The Most Effective Treatments for Depression
A meta-analysis of 15 evidence-supported therapies for depression is reviewed.
A meta-analytic review of 15 evidence-supported therapies for depression, using 385 therapy/control comparisons, was published in the March issue of Psychotherapy Research. The results showed that all therapies were effective. After adjusting for the risk of bias, however, only two remained significant: Self-examination therapy, and a psychoeducational intervention based on Lewinsohn’s The Coping With Depression Course.
The therapies examined in the meta-analysis were grouped into 15 categories. These are described below. For each category, the effect size, Hedges’ g, is also noted. Other results and additional discussion follow these descriptions.
The 15 evidence-supported therapies for depression
Three cognitive behavioral therapies (g = 0.73)
Cognitive behavioral therapy aims to modify maladaptive thoughts and behaviors.
1. Beck’s manual (g = 0.95).
2. The “Coping with Depression” course (g = 0.38).
3. David Burn’s Feeling Good (g = 0.97).
Two behavioral activation therapies (g = 1.05).
Behavioral activation teaches clients to identify and engage in rewarding activities.
1. Pleasant activity scheduling involves monitoring the relationship between mood and activities and engaging in more pleasant activities daily (g = 1.04).
2. Contextual behavioral activation requires “activity scheduling, self-monitoring, graded task assignment, role-playing, functional analysis, mental rehearsal” (p. 282),1 and in more recent versions, mindfulness (g = 1.06).
Three problem-solving therapies (g = 0.75).
Problem-solving therapy involves defining personal problems, generating solutions, and determining whether a solution works.
1. Brief problem-solving therapy consists of nine or fewer sessions (g = 0.81).
2. Extended problem-solving therapy focuses on changing maladaptive thoughts and attitudes, in addition to problem solving (g = 1.07).
3. Self-examination therapy focuses mainly on solving problems related to one’s goals and learning to accept what is beyond one’s control (g = 0.42).
Two third-wave cognitive behavioral therapies (g = 0.85).
The first wave is usually represented by behavioral therapies, the second wave by cognitive therapies, and the third wave by therapies emphasizing life goals and acceptance of experiences (instead of trying to control them).
1. Acceptance and commitment therapy, developed by Steven C. Hayes, promotes psychological flexibility and encourages reducing avoidant behaviors and living a life based on one’s values and commitments (g = 0.74).
2. Mindfulness-based CBT combines cognitive behavioral therapy with mindfulness and meditation practices (g = 0.71).
Two interpersonal psychotherapies (g = 0.60).
Interpersonal psychotherapy is a structured and relatively brief form of therapy that stresses attachment patterns and relationship issues.
1. Full interpersonal therapy uses the full manual and is longer (g = 0.57).
2. Brief interpersonal therapy consists of 10 or fewer sessions (g = 0.64).
Psychodynamic therapy (g = 0.39).
Psychodynamic therapy attempts to help clients become aware of their unconscious conflicts, many of which have their source in the past. Therefore, considerable time in therapy is spent exploring childhood experiences and past relationships with significant others, particularly parents.
Non-directive supportive therapy (g = 0.58).
Non-directive therapy is a form of supportive therapy. According to the authors, it is “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.”1
Life review therapy (g = 1.10).
Life review therapy assumes exploring memories and working through them helps older people resolve previous conflicts and reconstruct their life stories in a way that reduces depression and increases well-being.
The most effective treatment for depression: Methods, results, and conclusions.
After an initial examination of nearly 20,000 abstracts, the authors chose 2,323 papers for further evaluation. They then selected 309 trials (385 comparisons) for use in the meta-analysis. Only studies that involved a randomized trial and a control condition were included.
The results of the meta-analysis showed all the therapies examined had significantly positive effects (effect sizes ranging from moderate to large) on adult depression. The smallest effect sizes belonged to psychodynamic therapy, self-examination therapy, and the “Coping with Depression” course.
However, after taking into consideration publication bias, risk of bias (in 70% of studies), and a high level of heterogeneity, the only therapies for depression that remained significant were self-examination therapy and the “Coping with Depression” course.
But, as noted above, the effect size for “Coping with Depression” course had been among the smallest. How can we explain that? The authors believe this may be due to the nature of this intervention (the courage being psychoeducational as opposed to therapeutic), or studies commonly using this therapy in more complex groups (e.g., individuals with alcohol problems, juvenile delinquents).
Let us conclude this analysis by considering potential reasons most therapies appeared to be similarly effective. Perhaps each therapy is effective at changing a different aspect of depression. As the authors note, “It is very well possible that a therapy changes one specific dimension or characteristic, which in turn changes and improves the whole system of depression-related characteristics of the patient” (p. 291).
Another possibility is that different therapies work through the aspects common to all these therapies. These aspects are called common factors. For instance, compared to people not in therapy, those in therapy are more motivated to change, are engaged in a healthy and supportive relationship with a therapist who shows empathy and care, and are given hope and positive expectations for change and improvement, etc.
Arash Emamzadeh attended the University of British Columbia in Canada, where he studied genetics and psychology. He has also done graduate work in clinical psychology and neuropsychology in U.S.