressive symptoms.

In this study we explored predictors and moderators of response to Internet-based cognitive behavioral therapy (CBT) and Internet-based problem-solving therapy (PST) for depressive symptoms. The sample consisted of 263 participants with moderate to severe depressive symptoms. Of those, 88 were randomized to CBT, 88 to PST and 87 to a waiting list control condition. Outcomes were improvement and clinically significant change in depressive symptoms after 8 weeks. Higher baseline depression and higher education predicted improvement, while higher education, less avoidance behavior and decreased rational problem-solving skills predicted clinically significant change across all groups. No variables were found that differentially predicted outcome between Internet-based CBT and Internet-based PST. More research is needed with sufficient power to investigate predictors and moderators of response to reveal for whom Internet-based therapy is best suited.

Guided online treatment in routine mental health care: an observational study on uptake, drop-out and effects.

BACKGROUND: Due to limited resources patients in the Netherlands often have to wait for a minimum of six weeks after registration for mental health care to receive their first treatment session. Offering guided online treatment might be an effective solution to reduce waiting time and to increase patient outcomes at relatively low cost. In this study we report on uptake, drop-out and effects of online problem solving treatment that was implemented in a mental health center. METHODS: We studied all 104 consecutive patients aged 18-65 years with elevated symptoms of depression, anxiety and/or burnout who registered at the center during the first six months after implementation. They were offered a five week guided online treatment. At baseline, five weeks and twelve weeks we measured depressive (BDI-II), anxiety (HADS-A) and burnout symptoms (MBI). RESULTS: A total of 55 patients (53%) agreed to start with the online treatment. Patients who accepted the online treatment were more often female, younger and lower educated than those who refused. There were no baseline differences in clinical symptoms between the groups. There were large between group effect sizes after five weeks for online treatment for depression (d = 0.94) and anxiety (d = 1.07), but not for burnout (d = -.07). At twelve weeks, when both groups had started regular face-to-face treatments, we no longer found significant differences between the groups, except for anxiety (d = 0.69). CONCLUSION: The results of this study show that the majority of patients prefer online guided online treatment instead of waiting for face-to-face treatment. Furthermore, online PST increases speed of recovery and can therefore be offered as a first step of treatment in mental healthcare.

Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data.

OBJECTIVE: To assess how initial severity of depression affects the benefit derived from low intensity interventions for depression. DESIGN: Meta-analysis of individual patient data from 16 datasets comparing low intensity interventions with usual care. SETTING: Primary care and community settings. PARTICIPANTS: 2470 patients with depression. INTERVENTIONS: Low intensity interventions for depression (such as guided self help by means of written materials and limited professional support, and internet delivered interventions). MAIN OUTCOME MEASURES: Depression outcomes (measured with the Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale), and the effect of initial depression severity on the effects of low intensity interventions. RESULTS: Although patients were referred for low intensity interventions, many had moderate to severe depression at baseline. We found a significant interaction between baseline severity and treatment effect (coefficient -0.1 (95% CI -0.19 to -0.002)), suggesting that patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed. However, the magnitude of the interaction (equivalent to an additional drop of around one point on the Beck Depression Inventory for a one standard deviation increase in initial severity) was small and may not be clinically significant. CONCLUSIONS: The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.

Innovative ICT solutions to improve treatment outcomes for depression: the ICT4Depression project.

Depression is expected to be the disorder with the highest disease burden in high-income countries by the year 2030. ICT4Depression (ICT4D) is a European FP7 project, which aims to contribute to the alleviation of this burden by making use of depression treatment and ICT innovations. In this project we developed an ICT-based system for use in primary care that aims to improve access as well as actual care delivery for depressed adults. Innovative technologies within the ICT4D system include 1) flexible self-help treatments for depression, 2) automatic assessment of the patient using mobile phone and web-based communication 3) wearable biomedical sensor devices for monitoring activities and electrophysiological indicators, 4) computational methods for reasoning about the state of a patient and the risk of relapse (reasoning engine) and 5) a flexible system architecture for monitoring and supporting people using continuous observations and feedback via mobile phone and the web. The general objective of the ICT4D project is to test the feasibility and acceptability of the ICT4D system within a pilot study in the Netherlands and in Sweden during 2012 and 2013.

Cost-utility and cost-effectiveness of internet-based treatment for adults with depressive symptoms: randomized trial.

BACKGROUND: The effectiveness of Internet-based treatments for depression has been demonstrated; their cost-effectiveness, however, has been less well researched. OBJECTIVE: Evaluating the relative cost-utility and cost-effectiveness of (1) Internet-based cognitive behavioral therapy, (2) Internet-based problem-solving therapy, and (3) a waiting list for adults with depressive symptoms. METHODS: A total of 263 participants with clinically significant depressive symptoms were randomized to Internet-based cognitive behavioral therapy (n = 88), Internet-based problem-solving therapy (n = 88), and a waiting list (n = 87). End points were evaluated at the 12-week follow-up. RESULTS: Cost-utility analysis showed that cognitive behavioral therapy and problem-solving therapy had a 52% and 61% probability respectively of being more acceptable than waiting when the willingness to pay is € 30,000 for one quality-adjusted life-year. When society is prepared to pay € 10,000 for a clinically significant change from depression, the probabilities of cognitive behavioral therapy and problem-solving therapy being more acceptable than waiting are 91% and 89%, respectively. Comparing both Internet-based treatments showed no clear preference for one or the other of the treatments. CONCLUSIONS: Both Internet-based treatments have a high probability of being cost-effective with a modest value placed on clinically significant change in depressive symptoms. TRIAL REGISTRATION: ISRCTN16823487; http://www.controlled-trials.com/ISRCTN16823487 (Archived by WebCite at http://www.webcitation.org/5u8slzhDE).

Recruiting participants for interventions to prevent the onset of depressive disorders: possible ways to increase participation rates.

BACKGROUND: Although indicated prevention of depression is available for about 80% of the Dutch population at little or no cost, only a small proportion of those with subthreshold depression make use of these services. METHODS: A narrative review is conducted of the Dutch preventive services in mental health care, also addressing the problem of low participation rates. We describe possible causes of these low participation rates, which may be related to the participants themselves, the service system, and the communication to the public, and we put forward possible solutions to this problem. RESULTS: There are three main groups of reasons why the participation rates are low: reasons within the participants (e.g., not considering themselves as being at risk; thinking the interventions are not effective; or being unwilling to participate because of the stigma associated with depression); reasons within the health care system; and reasons associated with the communication about the preventive services. Possible solutions to increasing the participation rate include organizing mass media campaigns, developing internet-based preventive interventions, adapting preventive interventions to the needs of specific subpopulations, positioning the services in primary care, integrating the interventions in community-wide interventions, and systematically screening high-risk groups for potential participants. DISCUSSION: Prevention could play an important role in public mental health in reducing the enormous burden of depression. However, before this can be realized more research is needed to explore why participation rates are low and how these rates can be improved.

Online cognitive behavioral therapy and problem-solving therapy for depressive symptoms: Exploring mechanisms of change.

The purpose of this study was to evaluate treatment specificity and potential mediators of two online therapies for depressive symptoms. We conducted a randomized controlled trial in which 263 participants were randomized to online cognitive behavioral therapy (CBT), online problem-solving therapy (PST) or a waiting list control group. Both treatments were more effective than the control group in reducing dysfunctional attitudes, worry, negative problem orientation and enhancing feelings of control. No differences between the treatments were found on each of the potential mediators. Furthermore, results suggest that dysfunctional attitudes, worrying, a negative problem orientation and perceived control all played a mediating role in CBT as well as in PST. Our findings suggest that regardless of the theoretical background to the therapy, the psychological processes necessary for symptom reduction seem to be comparable.

Psychotherapy versus the combination of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis.

BACKGROUND: A large number of studies have shown that psychological treatments have significant effects on depression. Although several studies have examined the relative effects of psychological and combined treatments, this has not been studied satisfactorily in recent statistical meta-analyses. METHOD: We conducted a meta-analysis of randomized studies in which a psychological treatment was compared to a combined treatment consisting of the same psychological treatment with a pharmacological therapy. For each of these studies we calculated the effect size indicating the difference between the psychological and the combined treatment. RESULTS: All inclusion criteria were met by 18 studies, with a total of 1,838 subjects. The mean effect size indicating the difference between psychological and combined treatment was 0.35 (95% CI: 0.24 approximately 0.45; P<0.001), with low heterogeneity. Subgroup analyses indicated that the difference between psychological and combined treatments was significantly smaller in studies in which cognitive behavior therapy was examined. We also found a trend (P<0.1) indicating that the difference between psychological and combined treatment was somewhat larger in studies aimed at specific populations (older adults, chronic depression, HIV patients) than in studies with adults, and in studies in which Trycyclic antidepressants or SSRIs were examined, compared to studies in which a medication protocol or another antidepressant was used. At follow-up, no difference between psychological and combined treatments was found. CONCLUSION: We conclude that combined treatment is more effective than psychological treatment alone. However, it is not clear whether this difference is relevant from a clinical perspective.

Internet-based treatment for adults with depressive symptoms: randomized controlled trial.

BACKGROUND: Many depressed people do not receive help for their symptoms, and there are various barriers that impede help-seeking. The Internet may offer interesting alternatives for reaching and helping people with depression. Depression can be treated effectively with Internet-based cognitive behavioral therapy (CBT), but a short intervention based on problem solving therapy (PST) could constitute a worthwhile alternative to CBT. OBJECTIVE: In this study we evaluated the effectiveness of Internet-based CBT and Internet-based PST in comparison to a waiting list control group (WL), and we determined the differences between the two treatments. METHODS: We conducted a 3-arm randomized controlled trial to compare CBT, PST, and WL. The main inclusion criterion was presence of depressive symptoms (>or= 16 on the Center for Epidemiological Studies Depression scale). CBT and PST consisted of eight and five weekly lessons respectively. Participants were supported by email. Self-report measures of depression, anxiety, and quality of life were completed at pretest and after 5, 8, and 12 weeks. RESULTS: A total of 263 participants were randomized to the three conditions (CBT: n=88; PST: n=88; WL: n=87). Of the 263 participants, 184 (70%) completed questionnaires after 5 weeks, 173 (66%) after 8 weeks, and 151 (57%) after 12 weeks. Between-group effect sizes for depressive symptoms were 0.54 for CBT after 8 weeks (95% confidence interval (CI): 0.25 - 0.84) and 0.47 for PST after 5 weeks (95% CI: 0.17 - 0.77). These effects were further improved at 12 weeks (CBT: 0.69, 95% CI: 0.41 - 0.98; PST: 0.65, 95% CI: 0.36 - 0.95). For anxiety, effect sizes were also at a medium level. Effect sizes for quality of life were low. The number of participants showing clinically significant change at 12 weeks was significantly higher for CBT (n = 34, 38.6%) and PST (n = 30, 34.1%), compared to WL (n = 0). CONCLUSIONS: Both Internet-based treatments are effective in reducing depressive symptoms, although the effect of PST is realized more quickly. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 16823487; http://www.controlled-trials.com/ISRCTN16823487/16823487 (Archived by WebCite at http://www.webcitation.org/5cQsOj7xf).

Characteristics of effective psychological treatments of depression: a metaregression analysis.

Although many meta-analyses have shown that psychological therapies are effective in the treatment of depression, no comprehensive metaregression analysis has been conducted to examine which characteristics of the intervention, target population, and study design are related to the effects. The authors conducted such a metaregression analysis with 83 studies (135 comparisons) in which a psychological treatment was compared with a control condition. The mean effect size of all comparisons was 0.69 (95% confidence interval = 0.60-0.79). In multivariate analyses, several variables were significant: Studies using problem-solving interventions and those aimed at women with postpartum depression or specific populations had higher effect sizes, whereas studies with students as therapists, those in which participants were recruited from clinical populations and through systematic screening, and those using care-as-usual or placebo control groups had lower effect sizes.

Psychological treatment of depression: a meta-analytic database of randomized studies.

BACKGROUND: A large number of randomized controlled studies have clearly demonstrated that psychological interventions are effective in the treatment of depression. The number of studies in this area is increasing rapidly. In this paper, we present a database of controlled and comparative outcome studies on psychological treatments of depression, based on a series of meta-analyses published by our group. The database can be accessed freely through the Internet. DESCRIPTION: We conducted a comprehensive literature search of the major bibliographical databases (Pubmed; Psycinfo; Embase; Cochrane Central Register of Controlled Trials) and we examined the references of 22 earlier meta-analyses of psychological treatment of depression. We included randomized studies in which the effects of a psychological therapy on adults with depression were compared to a control condition, another psychological intervention, or a combined treatment (psychological plus pharmacological). We conducted nine meta-analyses of subgroups of studies taken from this dataset. The 149 studies included in these 9 meta-analyses are included in the current database. In the 149 included studies, a total of 11,369 patients participated. In the database, we present selected characteristics of each study, including characteristics of the patients (the study population, recruitment method, definition of depression); characteristics of the experimental conditions and interventions (the experimental conditions, N per condition, format, number of sessions); and study characteristics (measurement times, measures used, attrition, type of analysis and country). CONCLUSION: The data on the 149 included studies are presented in order to give other researchers access to the studies we collected, and to give background information about the meta-analyses we have published using this dataset. The number of studies examining the effects of psychological treatments of depression has increased considerably in the past decades, and this will continue in the future. The database we have presented in this paper can help to integrate the results of these studies in future meta-analyses and systematic reviews on psychological treatments for depression.

Are individual and group treatments equally effective in the treatment of depression in adults? A meta-analysis

No disponible

Background and Objectives: It is well-established that psychological interventions are effective in the treatment of depression. However, it is not yet clear what the optima format is in which psychological treatments should be delivered. Although several studies have examined whether individual and group treatments are equally effective in the treatment of depression, no comprehensive meta-analysis has examined this. Methods: We searched major bibliographical database and conducted a meta-analysis of 15 studies in which individual and group therapies were compared directly to each other. Results: The mean effect size indicating the difference between individual and group therapies in depressive symptomatology at post-test was 0.20 (95% CI: [0.05 0.35]; p < 0.01), in favor of individual therapies, with a lower drop-out rate in individual interventions (OR =0.56; 95% CI: [0.37, 0.86]; p < 0.01). At follow-up no significant differences were found. Conclusions: Although individual therapy seems to be somewhat more effective than group therapy at the short term, it is not clear whether this is relevant from a clinical point of view. Because of the small number of studies and the limited quality, more research is needed to examine whether the difference between individual and group treatment is clinically relevant (AU)

Internet-based treatment for adults with depressive symptoms: the protocol of a randomized controlled trial.

BACKGROUND: Depression is a highly prevalent condition, affecting more than 15% of the adult population at least once in their lives. Guided self-help is effective in the treatment of depression. The purpose of this study is to investigate the effectiveness of two Internet-based guided self-help treatments with adults reporting elevated depressive symptoms. Other research questions concern the identification of potential mediators and the search for subgroups who respond differently to the interventions. METHODS: This study is a randomized controlled trial with three conditions: two treatment conditions and one waiting list control group. The two treatment conditions are Internet-based cognitive behavior therapy and Internet-based problem-solving therapy. They consist of 8 and 5 weekly lessons respectively. Both interventions are combined with support by e-mail. Participants in the waiting list control group receive the intervention three months later. The study population consists of adults from the general population. They are recruited through advertisements in local and national newspapers and through banners on the Internet. Subjects with symptoms of depression (> or = 16 on the Center for Epidemiological Studies Depression scale) are included. Other inclusion criteria are having sufficient knowledge of the Dutch language, access to the Internet and an e-mail address. Primary outcome is depressive symptoms. Secondary outcomes are anxiety, quality of life, dysfunctional cognitions, worrying, problem solving skills, mastery, absence at work and use of healthcare. We will examine the following variables as potential mediators: dysfunctional cognitions, problem solving skills, worrying, anxiety and mastery. Potential moderating variables are: socio-demographic characteristics and symptom severity. Data are collected at baseline and at 5 weeks, 8 weeks, 12 weeks and 9 months after baseline. Analyses will be conducted on the intention-to-treat sample. DISCUSSION: This study evaluates two Internet-based treatments for depression, namely cognitive behavioral therapy and problem-solving therapy. The effectiveness of Internet-based problem-solving therapy suggest that this may be a worthwhile alternative to other more intensive treatment options. Strengths and limitations of this study are discussed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16823487.

Problem solving therapies for depression: a meta-analysis.

PURPOSE: In the past decades, the effects of problem-solving therapy (PST) for depression have been examined in several randomized controlled studies. However, until now no meta-analysis has tried to integrate the results of these studies. METHODS: We conducted a systematic literature search and identified 13 randomized studies examining the effects of PST, with a total of 1133 subjects. The quality of studies varied. RESULTS: The mean standardized effect size was 0.34 in the fixed effects model and 0.83 in the random effects model, with very high heterogeneity. Subgroup analyses indicated significantly lower effects for individual interventions in studies with subjects who met criteria for major depression, studies in which intention-to-treat analyses were conducted instead of completers-only analyses, and studies with pill placebo and care-as-usual control groups. Heterogeneity was high, and the subgroup analyses did not result in clear indications of what caused this high heterogeneity. This indicates that PST has varying effects on depression, and that it is not known to date what determines whether PST has larger of smaller effects. CONCLUSION: Although there is no doubt that PST can be an effective treatment for depression, more research is needed to ascertain the conditions and subjects in which these positive effects are realized.

Behavioral activation treatments of depression: a meta-analysis.

Activity scheduling is a behavioral treatment of depression in which patients learn to monitor their mood and daily activities, and how to increase the number of pleasant activities and to increase positive interactions with their environment. We conducted a meta-analysis of randomized effect studies of activity scheduling. Sixteen studies with 780 subjects were included. The pooled effect size indicating the difference between intervention and control conditions at post-test was 0.87 (95% CI: 0.60 - 1.15). This is a large effect. Heterogeneity was low in all analyses. The comparisons with other psychological treatments at post-test resulted in a non-significant pooled effect size of 0.13 in favor of activity scheduling. In ten studies activity scheduling was compared to cognitive therapy, and the pooled effect size indicating the difference between these two types of treatment was 0.02. The changes from post-test to follow-up for activity scheduling were non-significant, indicating that the benefits of the treatments were retained at follow-up. The differences between activity scheduling and cognitive therapy at follow-up were also non-significant. Activity scheduling is an attractive treatment for depression, not only because it is relatively uncomplicated, time-efficient and does not require complex skills from patients or therapist, but also because this meta-analysis found clear indications that it is effective.