A Synthesis of the Evidence: Brief Psychotherapy for Depression in Primary Care

Clinical guidelines recommend that both pharmacotherapy and psychotherapy should be considered as first-line treatments for depressive disorders. Because primary care settings are often the frontline of treatment, however, pharmacological treatments often take precedence. The perception that psychotherapy is time intensive may contribute to its under-utilization, but recent studies suggest that psychotherapies that are briefer in duration and intensity may be effective in treating depressive disorders. If true, these briefer psychotherapies may be more easily integrated in primary care settings.

Recently, investigators at the VA Evidence-Based Practice Center in Durham, NC conducted a systematic review to examine brief psychotherapeutic interventions for depression in primary care. Investigators evaluated two existing good quality systematic reviews and 15 randomized controlled trials (RCTs) conducted between 1982 and 2010 to answer the following four key questions.

Question #1
For primary care patients with depressive disorders, are brief evidence-based psychotherapies with durations of up to eight sessions more efficacious than control (treatment as usual and/or additional therapeutic component) for depressive symptoms and quality of life?

• Six to eight sessions of brief cognitive behavioral therapy (CBT) or problem-solving therapy (PST) were more efficacious than control for the treatment of depression within the primary care setting. The number needed to treat for one additional responder was between five and eight in various studies.
• No significant differences in efficacy were found between CBT and PST.

Question #2
For primary care patients with depressive disorders treated with brief psychotherapy, is there evidence that treatment effect may vary by the number of sessions delivered?

• A prior, good quality systematic review of psychotherapy for the treatment of depression in primary care found no statistically significant difference in efficacy between short-term (six sessions) and standard duration (10-16 sessions) psychotherapies, but the authors could not rule out a clinically meaningful difference.

Question #3
For psychotherapies demonstrating clinically significant treatment effects, what are the characteristics of treatment providers (i.e., type of provider), and what are the modalities of therapy (i.e., individual/group, teletherapy)?

• Of the 15 RCTs in this review, 13 used an individual psychotherapy format and two used group therapy.
• Length of sessions varied, but treatment was delivered primarily in individual, face-to-face sessions, with one trial using telephone-based psychotherapy.
• Treatment providers included psychologists (majority), nurses, graduate students, and others professionals (i.e., social workers, GPs).

Question #4
How commonly reported are the key clinical outcomes of quality of life, social functioning, occupational status, patient satisfaction, and adverse treatment effects in randomized trials of psychotherapy?

• There was a lack of consistency in assessing and reporting important outcome measures: only five measured HRQOL, five measured social functioning, two measured patient satisfaction, one measured adverse treatment effects, and zero reported on occupational status.

To view the full report, go to http://www.hsrd.research.va.gov/publications/esp/reports.cfm

Reference: Nieuwsma J, Trivedi R, McDuffie J, Kronish I, Benjamin D, and Williams J Jr. Brief Psychotherapy for Depression in Primary Care: A Systematic Review of the Evidence. VA-ESP Project #09-010; 2010

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