The effects of fifteen evidence-supported therapies for adult depression: A meta-analytic review

Figures & data

Table I. Definitions of psychological treatments of depression.

Generic types of therapy	Specific types of therapy
Cognitive Behavior Therapy (CBT) In CBT the therapists focus on the impact a patient’s present dysfunctional thoughts have on current behavior and future functioning. CBT is aimed at evaluating, challenging and modifying a patient’s dysfunctional beliefs (cognitive restructuring). In this form of treatment the therapist mostly emphasizes homework assignments and outside-of-session activities. Therapists exert an active influence over therapeutic interactions and topics of discussion, use a psycho educational approach, and teach patients new ways of coping with stressful situations.	CBT according to the Beck’s manual The manual developed by Beck and colleagues (1979) is the most widely used manual for CBT (which includes a module on behavioral activation, see below). Interventions were coded for this treatment when they explicitly referred to the manual and indicated that this manual was used in the intervention.
	“Coping with Depression” Course The “Coping with Depression” course is a psychoeducational intervention for depression that has been examined in many studies. The manual was developed in the late 1970s (Lewinsohn et al., 1984) and has since then been adapted for several specific target populations. A meta-analysis of these studies was published earlier (Cuijpers, Munoz, et al., 2009). An intervention was coded for this treatment when it explicitly referred to this manual (although it could be adapted for the target population).
	Guided self-help with the book “Feeling good” from David Burns The bestseller “Feeling good” by David Burns (1980), based on Beck’s CBT was used in a considerable number of studies as bibliotherapy in which the patient read the book and received weekly feedback and support by a coach.
Behavioral activation therapy (BA) We considered an intervention to be behavioral activation when the registration of pleasant activities and the increase of positive interactions between a person and his or her environment were the core elements of the treatment. Social skills training could be a part of the intervention. We defined subtypes of behavioral activation according to Mazzucchelli, Kane, and Rees (2009). They describe four subtypes of behavioral activation, but only two of these subtypes have sufficient trials to be reported here.	Pleasant activity scheduling The first type of behavioral activation was developed in the 1960s by Lewinsohn and colleagues (Dimidjian et al., 2011; Lewinsohn, 1974). This type of behavioral activation mostly consisted of monitoring and pleasant activity scheduling. We categorized an intervention as pleasant activity scheduling when they referred to the work of Lewinsohn.
	Contextual behavioral activation This version builds on the behavioral activation component of cognitive behavior therapy. It includes activity scheduling, self-monitoring, graded task assignment, role-playing, functional analysis, mental rehearsal, and in newer versions mindfulness. We categorized an intervention as contextual behavioral activation when it refers to the work of Jacobson or Martell and colleagues (Jacobson, Martell, & Dimidjian, 2001; Martell, Addis, & Jacobson, 2001).
Problem-solving therapy (PST) We defined PST as a psychological intervention in which the following elements had to be included: definition of personal problems, generation of multiple solutions to each problem, selection of the best solution, the working out of a systematic plan for this solution, and evaluation as to whether the solution has resolved the problem. We have examined PST in a recent meta-analysis (Cuijpers et al., 2017) and also worked out the subtypes of PST that are used in this study.	Extended problem-solving therapy Extended PST, which does not only focus on the problem-solving skills themselves, but also on changing those attitudes or beliefs that may inhibit or interfere with attempts to engage in the remaining problem-solving tasks. “Social problem-solving”, developed by Nezu in the 1970s (Nezu, 1986; Nezu & D’Zurilla, 1979) is the most important type of extended problem-solving. It is typically conducted in a group format of 10 or more sessions. We (arguably) considered an intervention as extended PST when it had 10 sessions or more.
	Brief problem-solving therapy Brief PST, which was originally developed for primary care in the 1990s (PST-PC; Mynors-Wallis, Gath, Day, & Baker, 2000; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995), focuses on the core elements of problem-solving and can be used by trained nurses. We considered an intervention as brief PST when it had 9 sessions or less.
	Self-examination therapy (SET) SET is aimed at determining the major goals in their life, investing energy only in those problems that are related to what matters and learning to accept those situations that cannot be changed. Problem-solving skills are the core element of this approach. SET is typically used in a guided-self-help format. We considered an intervention as SET when it was based on self-examination therapy (Bowman, Ward, Bowman, & Scogin, 1996) and was conducted in guided self-help format.
Third wave cognitive behavioral therapies Third wave therapies are a heterogeneous group of therapies that introduce several new techniques to cognitive behavior therapies. They have in common that they abandon or only cautiously use content-oriented cognitive interventions and the use of skills deficit models to delineate the core maintaining mechanisms of the addressed disorders (Kahl, Winter, & Schweiger, 2012). We found sufficient randomized trials for two types of 3rd wave therapies: Acceptance and Commitment Therapy and Mindfulness-based CBT.	Acceptance and Committment Therapy (ACT) In brief, ACT is a form a behavioral therapy that focuses on decreasing experiential avoidance and increasing value-based behavior (Hayes, Strosahl, & Wilson, 1999). Acceptance and mindfulness strategies are used in different ways to increase psychological flexibility.
	Mindfulness-based CBT (MBCT) MBCT is a psychological treatment that combines meditation or mindfulness exercises with cognitive restructuring techniques. It was developed for the prevention of relapse in people with recurrent depression (Segal, Williams, & Teasdale, 2002), but a considerable number of studies have now examined the effects in acute depression.
Interpersonal psychotherapy (IPT) IPT is a brief and highly structured manual-based psychotherapy that addresses interpersonal issues in depression, to the exclusion of all other foci of clinical attention. IPT has no specific theoretical origin although its theoretical basis can be seen as coming from the work of Sullivan, Meyer, and Bowlby. The current form of the treatment was developed by the late Gerald Klerman and Myrna Weissman in the 1980s (Klerman et al., 1984).	Full IPT We distinguished two types of IPT, one in which the full manual was used or referred to without attempt to make it more brief (full IPT), and the other in which a brief version of IPT was used (brief IPT). Full IPT may have been adapted to the population or setting where it was used (including the number of sessions unless there were 10 sessions or less), but there was no mention of substantial reduction of the number of sessions.
	Brief IPT IPT has also been used in settings and populations where full IPT is not feasible. In a considerable number of studies, brief versions of IPT have been developed in which the core of IPT was retained, but the number of sessions was considerably reduced. Interpersonal counseling (Weissman et al., 2014) is one of the brief versions of IPT. We (arguably) considered an intervention as brief IPT when it had 10 sessions or less.
Psychodynamic Therapy The primary objective in (short-term) psychodynamic therapy is to enhance the patient’s understanding, awareness and insight about repetitive conflicts (intra psychic and intrapersonal). An assumption in psychodynamic therapy is that a patient’s childhood experiences, past unresolved conflicts, and historical relationships significantly affect a person’s present life situation. In this form of treatment the therapist concentrates on the patient’s past, unresolved conflicts, historical relationships, and the impact these have on a patient’s present functioning. Furthermore, in psychodynamic therapy, the therapists explore a patient’s wishes, dreams, and fantasies. The time limitations and the focal explorations of the patient’s life and emotions distinguish psychodynamic therapy from psychoanalytic psychotherapy. We did not identify subtypes of psychodynamic therapy.
Non-directive supportive therapy We defined non-directive therapy as any unstructured therapy without specific psychological techniques other than those common to all approaches such as helping people to ventilate their experiences and emotions and offering empathy. It is not aimed at solutions, or acquiring new skills. It is based on the assumption that relief from personal problems may be achieved through discussion with others. These non-directive therapies are commonly described in the literature as either counseling or supportive therapy. We did not identify subtypes of non-directive supportive therapy.
Life review therapy Reminiscence is a naturally occurring process of recalling the past, that is hypothesized to resolve conflicts from the past and make up the balance of one’s life (Bohlmeijer, Smit, & Cuijpers, 2003; Butler, 1963). Since the beginning of the 1970s, reminiscence has been used by therapists as a specific treatment of depression in older adults. In these “life review” therapies the patients work through the memories of all phases in their life with the aim of re-evaluation of their life, resolving conflicts or assessing adaptive coping-responses. We defined life review therapies as all therapies that are aimed at the systematic evaluation of the lives of participants.

Figure 1. Flowchart on the selection of studies.

Table II. Effects of 15 therapies compared with control groups: Hedges’ g^a.

		Ncomp	g	95% CI^b	I^2	95% CI^c	Prediction interval	NNT	gadj	95% CI^d	Nimp
All comparisons		385	0.72	0.67∼0.78	81	79∼82	−0.17∼1.61	4.04	0.46	0.40∼0.52	103
One ES/study (highest)		309	0.73	0.67∼0.79	83	81∼84	−0.19∼1.65	3.98	0.45	0.38∼0.52	86
One ES/study (lowest)		309	0.67	0.61∼0.73	81	79∼83	−0.20∼1.54	4.39	0.43	0.36∼0.50	77
Outliers excluded (g > 2)		361	0.61	0.56∼0.65	68	64∼71	−0.01∼1.23	4.89	0.44	0.40∼0.49	89
Generic types
• CBT		205	0.73	0.65∼0.80	80	77∼82	−0.16∼1.62	3.98	0.47	0.39∼0.56	52
• BAT		21	1.05	0.80∼1.30	77	65∼84	0.02∼2.08	2.64	0.65	0.38∼0.92	9
• 3rd wave therapies		19	0.85	0.63∼1.07	75	59∼83	−0.02∼1.72	3.35	^e		0
• PST		30	0.75	0.53∼0.97	87	82∼90	−0.37∼1.87	3.86	0.31	0.06∼0.56	11
• IPT		27	0.60	0.34∼0.86	87	82∼90	−0.71∼1.91	4.99	^e		0
• Psychodynamic		12	0.39	0.16∼0.62	70	37∼82	−0.35∼1.13	8.14	0.30	0.06∼0.54	2
• Non-directive supportive		19	0.58	0.42∼0.75	45	0∼67	0.07∼1.09	5.18	0.42	0.23∼0.61	6
• Life review		14	1.10	0.68∼1.51	89	83∼92	−0.52∼2.72	2.51	0.61	0.13∼1.08	5
• Other		52	0.70	0.56∼0.84	78	71∼82	−0.15∼1.54	4.18	0.60	0.44∼0.76	4
	Specific types
• 3rd wave therapies	− ACT	8	0.74	0.61∼0.87	0	0∼56	0.58∼0.90	3.92	^e		0
	− MBCT	7	0.71	0.41∼1.01	58	0∼80	−0.15∼1.57	4.11	0.49	0.16∼0.81	3
• CBT	− GSH: Burns	7	0.97	0.62∼1.32	39	0∼73	0.09∼1.85	2.88	^e		0
	− CBT: Beck	37	0.95	0.77∼1.14	68	53∼76	0.01∼1.89	2.95	0.61	0.40∼0.82	14
	− CBT: CWD	26	0.38	0.27∼0.49	38	0∼61	0.02∼0.74	8.38	0.28	0.16∼0.40	7
• Behavioral activation	− BAT: Pleasant events	7	1.04	0.77∼1.30	0	0∼58	0.70∼1.38	2.67	^e		0
	− BAT: Contextual	7	1.06	0.46∼1.65	87	74∼92	−0.94∼3.06	2.62	0.49	−0.14∼1.26	3
• Problem-solving therapy	− PST: Extended	8	1.07	0.50∼1.63	88	78∼92	−0.81∼2.95	2.59	0.25	−0.34∼0.85	4
	− PST: Brief	14	0.81	0.42∼1.19	90	86∼93	−0.74∼2,36	3.53	0.26	−0.18∼0.69	6
	− PST: SET	8	0.42	0.21∼0.64	63	0∼81	−0.21∼1.05	7.49	0.28	0.05∼0.50	3
• IPT	− IPT: Full	14	0.57	0.31∼0.83	77	58∼85	−0.37∼1.51	5.29	^e		0
	− IPT: Brief	13	0.64	0.13∼1.15	91	87∼94	−1.41∼2.69	4.63	^e		0
• Psychodynamic		12	0.39	0.16∼0.62	70	37∼82	−0.35∼1.13	8.14	0.30	0.06∼0.54	2
• Non-directive supportive		19	0.58	0.42∼0.75	45	0∼67	0.07∼1.09	5.18	0.42	0.23∼0.61	6
• Life review		14	1.10	0.68∼1.51	89	83∼92	−0.52∼2.72	2.51	0.61	0.13∼1.08	5

Abbreviations: ACT, acceptance and commitment therapy; BAT, behavioral activation therapy; CBT, cognitive behavioral therapy; CI, confidence interval; CWD, coping with depression course; ES, effect size; g_adj, Hedges’ g adjusted for publication bias; GSH, guided self-help; IPT, interpersonal psychotherapy; MBCT, Mindfulness-based cognitive therapy; N_comp, number of comparisons; N_imp, number of imputated studies; NNT, numbers-needed-to-treat; PST, problem-solving therapy.

^aaccording to the random-effects model.

^bthis give the 95% CI of.

^cthis give the 95% CI of.

^dthis give the 95% CI of.

^eNo publication bias was detected according to Duvall and Tweedie’s trim and fill procedure.

Table III. Effects of 15 therapies stratified across different types of control groups: Hedges’ g^a.

		Waiting list				Care-as-usual				Other control group
		Ncomp	g	95% CI	I^2	Ncomp	g	95% CI	I^2	Ncomp	g	95% CI	I^2
All comparisons		157	0.73	0.69∼0.77	75 ***	165	0.63	0.55∼0.70	80 ***	63	0.57	0.43∼0.70	85 ***
One ES/study (highest)		111	0.96	0.85∼1.07	80 ***	147	0.65	0.57∼0.73	81 ***	51	0.56	0.41∼0.71	86 ***
One ES/study (lowest)		111	0.84	0.73∼0.94	77 ***	147	0.63	0.55∼0.71	82 ***	51	0.49	0.35∼0.63	84 ***
Outliers excluded (g ≥ 2)		140	0.73	0.66∼0.79	46 ***	160	0.57	0.50∼0.63	73 ***	61	0.47	0.37∼0.57	70 ***
Generic types
• CBT		90	0.96	0.83∼108	76 ***	86	0.59	0.50∼0.69	77 ***	28	0.54	0.35∼0.73	86 ***
• BAT		10	1.42	0.91∼1.93	80 ***	8	0.85	0.53∼1.18	76 ***	3	0.67	0.34∼0.99	11
• 3rd wave therapies		13	0.87	0.59∼1.16	81 ***	4	0.93	0.49∼1.38	53	2	0.71	0.25∼1.16	47
• PST		16	0.80	0.52∼1.08	80 ***	8	0.99	0.43∼1.54	93 ***	6	0.27	−0.03∼0.57	72 ***
• IPT		2	0.88	0.24∼1.52	55	19	0.63	0.29∼0.97	90 ***	6	0.35	0.09∼0.61	28
• Psychodynamic		1	1.09	0.19∼1.99	0	8	0.32	0.08∼0.55	66 **	3	0.38	−0.34∼1.09	77 *
• Non-directive supportive		4	1.11	0.32∼1.91	65 *	13	0.42	0.30∼0.54	0	2	0.97	0.52∼1.42	0
• Life review		4	0.61	0.29∼0.93	40	5	0.83	0.44∼1.22	46	5	1.74	0.62∼2.86	95 ***
• Other		21	0.61	0.49∼0.72	0	18	0.70	0.51∼0.88	70 ***	13	0.75	0.32∼1.18	92 ***
	Specific types
• 3rd wave therapies	− ACT	6	0.73	0.59∼0.86	0	1	0.66	−0.01∼1.33	0	1	0.92	0.49∼1.35	0
	− MBCT	4	0.49	0.27∼0.71	0	3	1.02	0.45∼1.59	65	0
• CBT	− GSH: Burns	7	0.97	0.62∼1.32	39	0				0
	− CBT: Beck	22	1.26	0.99∼1.54	62 ***	11	0.62	0.39∼0.85	49 *	4	0.54	0.28∼0.80	33
	− CBT: CWD	10	0.48	0.35∼0.61	0	14	0.37	0.21∼0.52	39	2	0.13	−0.24∼0.49	72
• Behavioral activation	− BAT: Pleasant events	6	1.03	0.75∼1.30	0	0				1	1.11	0.29∼1.93	0
	− BAT: Contextual	2	3.14	−1.86∼8.15	0	4	0.55	0.22∼0.87	34	1	0.85	0.18∼1.52	0
• Problem-solving therapy	− PST: Extended	5	1.86	1.10∼2.62	65 *	2	0.33	0.12∼0.55	0	1	−0.19	−0.54∼0.16	0
	− PST: Brief	3	0.68	−0.13∼1.49	78 *	6	1.24	0.42∼2.05	94 ***	5	0.37	0.06∼0.68	69 *
	− PST: SET	8	0.42	0.21∼0.64	63 **	0				0
• IPT	− IPT: Full	2	0.88	0.24∼1.52	55	7	0.63	0.26∼1.00	80 ***	5	0.31	0.04∼0.58	31
	− IPT: Brief	0				12	0.63	0.09∼1.17	92 ***	1	0.75	−0.07∼1.57	0
• Psychodynamic		1	1.09	0.19∼1.99	0	8	0.32	0.08∼0.55	66 **	3	0.38	−0.34∼1.09	77 *
• Non-directive supportive		4	1.11	0.32∼1.91	65 *	13	0.42	0.30∼0.54	0	2	0.97	0.52∼1.42	0
• Life review		4	0.61	0.29∼0.93	40	5	0.83	0.44∼1.22	46	5	1.74	0.62∼2.86	95 ***

Abbreviations: ACT, acceptance and commitment therapy; BAT, behavioral activation therapy; CBT, cognitive behavioral therapy; CI, confidence interval; CWD, coping with depression course; ES, effect size; g_adj, adjusted Hedge’s g; GSH, guided self-help; IPT, interpersonal psychotherapy; MBCT, mindfulness-based cognitive therapy; N_comp, number of comparisons; N_imp, number of imputations; NNT, numbers-needed-to-treat; PST, problem-solving therapy.

^aaccording to the random-effects model.

Table IV. Standardized regression coefficients of generic and specific treatments of depression: multivariate metaregression analyses.

		Coeff.	SE	p	p (set)	Coeff.	SE	p	p (set)
Generic therapies	CBT	Ref.			0.47
	3rd wave	0.13	0.17	0.43
	Behavioral activation	0.33	0.17	0.05
	Psychodynamic	−0.14	0.21	0.51
	IPT	−0.09	0.15	0.54
	PST	0.07	0.14	0.64
	Non-directive supportive	0.01	0.17	0.97
Specific therapies	Beck’s CBT					Ref.			0.16
	ACT					−0.20	0.23	0.37
	MBCT					−0.20	0.24	0.40
	CWD					−0.46	0.16	<0.01
	Burns GSH					−0.26	0.27	0.33
	BAT: pleasant events					−0.00	0.27	0.99
	BAT: Contextual					0.15	0.25	0.55
	PST extended					−0.04	0.25	0.86
	PST brief					−0.04	0.19	0.83
	PST SET					−0.43	0.23	0.07
	Full IPT					−0.34	0.19	0.07
	Brief IPT					−0.28	0.20	0.17
	Psychodynamic					−0.37	0.20	0.07
	Life review					0.07	0.20	0.73
	Non-directive supportive					−0.23	0.18	0.19
Western vs non-Western		0.49	0.22	<0.001		0.23	0.16	<0.14
Control group	Waiting list	Ref.			<0.01	Ref.			0.06
	Care as usual	−0.30	0.09	0.001		−0.22	0.13	0.05
	Placebo	−0.43	0.22	0.05		−0.50	0.20	0.01
	Other	−0.32	0.13	0.01		−0.12	0.16	0.46
Risk of bias (continuous)		−0.11	0.03	<0.001		−0.11	0.04	0.004
Intercept		1.14	0.10	<0.001		1.31	0.13	<0.001
R^2 analog		0.21				0.21

Abbreviations: ACT, acceptance and commitment therapy; BAT, behavioral activation therapy; CBT, cognitive behavioral therapy; Coeff, Coefficient; CWD, coping with depression course; GSH, guided self-help; IPT, interpersonal psychotherapy; MBCT, mindfulness-based cognitive therapy; N_comp, number of comparisons; N_imp, number of imputations; NNT, numbers-needed-to-treat; PST, problem-solving therapy; SET, self-examination therapy.

Table V. Effects of 15 therapies compared with control groups from randomized trials with low risk of bias: Hedges’ g^a.

	Ncomp	g	95% CI^b	I^2	95% CI^c	Prediction interval	NNT	gadj	95% CI^d	Nimp
All studies (low risk of bias)	103	0.48	0.42∼0.55	69	62∼74	−0.05∼1.01	6.44	0.36	0.29∼0.44	21
Generic types
• CBT	55	0.50	0.40∼0.60	73	64∼79	−0.12∼1.12	6.14	0.35	0.24∼0.46	12
• 3rd wave therapies	6	0.60	0.43∼0.76	0	0∼61	0.37∼0.83	4.99	0.54	0.40∼0.69	3
• BAT	8	0.78	0.52∼1.03	73	31∼85	−0.01∼1.57	3.69	0.62	0.34∼0.91	2
• PST	10	0.27	0.14∼0.41	54	0∼76	−0.14∼0.68	12.25	0.21	0.06∼0.36	2
• Psychodynamic	5	0.52	0.09∼0.95	79	31∼89	−0.98∼2.02	5.88	0.23	−0.24∼0.69	2
Specific types
• CBT according to Beck	5	0.87	0.23∼1.52	89	74∼93	−1.56∼3.30	3.26	0.41	−0.29∼1.11	2
• CBT: CWD	13	0.34	0.18∼0.49	56	0∼75	−0.14∼0.82	9.49	0.23	0.08∼0.39	4
• Psychodynamic	5	0.52	0.09∼0.95	79	31∼89	−0.98∼2.02	5.88	0.23	−0.24∼0.69	2
• PST SET	6	0.35	0.14∼0.56	62	0∼82	−0.28∼0.98	9.19	0.28	0.06∼0.50	1

Abbreviations: BAT, behavioral activation therapy; CBT, cognitive behavioral therapy; CI, confidence interval; CWD, coping with depression course; g_adj, Hedges’ g adjusted for publication bias; N_comp, number of comparisons; N_imp, number of imputated studies; NNT, numbers-needed-to-treat; PST, problem-solving therapy; SET, self-examination therapy.

^aaccording to the random-effects model.

^bthis give the 95% CI of.

^cthis give the 95% CI of.

^dthis give the 95% CI of.

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