Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program 

Brief Psychotherapy

for Depression in Primary Care:

A Systematic Review of the Evidence

Department of Veterans Affairs

Health Services Research & Development Service

January 2011

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Durham VA Medical Center

Durham, NC

John W. Williams Jr., MD, MHSc, Director

Investigators:

Principal Investigator:

Jason A. Nieuwsma, PhD

Co-Investigators:

Ranak B. Trivedi, PhD

Jennifer McDuffie, PhD

Ian Kronish, MD

Dinesh Benjamin, MD

John W. Williams Jr., MD, MHSc

Medical Editor:

Liz Wing, MA
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

PREFACE

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics of 

particular importance to Veterans Affairs (VA) managers and policymakers, as they work to improve 

the health and healthcare of Veterans. The ESP disseminates these reports throughout the VA. 

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The ESP 

Centers generate evidence syntheses on important clinical practice topics, and these reports help: 

• develop clinical policies informed by evidence, 

• guide the implementation of effective services to improve patient outcomes and to 

support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, an ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Nieuwsma JA, Trivedi RB, McDuffie J, Kronish I, Benjamin D, 

Williams JW Jr. Brief Psychotherapy for Depression in Primary Care: A Systematic Review of 

the Evidence. VA-ESP Project #09-010; 2011

This report is based on research conducted by the Evidence-based Synthesis 

Program (ESP) Center located at the Durham VA Medical Center, Durham, NC, 

funded by the Department of Veterans Affairs, Veterans Health Administration, 

Office of Research and Development, Health Services Research and Development. 

The findings and conclusions in this document are those of the author(s) who are 

responsible for its contents; the findings and conclusions do not necessarily represent 

the views of the Department of Veterans Affairs or the United States government. 

Therefore, no statement in this article should be construed as an official position of 

the Department of Veterans Affairs. No investigators have any affiliations or financial 

involvement (e.g., employment, consultancies, honoraria, stock ownership or options, 

expert testimony, grants or patents received or pending, or royalties) that conflict with 

material presented in the report.
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

TABLE OF CONTENTS

Executive Summary............................................................................................................................................. 1

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Results ........................................................................................................................................................... 2

Key Question 1 .................................................................................................................................... 3

Key Question 2 .................................................................................................................................... 3

Key Question 3 .................................................................................................................................... 3

Key Question 4 .................................................................................................................................... 3

Future Research Recommendations.............................................................................................................. 4

Conclusions ................................................................................................................................................... 4

Introduction .......................................................................................................................................................... 5

Methods................................................................................................................................................................... 7

Topic Development........................................................................................................................................ 7

Overall Approach........................................................................................................................................... 8

Search Strategy.............................................................................................................................................. 8

Study Selection.............................................................................................................................................. 8

Data Abstraction ............................................................................................................................................ 9

Quality Assessment ....................................................................................................................................... 9

Data Synthesis............................................................................................................................................. 10

Peer Review................................................................................................................................................. 11

Results ................................................................................................................................................................... 12

Literature Search and Study Characteristics................................................................................................ 12

Key Question 1............................................................................................................................................ 17

Key Question 2............................................................................................................................................ 20

Key Question 3............................................................................................................................................ 21

Key Question 4............................................................................................................................................ 21

Discussion.............................................................................................................................................................. 23

Strengths and Limitations............................................................................................................................ 24

Conclusions ................................................................................................................................................. 25

Future Research................................................................................................................................................ 26

References............................................................................................................................................................ 27
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Appendix A: Search Strategy....................................................................................................................... 32

Appendix B: Evidence Tables........................................................................................................................ 33

List of Included Studies............................................................................................................................... 48

Appendix C: Reviewer Comments and Responses ................................................................................. 49

Appendix D: Excluded Studies ..................................................................................................................... 55

List of Excluded Studies.............................................................................................................................. 58

Appendix E: Acronyms and Abbreviations............................................................................................... 62

Figures

Figure 1. Analytic Framework....................................................................................................................... 7

Figure 2. Literature Flow Diagram.............................................................................................................. 13

Figure 3. Meta-analysis of Brief CBT for Depression ................................................................................ 19

Tables

Table 1. Summary of Inclusion and Exclusion Criteria................................................................................. 9

Table 2. Definitions for Strength of Evidence Rating ................................................................................. 11

Table 3. Summary of Study Characteristics................................................................................................ 15

Table 4. Summary of Intervention Characteristics...................................................................................... 16

Table 5. Key Clinical Outcome Measures................................................................................................... 22

Table 6. Summary of the Strength of Evidence for Key Question 1........................................................... 25
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

EVIDENCE REPORT

INTRODUCTION

Depressive disorders present a major public health concern. The prevalence of current depression 

among U.S. adults is 6.6%,1 affecting up to 16 to 18% of the population over their lifetime.2 High 

prevalence rates have also been noted in the Veteran population,3 and particularly high rates have 

been found in primary care settings.4 Although primary care physicians treat a high proportion 

of patients with depressive disorders,5 the treatment of depression in primary care tends to be 

variable and suboptimal.6 Because of this, it is a public health priority to identify treatments for 

depression that are effective, evidence-based, and suitable for dissemination in primary care.

The two evidence-based, first-line interventions for depression recommended by VA/Department 

of Defense (DoD) guidelines are pharmacotherapy and/or psychotherapy.7 Based on several 

systematic reviews showing small-to-moderate benefit, the guideline recommends several 

classes of antidepressants as first-line therapy. Among psychotherapies, cognitive behavioral 

therapy (CBT), interpersonal psychotherapy (IPT) and problem-solving therapy (PST) are 

recommended as first-line treatment. For CBT and IPT, 16 to 20 sessions are recommended. 

Other psychotherapies are recommended for specific clinical situations, such as dialectical 

behavioral therapy (DBT), in combination with antidepressants for older adults with chronic 

major depressive disorder (MDD). In general, the evidence suggests that pharmacotherapy and 

psychotherapy are individually efficacious treatments and that there can be additive clinical 

benefit when these treatments are used in tandem.8,9

Despite persuasive evidence of effectiveness for both pharmacotherapy and psychotherapy in 

the treatment of depression, medication remains by far the most commonly utilized intervention 

in primary care settings.10-12 However, there has been a growing interest in and commitment to 

the integration of psychotherapy and other mental health services into primary care settings,13-

15 perhaps most notably within the Veterans Health Administration.16,17 Providing primary care 

patients with the option of receiving psychotherapy for their depression is an important objective 

for multiple reasons: there are many patients who, given the option, prefer psychotherapy to 

medication;18-21 there is a need to provide alternative treatments for patients who do not improve 

on or cannot tolerate antidepressant medication;22,23 and there may be unique benefits from 

psychotherapy in terms of costs24-28 and relapse prevention.29-31

While there is good rationale for increasing the availability of psychological treatments for 

depression in primary care, there are also substantial barriers to incorporating psychotherapies 

into this setting. As with the prescription of antidepressant medication, there is a significant 

problem in delivering psychotherapy at the proper dose and with fidelity to the treatment 

model.6,32 There are also a number of barriers to implementing psychotherapies in primary care 

that are distinct from barriers to providing effective pharmacological treatment. These barriers 

involve such pragmatic concerns as finding space in primary care clinics where psychotherapy 

can be provided in confidentiality and securing an adequate workforce with the proper training to 

meet the demand for psychotherapy.
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Perhaps the most significant barrier to providing psychotherapies in primary care settings is 

that, unlike pharmacological treatment, many empirically supported psychotherapy treatment 

protocols consist of at least 12 to 16 weekly 1-hour sessions.33,34 While this treatment duration 

is much abbreviated compared with older approaches to the provision of psychotherapy,35 it is 

arguably still too intensive for reliable implementation in primary care settings.

Recognizing that time and resource constraints present important barriers to effectively 

implementing standard-duration psychotherapies (i.e., 12 to 20 sessions) for depression in 

primary care settings, this report evaluates whether psychotherapy for depression can be 

efficacious after a period of 8 or fewer sessions—what we define as brief psychotherapy. In 

examining the evidence on brief psychotherapies for depression, this report also aims to address 

issues of the amount of training necessary to deliver psychotherapeutic treatment effectively and 

the availability of data on key clinical outcomes like social functioning and satisfaction with 

treatment. Effectively treating depression in primary care patients is an important public health 

priority. With that in mind, this report endeavors to examine whether brief psychotherapies 

are often tailored specifically for primary care settings and are efficacious for the treatment of 

depression. 
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

METHODS

Topic Development

This review was commissioned by the Department of Veterans Affairs’ Evidence-based Synthesis 

Program. The topic was selected after a formal topic nomination and prioritization process that 

included representatives from the Office of Mental Health Services, Health Services Research 

and Development, the Mental Health QUERI, and the Office of Mental Health and Primary Care 

Integration. The key research questions for this review were developed and refined after preliminary 

review of published peer-reviewed literature and consultation with VA and non-VA experts to select 

the patients and subgroups, interventions, outcomes, and settings addressed in this review. 

The final key questions were as follows: 

Key Question 1: For primary care patients with depressive disorders, are brief, evidencebased psychotherapies with durations of up to eight sessions more efficacious than control for 

depressive symptoms (i.e., on self-report and/or clinician-administered measures) and quality of 

life (i.e., functional status and/or health-related quality of life)?

Key Question 2: For primary care patients with depressive disorders treated with a brief, 

evidence-based psychotherapy, is there evidence that treatment effect may vary by the number of 

sessions delivered?

Key Question 3: For psychotherapies demonstrating clinically significant treatment effects, what 

are the characteristics of treatment providers (i.e., type of provider and training), and what are the 

modalities of therapy (i.e., individual/group, face-to-face/teletherapy/Internet-based)?

Key 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?

We developed and followed a standard protocol for all steps of this review. Our approach was 

guided by the analytic framework shown in Figure 1.

Figure 1. Analytic Framework

Primary care 

patients with 

depressive 

disorders

Brief 

psychotherapy for 

depressive disorders

Depressive

symptoms

Health-related 

quality of life

KQ 3 KQ 1, KQ 2

KQ 4 Social functioning,

occupational status,

treatment adherence, 

patient satisfaction

Adverse effects

of treatment
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Overall Approach

We utilized a combined approach, identifying and evaluating existing, good-quality systematic 

reviews and supplementing these reviews by searching for and evaluating original research not 

included in these reviews. We were guided in this process by published recommendations for 

conducting “complex systematic reviews,”36 which integrate findings from previous systematic 

reviews and findings from newly identified original research.

Search Strategy

We conducted our search strategy using the following three complementary approaches:

1. We searched for relevant, good-quality, English-language systematic reviews in 

MEDLINE (via PubMed), Embase, and PsycINFO from database inception through May 

2010.

2. We used a well-documented Internet-accessible database of 243 psychotherapy trials 

(www.psychotherapyrcts.org/index.php?id=3), current through January 2010, as a data 

source for original research. Using this database, we searched for studies coded as 

including adults with a mood disorder who received face-to-face psychotherapy at a dose 

of eight or fewer therapy sessions.

3. To identify any recent literature not yet catalogued in the Internet-accessible database, we 

searched for English-language publications in MEDLINE (via PubMed), Embase, and 

PsycINFO from January 2009 (one year prior to the search date of the online database)

through August 1, 2010.

We developed search strategies in consultation with a master librarian. The search terms and 

MeSH headings for the search strategies appear in Appendix A. We supplemented electronic 

searching by examining the bibliographies of included studies and systematic review articles.

Study Selection

Using prespecified inclusion/exclusion criteria, two trained researchers reviewed the list of titles 

and abstracts, then selected articles, identified from any of the computerized and manual searches 

described above, for further review. Each article retrieved was reviewed using a brief screening 

form to determine eligibility. Systematic reviews were evaluated as “good,” “fair,” or “poor” 

using quality criteria (see Quality Assessment below) adapted from a previous report,37,38 and 

only good-quality reviews relevant to one of our study questions were retained. To be included in 

our evidence report, original research studies had to (1) be a randomized controlled trial (RCT), 

(2) compare an eligible psychotherapy of eight or fewer sessions to control, and (3) report effects 

on depression. Detailed eligibility criteria are described in Table 1.
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Table 1. Summary of Inclusion and Exclusion Criteria

Study characteristic Inclusion criteria Exclusion criteria

Study design Randomized controlled trial None

Population Adults with major depressive disorder 

(MDD), dysthymic disorder, or subthreshold 

(minor) depression in acute-phase 

treatment

Treatment-resistant depression, 

postpartum depression, premenstrual 

dysphoric disorder, bipolar disorder, 

seasonal affective disorder, or double 

depression (i.e., MDD and dysthymia)

Interventions Cognitive behavioral therapy (CBT) 

(including cognitive therapy and 

behavior therapy), interpersonal therapy 

(IPT), problem-solving therapy (PST), 

mindfulness-based cognitive therapy 

(MBCT), cognitive behavioral analysis 

system of psychotherapy (CBASP), 

dialectical behavioral therapy (DBT), 

functional analytic psychotherapy (FAP), 

acceptance and commitment therapy 

(ACT), or short-term psychodynamic 

therapy with ≤ 8 planned sessions

Generic counseling, life review therapy, 

psychoeducational therapy, supportive 

therapy, bibliotherapy, or Internet-based 

psychotherapies 

Comparators Waitlist, attention control, usual care

Antidepressant medication if intervention is 

psychotherapy and an antidepressant

Another psychotherapy

Setting Outpatient general medical or general 

mental health

Study conducted outside of North 

America, Western Europe, New Zealand, 

or Australia

Outcome Depressive symptoms using a validated 

instrument reported at ≥ 6 weeks after 

randomization

None

Data Abstraction

For each newly identified primary research study, a trained researcher abstracted data from 

published reports into evidence tables (Appendix B). A second reviewer overread all data 

abstractions. We resolved disagreements by consensus among the first and second reviewer 

or by obtaining a third reviewer’s opinion when consensus could not be reached. For eligible 

trials included in the two systematic reviews, we abstracted summary data from the reviews and 

supplemented these data by using the original publications when the reviews had incomplete 

information. We abstracted the following data: (1) study design and setting, (2) eligibility criteria, 

(3) exclusion criteria, (4) sample size, (5) demographics, (6) duration of followup, (7) depression 

clinical category, (8) intervention characteristics (e.g., type of therapy, mode, frequency, therapist), 

(9) comparator characteristics, (10) outcome measures, (11) results, and (12) adverse effects.

Quality Assessment

For systematic reviews, we assessed the comprehensiveness of the search strategy, the 

description and appropriateness of inclusion criteria, whether primary studies were assessed for 

quality and the adequacy of the quality measure, the reproducibility of methods to assess studies, 

whether the results of relevant studies were combined appropriately, whether heterogeneity 

and publication bias were assessed, and whether the conclusions were supported by the data 
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

presented. Systematic reviews were rated “good” if the conclusions were supported by the 

data presented and there were no important study limitations. For original research studies, 

we assessed risk of bias using the key quality criteria described in the Agency for Healthcare 

Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative Effectiveness 

Reviews,39 adapted for this specific topic. We abstracted data on adequacy of randomization and 

allocation concealment, comparability of groups at baseline, blinding, completeness of followup 

and differential loss to followup, whether incomplete data were addressed appropriately, validity 

of outcome measures, and conflict of interest. Using these data elements, we assigned a summary 

quality score of “good,” “fair,” or “poor” to individual RCTs.

Data Synthesis

When good-quality systematic reviews were identified, we summarized the reviews’ findings in 

narrative form. For original research studies that were not included in the systematic reviews, 

results were summarized descriptively in tables that include the study sample, intervention, 

comparator, duration of followup, and primary outcomes. We critically analyzed these studies 

to compare their characteristics, methods, and findings. We then evaluated whether the new 

evidence was likely to change estimates from prior reviews by considering the precision and 

stability of estimates from the original review, the number and size of the new studies relative 

to studies in the original review, the quality of the new studies, and the consistency in estimates 

and conclusions between the new evidence and the original reviews.39 After considering these 

issues, we updated prior meta-analyses when substantial new evidence was available and a new 

summary estimate might lead to different conclusions. 

Because studies did not use a single common instrument to measure depression severity, our 

meta-analysis used effect sizes to summarize intervention effects. Effect sizes were calculated for 

each study by subtracting (at posttest) the average score of the control group from the average 

score of the experimental group and dividing the result by the pooled standard deviations 

(SDs) of the experimental and control groups. A negative effect size indicates a greater effect 

in the intervention group. For example, an effect size of -0.5 indicates that the mean decline 

in depression severity for the experimental group is half an SD greater than the mean decline 

in the control group. We applied this convention of a negative effect size indicating a greater 

intervention effect to our summary of existing systematic reviews, converting signs when 

necessary for consistency. Effect sizes are commonly interpreted as small (0.2), moderate (0.5), 

and large (≥ 0.80).40,41 To further aid interpretation of effect sizes, we converted these estimates to 

the number needed to treat (NNT) using the approach described by Kraemer.41 When studies used 

more than one validated instrument to assess depression severity, we used the mean of the effect 

sizes so that each study (or control group) contributed only one effect size. When means and 

SDs were not reported, we used other statistics (e.g., event rates) to calculate the effect size. For 

studies with more than one active eligible intervention (e.g., behavioral therapy and cognitive 

therapy arms) compared to a single control, we combined the intervention arms to avoid lack of 

independence that would be created if we entered each intervention into the analysis separately.42

Because considerable heterogeneity was expected, we used a random effects model to calculate 

a pooled mean effect size. We used the Q statistic and the I2 statistic to assess for heterogeneity 

in outcomes between studies. Because the Q statistic is underpowered, we consider a p < 0.10 
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

as statistically significant. The I2 statistic is an indicator of heterogeneity in percentages. The 

importance of between-study heterogeneity was represented by the I2 statistic thresholds of 0% 

to 40% as likely not important, 30% to 60% as moderate, 50% to 90% as substantial, and 75% 

to 100% as considerable.43 Publication bias was tested by inspecting the funnel plot of the metaanalysis. This procedure is based on the expectation that if no publication bias is present, the effect 

sizes will be dispersed equally on either side of the overall effect. However, this method has limited 

power to detect publication bias, particularly when the number of included studies is few.

We conducted preplanned subgroup analyses by study quality and type of control group. For 

other study characteristics (e.g., sessions delivered, type of depression), there was not sufficient 

variability and numbers of studies to conduct subgroup analyses. We used an influence analysis, 

recomputing the pooled mean effect by removing one study at a time, to determine the influence 

of individual studies on the overall effect. We used the computer program Comprehensive Metaanalysis, Version 2.2.021 (www.meta-analysis.com/pages/about_us.html), to conduct all metaanalyses.

Grading the Evidence for Each Key Question 

We graded the strength of evidence for each key question using principles from the Grades of 

Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group.44 This 

approach assesses the strength of evidence for each critical outcome by considering risk of bias, 

consistency, directness, precision, and publication bias. Other domains relevant to observational 

designs were not pertinent to our review. After considering each domain, a summary rating of 

“high,” “moderate,” “low,” or “insufficient” strength of evidence was assigned after discussion 

by two reviewers (Table 2).

Table 2. Definitions for Strength of Evidence Rating

Strength of evidence 

rating Definition

High Further research is very unlikely to change our confidence in the 

estimate of effect

Moderate Further research is likely to have an important impact on our 

confidence in the estimate of effect and may change the estimate

Low 

Further research is very likely to have an important impact on our 

confidence in the estimate of effect and is likely to change the 

estimate

Insufficient Evidence on an outcome is absent or too weak, sparse, or 

inconsistent to estimate an effect

Peer Review

A draft version of this report was sent to five peer reviewers. Their comments and our responses 

are presented in Appendix C.
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

RESULTS

Our general approach throughout the Results section is first to describe the relevant systematic 

reviews and then to describe the primary literature, with syntheses of the reviews and the primary 

literature occurring in conjunction with descriptions of the primary literature. This approach 

to integrating existing systematic reviews and new primary literature into a new “complex 

systematic review” was adopted and implemented in accordance with the recommendations for 

conducting complex systematic reviews proposed by Whitlock and colleagues.36

Literature Search and Study Characteristics

Systematic Reviews

Using the combined literature search of PubMed, Embase, PsycINFO, and Cochrane databases 

(Appendix A), we identified references for 560 potential systematic reviews (Figure 2). Of 

these, 528 were excluded at the title-and-abstract level, and 30 were excluded after conducting 

a full-text review. Two eligible reviews were retained: Cuijpers and colleagues45 and Cape and 

colleagues.46

Cuijpers45 completed a good-quality meta-analysis of 15 studies that examined psychotherapeutic 

interventions for depression in primary care. Studies were identified through an Internetaccessible database of psychotherapy trials47 that was created by the authors via comprehensive 

literature searches in PubMed, PsycINFO, Embase, and the Cochrane Central Register of 

Controlled Trials from 1966 to December 2007. Included studies had interventions ranging 

in length from 6 to 16 sessions; only CBT and PST used 8 or fewer sessions. The majority of 

treatments were either CBT or PST, with two studies examining IPT and one study examining 

psychodynamic counseling. Most comparator conditions were care as usual (which was noted 

as being poorly described and variable in the reviewed studies), three were placebo, and two 

were waitlist. Half of the studies contained participants diagnosed with MDD, and the other 

half contained participants with other depressive conditions. Eight studies were conducted in 

the U.K., five in the U.S., and two in the Netherlands. The risk of bias varied across studies. Of 

the 15 trials, 13 assessed outcomes blind to treatment assignment, 10 were analyzed using the 

intent to treat principle, and dropout rates varied from 3.3 to 41.2%. The authors separated the 

seven studies with six or fewer sessions from the eight studies with more than six sessions; this 

subgroup analysis was of particular interest for the present review.
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sion in Primary Care Evidence-based Synthesis Program

560 references 

identified by 

literature search 

for systematic 

reviews (SRs)

2 SRs identified 

for inclusion

32 references 

identified for fulltext review

866 references identified by literature search for RCTs• Internet database (243)• Online databases (516)• Bibliographies (107)

86 references identified for 

full-text review

12 articles representing 

7 studies identified as 

relevant RCTs

21 articles representing 

15 unique studies

From SRs, 9 articles 

representing 8 studies 

identified as relevant RCTs

780 excluded at title/abstract level (for Internet database, 185 excluded using database variables, and 33 excluded using title/abstract)

74 excluded:• Population not 

appropriate (22)

• Comparator not 

appropriate (16)

• More than 8 sessions 

(19)

• Intervention not of 

interest (11)

• Not RCT or peerreviewed (3)• Outcome not appropriate 

(3)

ram
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Cape46 completed a good-quality meta-analysis and meta-regression of 34 studies examining the 

effectiveness of brief psychological therapies in primary care for anxiety disorders, depressive 

disorders, and mixed anxiety and depression. Studies were identified via searches in MEDLINE, 

Embase, and PsycINFO databases from inception through July 2008. Included RCTs had number 

of sessions ranging from 2.3 to 9.8, with a median and mode of six sessions. Active treatment 

conditions had roughly equal distributions between studies for CBT, PST, and counseling. All 

comparator conditions were “general practitioner care as usual,” which was not further described. 

Seven studies included patients with anxiety disorders, 14 included patients with depression, and 

13 included patients with mixed anxiety and depression. Of the 14 depression studies, 6 enrolled 

patients with MDD, 6 enrolled mixed depressive disorders including minor depression, and 2 

enrolled only those with minor depression. For the 14 depression studies, 8 were analyzed using 

the intent-to-treat principle, and 10 had lost to followup less than 20%. The number with blinded 

outcome assessment was not reported. Approximately two-thirds of the studies were conducted 

in the U.K., with the remaining third conducted in other European countries and the U.S. The 

authors separately reviewed the studies of brief psychotherapy for depression, and this subgroup 

analysis was used in the present review.

After articles from the Cuijpers45 and Cape46 reviews were screened by two independent 

reviewers, nine articles representing eight unique studies met eligibility criteria and were retained 

for further analysis in tandem with the additional original research studies identified from the 

primary literature searches.

Primary Literature 

The combined searches for primary literature in electronic databases (MEDLINE, Embase, and 

PsycINFO), in a well-documented Internet-accessible database of psychotherapy trials,47 and in 

bibliographies of included studies (Appendix A) identified 866 citations. Of these, 12 articles 

representing 7 unique studies met eligibility criteria (Figure 2).

Study characteristics from the 15 relevant RCTs of brief psychotherapy—8 from the Cuijpers45

and Cape46 reviews and 7 from the additional RCTs identified in our primary literature search—

are summarized in Table 3. Characteristics of psychotherapy interventions used in the 15 RCTs 

of brief psychotherapy are summarized in Table 4.
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sion in Primary Care Evidence-based Synthesis Program

haracteristics

Depressive disorder Age mean (SD) % Female % White Setting Recruitment Most distal followupa Depression outcomes Qualityb

or depression or 

thymia 43.6 (NR) 67% 89% PC Screening and referral 11 weeks HRSD-17; HSCL-20 –

D, dysthymia, adjustment 

order, or other depression NR; Range: 18-65 66% NR PC Screening from census and registry 52 weeks BDI –

vated depressive 

mptoms without MDD 48.4 (NR) 86% NR PC Screening 7 weeks HRSD; BDI –

vated depressive 

mptoms 38.5 (13.7) 83% NR PC Screening 6 weeks HRSD; BDI; DHP –

D 37.1 (11.4) 77% 95% PC Referral 12 weeks HRSD; BDI –D 41 (10.4) 67% NR PC Referral 52 weeks HRSD; BDI Fair

pression or mixed 

iety depression 36.8 (12.2) 76% 89% PC Referral 52 weeks BDI-21 Fair

sthymia or minor 

ression 71 (7.1) 43% 76% PC Screening and referral 11 weeks HSCL-D-20; HRSD –

D or subthreshold MDD 41.9 (10.4) 68% NR MH Advertisement and referral 8 weeks BDI GoodD 74.0 (8.0) 73% NR PC Referral 26 weeks BDI; GDS; HRSD FairD 34.5 (NR) 78%

93% PC Referral

52 weeks HRSD; BDI Good

D 41.7 (12.8) 81% NR MH Advertisement 26 weeks BDI; MMPI-D Fair

depressant and 

ressive symptoms 44.8 (15.5) 74% 80% PC Registry 24 weeks SCL Good

f-report of depression 38.8 (NR) 66% NR MH Advertisement

26 weeks

BDI Poor

f-report of depression 39.5 (NR) 80%

NR MH

Advertisement 8 weeks BDI; HRSD Fair

or the seven newly identified RCTs, and in order to conduct the meta-analysis on studies of brief CBT, quality assessments were completed for two studies that 

iews.

 Inventory, DHP = Diabetes Health Profile, DIS = Diagnostic Interview Schedule, GDS = Geriatric Depression Scale, GP = general practitioner, HRSD = 

HSLC-D = Headache Specific Locus of Control-Depression, MDD = major depressive disorder, MH = mental health, MMPI-D = Minnesota Multiphasic 

, MOS-D = Medical Outcomes Study-Depression, NR = not reported, PC = primary care, PRIME-MD = Primary Care Evaluation of Mental Disorders 

esearch Diagnostic Criteria, SADS-L = Schedule for Affective Disorders and Schizophrenia–Lifetime Version, SCAN = Schedules for Clinical Assessment in 

cklist
16

sion in Primary Care Evidence-based Synthesis Program

tion Characteristics

Therapy # sessions Session length Session frequency Modality Therapist Treatment fidelity? Therapy completed [n (%)] Control

 

 80) 6 30 min Ever 2 weeks Individual PhD psychologist Yes 64 (80%) Placebo (n = 81)

 

 128) 6 30 min NR Individual Psychologists, nurses, allied health professionals Yes 80 (63%) Waitlist (n = 189)

 

 15) 6 20 min Weekly Individual; telephone Graduate students No 11 (73%) Usual care (n = 14)

 

 18) 6 NR Weekly Individual; telephone Nurses Yes NR Usual care (n = 18)

 

 30) 6 30 min Every 2 weeks Individual Experienced psychiatrist and trained GPs No 28 (93%) Placebo (n = 30)

 

 24) 6 30 min Weekly Individual CBT therapist Yes 18 (75%) Usual care (n = 24)

 

 63) 6 50 min Weekly Individual Experienced psychologists Yes 56 (89%) Usual care (n = 67)

 

 138) 6 30 min Every 2 weeks Individual

PhD psychologist, social workers, master’s-level counselors

Yes 108 (78%)

Medication; placebo (n = 140)

CT 

 16) 8 2 hours Weekly Group MBCT therapists Yes 14 (88%) TAU (n = 14)

 

 21) 8 NR NR Individual Master’s-level psychologist Yes 20 (95%) TAU (n = 23)

 + Med. 

 35) 6 30 min Every 2 weeks Individual Research practice nurse No 34 (97%) Medication alone (n = 36)

 

 12) 8 1.75 hours Weekly Group Graduate students Yes 11 (92%) Waitlist control (n = 9)

+TCM 

 195) 8 35 min Every ≈1.5 weeksa Individual; Telephone Master’s-level psychologist No 167 (86%) TCM (n = 207)

 

32)b 7 1 hour Weekly Individual Graduate students NR 21 (66%) Minimal contactc (n ≈ 32)b

 

 16) 8 1 hour Weekly Individual NR No 12 (75%) Waitlist (n = 9)

h frequency ranging from every 1 to 4 weeks for remaining four sessions.

icle.

ur nondirective therapy sessions to coincide with medication refills.

oral therapy (includes cognitive therapy and behavioral therapy), MBCT = mindfulness-based cognitive therapy, min = minutes, NR = not reported, PST = 

ent as usual, TCM = telephone case management 
17

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Of the 15 unique studies, 6 studies were conducted in the U.S., 6 in the U.K., 2 in Australia, and 

1 recruited patients across several European countries. All studies were conducted with Englishspeaking patients. Patients were predominantly treated in primary care, with 11 trials taking place 

in a primary care setting, and 4 taking place in a mental health outpatient setting. Recruitment 

strategies varied such that participants were recruited via screening in five studies, referral from a 

provider in eight studies, advertisement in four studies, and registries in two studies; many trials 

used more than one recruitment method. Studies had varying diagnostic criteria for inclusion, 

with six trials specifically allowing for the inclusion of subthreshold depression (e.g., minor 

depression, adjustment disorder, depressive symptoms), five requiring a diagnosis of MDD, and 

the remaining four using other criteria (e.g., beginning antidepressant, self-report of depression).

The intervention in eight studies was PST; in six studies, CBT; and in one study, mindfulnessbased cognitive therapy (MBCT). No trials of other psychotherapies using interventions of eight 

sessions or fewer were identified. Interventions were monitored for treatment fidelity in nine 

studies. Included studies most commonly measured depressive symptoms using the clinicianadministered Hamilton Rating Scale for Depression (HRSD) and the self-report Beck Depression 

Inventory (BDI); only one study used neither of these measures. Even though no study extended 

treatment beyond eight sessions, followup duration was less than 6 months for seven studies and 

was 6 months or greater for eight studies. In all but one study, females outnumbered males by a 

ratio of at least 2 to 1. The average age for study participants ranged from 35 to 48 years of age 

in 13 of the 15 studies, with the 2 remaining studies having participants with average ages of 71 

and 74 years of age. These two studies of elderly patients had mixed results: one found small to 

no benefit in elderly patients receiving PST for depression,55 and the other found significant and 

sustained benefit in elderly patients receiving CBT for depression.57 Most studies did not report 

race, and the six studies that did report race had heavily Caucasian samples. Only two study 

samples included any Veteran representation.48,55 In both samples, Veterans composed only a 

portion of the overall sample, and data on Veterans were not presented separately.

Quality assessments were conducted for the seven RCTs identified in the primary literature 

searches—one was rated as poor, three as fair, and three as good. Fair and poor studies were 

often rated as such due to inadequately addressing incomplete outcome data and not having 

outcome assessors who were blind to treatment assignment. In order to conduct the meta-analysis 

on studies of brief CBT, quality assessments were completed for two studies that had been 

included in the systematic reviews; both were rated as fair.

Key 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 for depressive symptoms (i.e., on self-report and/or 

clinician-administered measures) and quality of life (i.e., functional status and/or 

health-related quality of life)?

Systematic Reviews

Cuijpers’45 systematic review of 15 RCTs found psychological treatment from a range of 6 to 16 

sessions to be significantly more effective than control for treatment of depression in primary 

care (ES -0.31, 95% CI -0.45 to -0.17, NNT = 5.75). They found significantly larger effect sizes 
18

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

for studies in which participants were referred by their general practitioner (GP) (ES -0.43, 95% 

CI -0.58 to -0.28, NNT = 4.20) than for studies in which participants were recruited through 

systematic screening (ES -0.13, 95% CI -0.34 to 0.08, NNT = 13.51). The lower effect size 

for brief psychotherapy in the subgroup of primary care patients recruited through systematic 

screening was suggested as the reason why an initial comparison favored brief psychotherapy 

delivered in non–primary care settings (ES -0.67, 95% CI -0.75 to -0.58, NNT = 2.75) compared 

to brief psychotherapy delivered in primary care settings (ES -0.31, 95% CI -0.45 to -0.17, 

NNT = 5.75). The authors found no significant difference between studies in which participants 

were diagnosed with MDD (ES -0.21, 95% CI -0.42 to 0.00, NNT = 8.47) and studies in which 

participants’ depressive symptomatology was alternatively determined (ES -0.40, 95% CI -0.56 

to -0.23, NNT = 4.50). The multiple subgroup analyses conducted in this good-quality review 

allowed for the authors to present both robust and nuanced findings. In regard to psychotherapies 

with a fewer number of sessions, the authors found that, compared to control, psychotherapies 

of ≤ 6 sessions (n = 7) had a small but significant positive effect for the treatment of depression 

in primary care (ES -0.25, 95% CI -0.48 to -0.02, NNT = 7.14). HRQOL outcomes were not 

reported in this review.

Cape’s46 meta-analysis of 34 studies examined efficacy in regard to treatment type and in regard 

to three diagnostic categories: anxiety, depression, and mixed depression and anxiety. For certain 

analyses, they combined patients with diagnoses in the latter two categories. They found smaller 

treatment effects when CBT was used for mixed depression and anxiety (ES -0.26, 95% CI -0.44 

to -0.08) than for anxiety (i.e., predominantly panic disorder and generalized anxiety disorder; 

ES -1.06, 95% CI -1.31 to -0.80). They found similar small effect sizes for PST for depression 

and mixed depression and anxiety (ES -0.21, 95% CI -0.37 to -0.05) and for counseling for 

depression and mixed depression and anxiety (ES -0.32, 95% CI -0.52 to -0.11). The examination 

of different psychotherapies in three different diagnostic groups (i.e., depression, anxiety, 

and mixed depression and anxiety) was a particular strength of this review. In regard to brief 

psychotherapies specifically for patients with depression, the authors found a significant but 

small effect favoring brief CBT over usual GP care for depression (ES -0.33, 95% CI -0.60 to 

-0.06) and found a positive but statistically nonsignificant effect for PST over usual GP care (ES 

-0.26, 95% CI -0.49 to 0.03). No significant differences in efficacy were found between CBT and 

PST. HRQOL outcomes were not reported in this review.

Primary Literature

Among the seven studies that we discovered were not included in the systematic reviews were 

two studies of PST, one of MBCT, and four of CBT. The 4 studies of CBT randomized 535 

participants to treatment or control, whereas the 2 relevant studies of brief CBT covered in the 

systematic reviews randomized 178 participants to treatment or control. Because of the number 

of CBT trials not considered in the previous 2 systematic reviews, we conducted a meta-analysis 

of the 6 trials involving 713 patients to evaluate the effects of brief CBT (6 to 8 sessions) for 

depression.

For the 6 trials, study quality was rated as good (n = 1), fair (n = 4), or poor (n = 1). Studies 

enrolled patients with MDD (n = 2), depressive symptoms (n = 2), depression or mixed anxiety 

depression (n = 1), or patients with depressive symptoms who were starting an antidepressant (n 

= 1). Control conditions were treatment as usual in four of the six trials, and in two trials control 
19

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

conditions contained an additional therapeutic component beyond usual care.60,62 Care as usual in 

these trials was typically described as allowing the primary care provider their usual discretion 

in treating depression; some studies noted that this could include antidepressant medication, 

counseling, or referral, whereas other studies did not specify the range of options left open to 

providers.

Participants receiving brief CBT for depression were more likely than participants receiving a 

control treatment to have reduced symptoms of depression (ES -0.42, 95% CI -0.74 to 

-0.10), but treatment effects differed significantly across studies (Cochran Q = 13.74, p = 0.03, I2

= 56%) (Figure 3). The ES of -0.42 corresponds to an NNT of approximately 4.5. A funnel plot 

did not suggest significant publication bias, but with only six studies, this method has limited 

power to detect publication bias. To examine the moderate level of variability present, we 

conducted an influence analysis. In this analysis, the summary estimate ranged from -0.24 to 

-0.53, with the trial by Wilson63 having the greatest influence. This trial was the only one of 

the six CBT studies to use a waitlist control condition as the comparator. Based on a priori 

hypotheses of variables that might influence the effect size estimate, we conducted two 

sensitivity analyses: in the first, we removed poor-quality studies from the meta-analysis; in the 

second, we removed both poor-quality studies and studies that used nontherapeutic comparator 

conditions (e.g., waitlist) from the meta-analysis. In the meta-analysis with the poor-quality study 

removed,62 brief CBT for depression continued to be significantly more effective than control 

(ES -0.50, 95% CI -0.91 to -0.09), but treatment effects remained significantly heterogeneous 

(Cochran Q = 13.71, p = 0.008, I2 = 71%). With the poor-quality study62 and the study with a 

waitlist comparator63 removed, treatment effects of brief CBT for depression were smaller (ES 

-0.24, 95% CI -0.42 to -0.06) but homogeneous (Cochran Q = 1.44, p = 0.70, I2 = 0%). This 

effect size corresponds to an NNT of approximately eight. These results are highly consistent 

with both Cuijpers’45 and Cape’s46 estimates of effect size for brief CBT for the treatment of 

depression.

Figure 3. Meta-analysis of Brief CBT for Depression

Study Name Outcome Statistics for each study Std diff in means and 95% CI

Std diff Standard Relative

in means error p-Value weight

Wilson 1982a Self-report -0.25 0.44 0.57 9.34

Wilson 1982b Self-report -0.23 0.43 0.59 9.73

Wilson 1983 Combined -2.13 0.53 0.00 7.15

Scott 1997 Combined -0.48 0.35 0.16 12.63

King 2000 Self-report -0.34 0.19 0.06 21.47

Simon 2004 Self-report -0.16 0.12 0.18 25.73

Laidlaw 2008 Combined -0.36 0.32 0.26 13.94

-0.42 0.16 0.01

-1.00 -0.50 0.00 0.50 1.00

Favors CBT Favors Control

Meta Analysis
20

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

The 2 studies of PST identified in the primary literature searches and not included in the 

systematic reviews randomized 92 participants to treatment or control, whereas the 6 studies 

of PST covered in the systematic reviews randomized 881 participants. Thus, we did not 

conduct an updated meta-analysis for PST. The two studies of PST identified in the primary 

literature searches were conducted by Mynors-Wallis and colleagues58 and Nezu.59 In a 

good-quality trial involving 71 participants, Mynors-Wallis58 found that adding six sessions 

of PST to antidepressant medication did not significantly enhance outcomes over treatment 

with antidepressant medication alone after 12 weeks (60% recovered versus 67%). They 

also found that after 12 and 52 weeks antidepressant alone was not significantly different in 

effectiveness from PST alone. In a small, fair-quality trial, Nezu59 found eight sessions of PST 

to be significantly more effective in reducing depressive symptoms than either problem-focused 

therapy or a waitlist control at 8 weeks (t = 3.25, p < .01). These results are consistent with 

both Cape’s46 and Cuijpers’45 conclusion that PST is an efficacious option for the treatment of 

depression.

No studies of MBCT were included in the systematic reviews. We identified a single goodquality study of MBCT that met our inclusion criteria.56 This study randomized 30 subjects with 

MDD or subthreshold depression, recruited from a mental health setting, and found 8 sessions 

of MBCT to be more efficacious than treatment as usual at reducing depressive symptoms at 8 

weeks (F = 13.42, p = 0.001). 

Quality of life was too infrequently reported across studies to synthesize into any quantitative 

analyses. The two studies of CBT from the present meta-analysis that included data on quality 

of life did not find significant differences on quality-of-life outcomes between participants in 

the CBT conditions compared to participants in the control conditions.53,57 No other trials from 

the studies identified via the primary literature searches included data on quality of life. The 

frequency with which data on quality of life were reported is considered in Key Question 4.

Key Question 2. For primary care patients with depressive disorders treated 

with a brief, evidence-based psychotherapy, is there evidence that treatment effect may vary by the number of sessions delivered?

Cuijpers45 found a small difference in effect size between psychotherapies of six or fewer 

sessions (ES -0.25, 95% CI -0.48 to -0.02) compared to psychotherapies of seven or more 

sessions (ES -0.36, 95% CI -0.54 to -0.17), but confidence intervals overlapped. Should a more 

adequately powered meta-analysis be possible in the future, the means and confidence intervals 

surrounding these effect sizes leave room for the possibility of a clinically significant difference 

between brief and standard-duration psychotherapies.

Cape46 did not conduct a comparison based on number of psychotherapy sessions delivered, as 

their review was limited to therapies of fewer than 10 sessions in duration. Similarly, because the 

present review included only studies with eight or fewer sessions and there was little variability 

in session number (six to eight), an analysis of whether treatment effect varies by quantity of 

therapy sessions could not be conducted.
21

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Key Question 3. For psychotherapies demonstrating clinically significant 

treatment effects, what are the characteristics of treatment providers (i.e., type 

of provider and training), and what are the modalities of therapy (i.e., individual/

group, face-to-face/teletherapy/Internet-based)?

Of the 15 RCTs evaluating brief therapies, 13 used an individual psychotherapy format, and 

2 relied on a group therapy format. Two of the individual PST treatments and one of the 

individual CBT treatments were conducted over the phone. PST treatment providers included 

psychologists in three studies, nurses in three studies, graduate students in two studies, and other 

health professionals in three studies (e.g., GPs, allied health professionals, social workers). CBT 

treatment providers included psychologists in three studies, graduate students in one study, and 

nonidentified professionals in two studies. The MBCT treatment provider had completed an 

internship under the supervision of an expert MBCT therapist. There was substantial variability 

in the level of detail provided about therapists’ training. Most therapists were noted either as 

having previous experience in the intervention treatment model or as having been trained and 

supervised for study purposes by one of the study’s investigators.

While the number of sessions ranged only from six to eight, there was substantial variance in the 

intensity at which psychotherapies were provided. The most intensive therapy, MBCT, required 

2 hours per week for 8 weeks, whereas multiple PST protocols required only 30-minute sessions 

spaced approximately every other week. Although it would appear that the two were separated 

by a difference of only two sessions, the intensity was different because the MBCT protocol 

specified a total of 16 hours of treatment, whereas the PST protocols specified a total of only 3.5 

hours (first session is typically 1 hour). Three of the CBT protocols consisted of 50- to 60-minute 

sessions, and two consisted of 30- to 35-minute sessions.

Quantitative syntheses to examine differences on the basis of treatment intensity, provider type, 

individual versus group, and telephone versus in-person could not be completed because there 

was not an adequate number of studies in each of these subgroups.

Key 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?

Neither of the two systematic reviews reported on quality of life, social functioning, occupational 

status, patient satisfaction, or adverse treatment effects. Of the 15 RCTs contained in this 

evidence report, 5 reported HRQOL, 5 reported social functioning, 0 reported occupational 

status, 2 reported patient satisfaction with treatment, and 1 reported adverse treatment effects 

(Table 5). The most commonly used measure of quality of life for studies that examined this 

clinical outcome was the SF-36. The one study that reported adverse treatment effects examined 

the side effects of taking psychotropic medication in tandem with psychotherapy.
22

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

Table 5. Key Clinical Outcome Measures

Study Quality of 

life

Social 

functioning

Occupational 

status

Patient 

satisfaction

Adverse 

treatment 

effects

RCTs from systematic reviews

Barrett et al, 200148

and Frank et al., 

20024

Yes, SF-36 NR NR NR NR

Dowrick et al., 20005 Yes, SF-36 NR NR NR NR

Lynch et al., 199749 NR Yes NR NR NR

Lynch et al., 200450 NR NR NR NR NR

Mynors-Wallis et al., 

199551 NR Yes NR Yes NR

Scott et al., 199752 NR NR NR NR NR

Ward et al., 200053

and King et al., 

200054

Yes, EuroQoL Yes NR NR NR

Williams et al., 

200055 and Frank et 

al., 20024

Yes, SF-36 NR NR NR NR

RCTs from primary literature 

searches

Barnhofer et al., 

200956 NR NR NR NR NR

Laidlaw et al., 

200857

Yes, 

WHOQOLBREF

Yes, social 

relationships NR NR NR

Mynors-Wallis et al., 

200058 NR

Yes, Social 

Adjustment 

Scale

NR NR

Yes, 

medication 

side effects

Nezu, 198659 NR NR NR NR NR

Simon et al., 200460

and Simon et al., 

200961

NR NR NR Yes NR

Wilson, 198262 NR NR NR NR NR

Wilson, 198363 NR NR NR NR NR

Abbreviations: NR = not reported, WHOQOL = World Health Organization Quality of Life
23

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

DISCUSSION

Based on our complex systematic review of two recent literature reviews and seven additional 

RCTs not considered in these previous reviews, the collective evidence suggests that six to eight 

sessions of brief CBT or PST for acute-phase treatment in primary care are more efficacious 

than usual care, but effects are modest. However, insofar as usual care consists of treatments 

that are intended to be effective and that may in some cases be “best practice” treatments, usual 

care could represent a more potent control condition than placebo controls used in antidepressant 

trials. Also, there is some evidence to indicate that brief psychotherapy may be more efficacious 

when patients are referred at the discretion of their primary care provider than when patients 

are selected for treatment on the basis of systematic depression screening. We conclude that 

brief psychotherapy may prove an efficacious treatment option for a number of patients with 

depression in VA primary care settings. Because the reviewed studies contained little Veteran 

representation, relied heavily on samples of predominantly middle-aged Caucasian females, 

and frequently excluded patients with complex or comorbid psychiatric conditions, additional 

research is needed to more definitively confirm the effectiveness of brief psychotherapy for 

depression in the Veteran population (Key Question 1).

Whether brief psychotherapies significantly differ in efficacy from standard-duration 

psychotherapies (12 to 20 sessions) is a question that we could not directly address given the 

limited range of session duration (6 to 8) in the 15 studies included in this review. Cuijpers’ 

(2009) review45 found no statistically significant differences between psychotherapies 

delivered in six or fewer sessions compared to psychotherapies delivered over seven or more 

sessions; however, the wide confidence intervals for effect sizes of brief and standard-duration 

psychotherapies leave open the possibility of clinically significant differences (Key Question 2).

Our review found that brief psychotherapies have been provided by an array of trained health 

care professionals, including non–mental health professionals. The efficacious treatments 

included in this review were provided not only by psychologists but also by graduate students, 

nurses, general practitioners, and other allied health professionals who had received training 

and supervision specific to the intervention being conducted. Details about training were sparse, 

meaning that the degree of training necessary to replicate studies’ results is uncertain (Key 

Question 3). Finally, we discovered that effects on occupational status, patient satisfaction with 

treatment, and adverse treatment effects were seldom reported; HRQOL and social functioning 

were more commonly reported but still only considered in less than half the trials examined in 

this review (Key Question 4). 

Depressive disorders cause enormous human suffering and impose a high economic burden. 

Ensuring access to evidence-based treatments for Veterans is critical to the VA mission. The 

current emphasis on evidence-based care management in the VA has the potential to significantly 

enhance the usual care of depression in VA primary care settings, and the Primary Care/Mental 

Health Integration program in the VA represents an important organizational strategy to improve 

access and the quality of mental health care. If the VA were to expand its capability to provide 

brief psychotherapy for primary care patients in the acute phase of depression, this too has the 

potential to improve access and quality. Fewer sessions would mean that the same workforce 

could provide treatment to a larger number of patients, potentially more cost-effectively. In 
24

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

addition, clinicians from a variety of disciplines, if given adequate training and under appropriate 

supervision, may be able to provide brief therapies, further expanding access. Although the exact 

training was often incompletely described, many studies used focused training with non–mental 

health specialists, followed by fidelity monitoring to ensure quality. Fidelity monitoring may 

be a key component of replicating the positive treatment effects, particularly with generalist 

clinicians. Within the VA, a range of providers could be considered, including nurses, nurse 

practitioners, primary care physicians, social workers, and chaplains. However, given the current 

nursing shortage and high demands on primary care physicians, any change or expansion in roles 

would need to be considered carefully.

If non–mental health professionals were to assume the role of providing brief therapies, 

patients should be screened carefully for those without high complexity, and oversight should 

be provided by qualified mental health professionals to ensure the safety of the patient. In 

the VA, integrated primary care/mental health teams often consist of primary care clinicians, 

psychiatrists, psychologists, and nurses and may provide an ideal context and support system in 

which to implement such a model. 

One of our key questions was to assess how frequently key clinical outcomes were assessed. 

Review results revealed a striking lack of consistency in assessing and reporting important 

outcome measures. Of the 15 RCTs contained in this review, only 5 reported HRQOL, 5 

reported social functioning, 0 reported of occupational status, 2 reported patient satisfaction 

with treatment, and 1 reported adverse treatment effects. Evaluating the efficacy of treatment is 

clearly important; however, without measuring key clinical outcomes like quality of life, social 

functioning, and occupational functioning, we constrict ourselves to understanding only a very 

limited range of how psychotherapies can impact mental and physical health. 

Strengths and Limitations

Our study has a number of strengths, including a protocol-driven review, a comprehensive 

search, careful quality assessment, and rigorous quantitative synthesis methods. For the included 

systematic reviews, we verified outcomes reported and supplemented the descriptions of included 

trials by abstracting missing data from the primary publications. We also combined a narrative 

review of recent, good-quality systematic reviews with new meta-analyses when indicated. This 

approach allowed us to capitalize on the strengths and often detailed analyses performed in 

existing reviews while updating those results to include the most recent and relevant studies.

However, several questions still remain. First, the efficacy of brief psychotherapy modalities 

other than CBT and PST could not be determined. Although we had hoped to review a variety 

of interventions, CBT and PST were the only treatments in our review for which more than one 

trial had been completed. Second, it is not clear if efficacy differs by the number of treatment 

sessions. This was a key question for our review that we were unable to answer. For CBT and 

PST, six to eight sessions has a small, beneficial effect compared to usual care, but a lower bound 

or dose-response relationship could not be determined. Third, the studies included in this review 

were composed primarily of Caucasian, middle-aged females. This limits applicability to the 

VA and to many other segments of society. Research is needed to evaluate whether results are 

applicable across diverse populations. Fourth, it remains unclear whether the efficacy of brief 
25

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

psychotherapies varies according to depression severity (i.e., mild, moderate, severe). Fifth, 

major intervention outcomes (e.g., quality of life, social functioning, occupational status) are 

measured too infrequently. While these outcomes are often considered “secondary,” they are 

critical in evaluating the safety and generalizability of treatments for real-world practice. 

Despite these limitations, it appears that brief psychotherapy is effective in primary care settings

in the acute-phase treatment of depression. Increasing the availability of psychotherapy, either 

through enlarging the pool of mental health professionals or by training non–mental health 

professionals, will advance the VA toward its mission of providing easy access to care for 

Veterans.64

Conclusions

We identified two systematic reviews and 15 trials of brief psychotherapy (i.e., ≤ 8 sessions) 

for depression, encompassing 1716 patients with MDD or depressive symptomatology. Both 

systematic reviews concluded that brief CBT and PST are efficacious for the acute-phase 

treatment of depression in primary care. This conclusion was corroborated by our analyses that 

included seven additional studies. Table 6 summarizes the strength of evidence for the question 

of whether brief psychotherapies are more efficacious than control for depressive symptoms. 

GRADE criteria were not applicable to the other key questions.

Table 6. Summary of the Strength of Evidence for Key Question 1

Number of 

studies 

(subjects)

Domains pertaining to strength of evidence

Magnitude of effect 

and strength of 

evidence

Risk of Bias:

Design/Quality

Consistency Directness Precision Standardized mean 

difference (95% CI)

Key Question 1: Efficacy of brief psychotherapies

Brief CBT

6 (713)

RCTs/Fair Consistent Direct Some 

imprecision

-0.42 (-0.10 to -0.74)

Moderate

Brief PST

8 (973)

RCTs/Good Consistent Direct Some 

imprecision

-0.26 (-0.49 to -0.30)

Moderate

MBCT

1 (30)

RCT/Good NA Direct Serious 

imprecision

Low

Other therapies NA NA NA NA Insufficient
26

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

FUTURE RESEARCH

The present review confirmed that brief psychotherapies (i.e., ≤ 8 sessions), such as brief 

CBT and brief PST, are efficacious as acute-phase treatments for depression. However, many 

questions remain to be answered about the effectiveness of brief psychotherapy. First, future 

research should rigorously test whether brief psychotherapies are of comparable efficacy to 

standard-duration psychotherapies (i.e., 12 to 20 sessions). This question was not directly tested 

by any trials in our review. Hence, our analysis of this question relied on pooled comparisons 

of various treatment durations from different trials, a method that is vulnerable to multiple 

confounders. Future research should include RCTs that compare psychotherapies that differ 

according to the number of sessions.

Existing research has also been limited by an inadequate consideration of patient outcomes. 

Accordingly, we advise future researchers to assess longer term outcomes after the conclusion 

of brief psychotherapies (e.g., 6 months or longer). Researchers should also assess a broader set 

of outcomes, such as social functioning, occupational status, and quality of life, instead of solely 

assessing depression severity. Quality-of-life measures are especially desirable as these allow 

for the computation of cost-effectiveness and cost-utility ratios, which are crucial for informing 

policy decisions. 

Another priority for future research should be to evaluate whether the administration of brief 

psychotherapies in primary care settings actually produces the benefits that proponents claim. 

These include claims that (1) brief psychotherapies provided in the primary care context reduce 

the stigma of receiving treatment for mental health problems, (2) providing brief psychotherapies 

broadens the population that will initiate and complete treatment by placing a lower time burden 

on patients, and (3) brief psychotherapies increase the cost-effectiveness of psychotherapy. 

Proponents have also claimed that brief psychotherapies can be used to prevent the development 

of MDD in at-risk patients, such as patients with minor depression. These hypotheses should be 

tested empirically. 

Finally, it is crucial to assess which types of brief psychotherapies can be provided with high 

treatment fidelity and efficacy and by which types of providers. Additional studies are needed 

to determine whether brief psychotherapies other than CBT and PST are efficacious. Also, an 

important consideration to be assessed is patient preferences for different treatment modalities 

and providers. Further, more research is needed to determine which providers are best suited 

to provide brief therapies. In the VA, these providers could include not only mental health 

professionals like psychologists, psychiatrists, and social workers but also appropriately trained 

and supervised registered nurses, nurse practitioners, physician’s assistants, primary care 

physicians, and chaplains. 

The VA has been a leader in fostering models of integrated primary care and mental health care, 

and in doing so, the VA is in a unique position to address many of the previously stated research 

needs within the context of integrated health care teams.
27

Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

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