It is not yet clear what mental disorders are and what are the causal pathways that lead to them. That makes it difficult to decide what the targets and outcomes of psychotherapies should be. In this ...paper, the main types of targets and outcomes of psychotherapies are described, and a brief overview is provided of some of the main results of research on these types. These include symptom reduction, personal targets and outcomes from the patient's perspective, improvement of quality of life, intermediate outcomes depending on the theoretical framework of the therapist, negative outcomes to be avoided, and economic outcomes. In line with the dominance of the DSM and ICD systems for diagnoses, most research has been focused on symptom reduction. This considerable body of research, with hundreds of randomized trials, has shown that for most mental disorders effective psychotherapies are available. There is also research showing that psychotherapies can result in improvement of quality of life in most mental disorders. However, relatively little research is available on patient‐defined outcomes, intermediate outcomes, negative outcomes and economic outcomes. Patients, relatives, therapists, employers, health care providers and society at large each have their own perspectives on targets and outcomes of psychotherapies. The perspective of patients should have more priority in research, and a standardization of outcome measures across trials is much needed.
Leading biological hypotheses propose that biological changes may underlie major depressive disorder onset and relapse/recurrence. Here, we investigate if there is prospective evidence for biomarkers ...derived from leading theories. We focus on neuroimaging, gastrointestinal factors, immunology, neurotrophic factors, neurotransmitters, hormones, and oxidative stress. Searches were performed in Pubmed, Embase and PsychInfo for articles published up to 06/2019. References and citations of included articles were screened to identify additional articles. Inclusion criteria were having an MDD diagnosis as outcome, a biomarker as predictor, and prospective design search terms were formulated accordingly. PRISMA guidelines were applied. Meta-analyses were performed using a random effect model when three or more comparable studies were identified, using a random effect model. Our search resulted in 67,464 articles, of which 75 prospective articles were identified on: Neuroimaging (N = 24), Gastrointestinal factors (N = 1), Immunology (N = 8), Neurotrophic (N = 2), Neurotransmitters (N = 1), Hormones (N = 39), Oxidative stress (N = 1). Meta-analyses on brain volumes and immunology markers were not significant. Only cortisol (N = 19, OR = 1.294, p = 0.024) showed a predictive effect on onset/relapse/recurrence of MDD, but not on time until MDD onset/relapse/recurrence. However, this effect disappeared when studies including participants with a baseline clinical diagnosis were removed from the analyses. Other studies were too heterogeneous to compare. Thus, there is a lack of evidence for leading biological theories for onset and maintenance of depression. Only cortisol was identified as potential predictor for MDD, but results are influenced by the disease state. High-quality (prospective) studies on MDD are needed to disentangle the etiology and maintenance of MDD.
More than 100 comparative outcome trials, directly comparing 2 or more psychotherapies for adult depression, have been published. We first examined whether these comparative trials had sufficient ...statistical power to detect clinically relevant differences between therapies of d=0.24. In order to detect such an effect size, power calculations showed that a trial would need to include 548 patients. We selected 3 recent meta-analyses of psychotherapies for adult depression (cognitive behaviour therapy (CBT), interpersonal psychotherapy and non-directive counselling) and examined the number of patients included in the trials directly comparing other psychotherapies. The largest trial comparing CBT with another therapy included 178 patients, and had enough power to detect a differential effect size of only d=0.42. None of the trials in the 3 meta-analyses had enough power to detect effect sizes smaller than d=0.34, but some came close to the threshold for detecting a clinically relevant effect size of d=0.24. Meta-analyses may be able to solve the problem of the low power of individual trials. However, many of these studies have considerable risk of bias, and if we only focused on trials with low risk of bias, there would no longer be enough studies to detect clinically relevant effects. We conclude that individual trials are heavily underpowered and do not even come close to having sufficient power for detecting clinically relevant effect sizes. Despite this large number of trials, it is still not clear whether there are clinically relevant differences between these therapies.
Background
Although depression is one of the main public health challenges of our time, the uptake of interventions aimed at the prevention and treatment is low to modest. New approaches are needed ...to reduce the disease burden of depression.
Method
Indirect prevention and treatment may be one method to increase uptake of services. Indirect interventions aim at problems related to depression but with lower stigma and prevent or treat depression indirectly. This paper describes the approach, the empirical support and limitations.
Results
A growing number of studies focus on indirect prevention and treatment. Several studies have examining the possibilities to prevent and treat depression through interventions aimed at insomnia. Several other studies focus on indirect interventions aimed at for example stress and perfectionism. Digital ‘suites’ of interventions may focus on daily problems of for example students or the workplace and offer a broad range of indirect interventions in specific settings.
Conclusion
Indirect prevention and treatment may be a new approach to increase uptake and reduce the disease burden of depression.
Highlights
Effective treatments and preventive interventions are available for depression but uptake is low.
Indirect prevention and treatment focus on problems related to depression.
Uptake of indirect interventions is higher because they focus on daily problems.
Indirect interventions may provide a new paradigm for prevention and treatment.
Summary Insomnia is a major public health problem considering its high prevalence, impact on daily life, co-morbidity with other disorders and societal costs. Cognitive behavioral treatment for ...insomnia (CBTI) is currently considered to be the preferred treatment. However, no meta-analysis exists of all studies using at least one component of CBTI for insomnia, which also uses modern techniques to pool data and to analyze subgroups of patients. We included 87 randomized controlled trials, comparing 118 treatments (3724 patients) to non-treated controls (2579 patients). Overall, the interventions had significant effects on: insomnia severity index (ISI; g =0.98), sleep efficiency (SE; g =0.71), Pittsburgh sleep quality index (PSQI; g =0.65), wake after sleep onset (WASO; g=0.63) and sleep onset latency (SOL; g =0.57), number of awakenings (NWAK; g = 0.29) and sleep quality (SQ; g = 0.40). The smallest effect was on total sleep time (TST; g =0.16). Face-to-face treatments of at least 4 sessions seem to be more effective than self-help interventions or face-to-face interventions with fewer sessions. Otherwise the results seem to be quite robust (similar for patients with or without comorbid disease, younger or older patients, using or not using sleep medication). We conclude that CBTI, either its components or the full package, is effective in the treatment of insomnia.
Several meta-analyses have shown that psychotherapy is effective for reducing depressive symptom severity. However, the impact on quality of life (QoL) is as yet unknown.
To investigate the ...effectiveness of psychotherapy for depression on global QoL and on the mental health and physical health components of QoL.
We conducted a meta-analysis of 44 randomised clinical trials comparing psychotherapy for adults experiencing clinical depression or elevated depressive symptoms with a control group. We used subgroup analyses to explore the influence of various study characteristics on the effectiveness of treatment.
We detected a small to moderate effect size (Hedges' g = 0.33, 95% CI 0.24-0.42) for global QoL, a moderate effect size for the mental health component (g = 0.42, 95% CI 0.33-0.51) and, after removing an outlier, a small but statistically significant effect size for the physical health component (g = 0.16, 95% CI 0.05-0.27). Multivariate meta-regression analyses showed that the effect size of depressive symptoms was significantly related to the effect size of the mental health component of QoL. The effect size of depressive symptoms was not related to global QoL or the physical health component.
Psychotherapy for depression has a positive impact on the QoL of patients with depression. Improvements in QoL are not fully explained by improvements in depressive symptom severity.
Depressive disorders constitute an important and costly public health problem and worldwide most of the disease burden is suffered in low-and middle-income countries (LMICs). Treatments only have ...limited possibilities to reduce the disease burden of depressive disorders. Prevention may be one of the alternative ways to further reduce the disease burden of depressive disorders. In this paper, the results of a subgroup analysis of a previous meta-analysis on the effect of preventive interventions on the incidence of depressive disorders was undertaken. Only 6% of all trials examining the possibility to prevent the onset of major depression have been conducted in LMICs, and these studies find significantly smaller effects than those in high-income settings. It is too early, therefore, to consider implementing and disseminating preventive interventions in LMICS. However, in optimal conditions and assuming that evidence-based preventive interventions will be developed, investments should be made into treatment, universal, selective and indicated prevention, as well as in social institutions focusing on larger risk factors for mental health problems.
Depression and anxiety disorders are highly prevalent and disabling disorders, which result not only in an enormous amount of human misery and lost health, but also lost economic output. Here we ...propose a global investment case for a scaled-up response to the public health and economic burden of depression and anxiety disorders.
In this global return on investment analysis, we used the mental health module of the OneHealth tool to calculate treatment costs and health outcomes in 36 countries between 2016 and 2030. We assumed a linear increase in treatment coverage. We factored in a modest improvement of 5% in both the ability to work and productivity at work as a result of treatment, subsequently mapped to the prevailing rates of labour participation and gross domestic product (GDP) per worker in each country.
The net present value of investment needed over the period 2016–30 to substantially scale up effective treatment coverage for depression and anxiety disorders is estimated to be US$147 billion. The expected returns to this investment are also substantial. In terms of health impact, scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period. Placing an economic value on these healthy life-years produces a net present value of $310 billion. As well as these intrinsic benefits associated with improved health, scaled-up treatment of common mental disorders also leads to large economic productivity gains (a net present value of $230 billion for scaled-up depression treatment and $169 billion for anxiety disorders). Across country income groups, resulting benefit to cost ratios amount to 2·3–3·0 to 1 when economic benefits only are considered, and 3·3–5·7 to 1 when the value of health returns is also included.
Return on investment analysis of the kind reported here can contribute strongly to a balanced investment case for enhanced action to address the large and growing burden of common mental disorders worldwide.
Grand Challenges Canada.
During the last two decades, Internet-delivered cognitive behavior therapy (ICBT) has been tested in hundreds of randomized controlled trials, often with promising results. However, the control ...groups were often waitlisted, care-as-usual or attention control. Hence, little is known about the relative efficacy of ICBT as compared to face-to-face cognitive behavior therapy (CBT). In the present systematic review and meta-analysis, which included 1418 participants, guided ICBT for psychiatric and somatic conditions were directly compared to face-to-face CBT within the same trial. Out of the 2078 articles screened, a total of 20 studies met all inclusion criteria. Results showed a pooled effect size at post-treatment of Hedges g = .05 (95% CI, −.09 to .20), indicating that ICBT and face-to-face treatment produced equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there have been few studies of the individual psychiatric and somatic conditions so far, and for the majority, guided ICBT has not been compared against face-to-face treatment. Thus, more research, preferably with larger sample sizes, is needed to establish the general equivalence of the two treatment formats.
Computerized and, more recently, Internet-based treatments for depression have been developed and tested in controlled trials. The aim of this meta-analysis was to summarize the effects of these ...treatments and investigate characteristics of studies that may be related to the effects. In particular, the authors were interested in the role of personal support when completing a computerized treatment. Following a literature search and coding, the authors included 12 studies, with a total of 2446 participants. Ten of the 12 studies were delivered via the Internet. The mean effect size of the 15 comparisons between Internet-based and other computerized psychological treatments vs. control groups at posttest was d = 0.41 (95% confidence interval CI: 0.29-0.54). However, this estimate was moderated by a significant difference between supported (d = 0.61; 95% CI: 0.45-0.77) and unsupported (d = 0.25; 95% CI: 0.14-0.35) treatments. The authors conclude that although more studies are needed, Internet and other computerized treatments hold promise as potentially evidence-based treatments of depression.
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