Evidence-based Synthesis Progra

(ESP)

Brief Psychotherapy for Depression: 

from a Systematic Review and Implifrom

a Systematic Review and Impli

for Primary Care

Jason A. Nieuwsma, PhD

Associate Director, VA Mental Health & Chaplain

Assistant Professor, Duke University Medical CenAssistant Professor, Duke University Medical Cen

VA Mid-Atlantic MIRECC, Durham, NC

Jo a s J , hn W. Willi

a

m

s

Jr.

, MD

Director, Durham ESP Center

Professor of Medicine and Psychiatry, Duke University Me

Durham VA Medical Center, Durham

, NC

, ,

April 5, 2011
Evidence-based Synthesis Progra

(ESP)

Acknowledgements

CoAuthors/Collaborators

o Jason A. Nieuwsma, PhD (PI)o John W. Williams Jr.

, MD 

Expert Panel/Re

o Linda Hump

,

o Brad Karlin

, 

(Durham ESP Center Director)

o Ranak B. Trivedi, PhD

,

o Neil Korsen, o David Steffe

o Ranak B. Trivedi, PhD

o Wendy Tenh

o Jennifer McDuffie, PhDo Ian Kronish, MDo Dinesh Benjamin MD

o Wendy Tenh

o Dinesh Benjamin, MD

Medical Editor

Li Wing MA

o Liz Wing, MA
Evidence-based Synthesis Progra

(ESP)

Disclosure

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

-b

Synthesis Program (ESP) Center located at the Durham VA MDurham, NC funded by the Department of Veterans Affairs, V

Health Administration Office of Research and Development Health Administration, Office of Research and Development, 

Services Research and Development. The findings and concldocument are those of the author(s) who are responsible for 

the findings and conclusions do not necessarily represent the the findings and conclusions do not necessarily represent the 

Department of Veterans Affairs or the United States governmTherefore, no statement in this article should be construed as 

position of the Department of Veterans Affairs No investigatposition of the Department of Veterans Affairs. No investigat

affiliations or financial involvement (e.g., employment, consuhonoraria, stock ownership or options, expert testimony, gran

i d di lti ) th t fli t ith t i l 

receive

d or pending, or royalties

) th

a

t confli

c

t with ma

terial p

the report.
Evidence-based Synthesis Progra

(ESP)

VA Evidence-based Synthesis (E

Program Overview Program Overview

• Sponsored by VA Office of R&D and HSR&D.• Established to provide timely and accurate Established to provide timely and accurate

syntheses/reviews of healthcare topics identified clinicians, managers and policy-makers, as they wimprove the health and healthcare of Veterans improve the health and healthcare of Veterans. 

• Builds on staff and expertise already in place at th

Evidence-based Practice Centers (EPC) designate

Four of these EPCs are also ESP Centers: 

o Durham VA Medical Center; VA Greater Los Angeles 

System; Portland VA Medical Center; and MinneapoliSystem; Portland VA Medical Center; and Minneapoli

Center.
Evidence-based Synthesis Progra

(ESP)

• Provides evidence syntheses on important clinica

topics relevant to Veterans, and these reports hel

o d l li i l li i i f d b id develop cli

nical poli

cies in

forme

d

by evidence, 

o the implementation of effective services to impro

outcomes and to support VA clinical practice guid

performance measures, and 

o guide the direction for future research to addres

clinical knowled

ge.

• Broad topic nomination process – e.g. VACO, VISN

facilitated by ESP Coordinating Center (Portland) 

online process: online process:

http://www.hsrd.research.va.gov/publications/esp/TopicNom
Evidence-based Synthesis Progra

(ESP)

• Steering Committee representing research and op

(PCS, OQP, ONS, and VISN) provides oversight an

program di ti rec on.

• Technical Advisory Panel (TAP)

o Recruited for each to

pp p ic to 

provide content ex

pe

o Guides topic development; refines the key questo Reviews data/draft report.

• External Peer Reviewers & Policy Partners External Peer Reviewers

& Policy Partners

o Reviews and comments on draft report

• Final reports posted on VA HSR&D website and di

widely through the VA. 

http://www.hsrd.research.va.gov/publications/esp/repor
Evidence-based Synthesis Progra

(ESP)

Current Report

Brief Psychotherapy for Depressio

Primary Care: A Systematic Review Primary Care:

A Systematic Review 

Evidence

(February 2011) (February 2011)

Full-length report available on ESP website:http://www hsrd research va gov/publications/esp/brief-psychotherapy cfmhttp://www.hsrd.research.va.gov/publications/esp/brief-psychotherapy.cfm
Evidence-based Synthesis Progra

(ESP)

Cyber Poll

1. Do you provide psychotherapy?

a. Yesb. No
Evidence-based Synthesis Progra

(ESP)

Cyber Poll

2. Among psychotherapy practitioners, what is the 

number of sessions that you provide to patients?

2. 1-33. 4-84. 9-115. 12-166. 17-207. 21-308. 31+
Evidence-based Synthesis Progra

(ESP)

Background

• Depression is a major public health concern.

o High prevalence rateso Common among Veteranso Primary care is frontline of treatment

• Efficacious treatments are available.

o Ph th armacotherapyo Psychotherapy
Evidence-based Synthesis Progra

(ESP)

Background

• Psychotherapy may have unique benefits.

o Patient preferenceo Medication alternative Medication alternativeo Additive benefit w/ medicationo Cost-effectivenesso Relapse prevention Relapse prevention

• Psychotherapy is underutilized in primary care se

o Space constraintso Lack of adequately trained workforceo Intervention fit 
Evidence-based Synthesis Progra

(ESP)

Background

• Brief psychotherapy (i.e., 

≤ 8 sessions) may fit be

p y rimar care than standard-duration 

( , i.e.

, 12-20 s

o Six is the new “brief.”o Man

yp p atients won’t com

plete 12-20 sessions.

• Current Review:

o Are brief psychotherapies efficacious?o NOT: Should all psychotherapy be brief?
Evidence-based Synthesis Progra

(ESP)

Methods

1. Topic development2. S

ystematic searches for literature

3. Study selection4. Data abstraction Data abstraction5. Quality Assessment6. Data Synthesis Data Synthesis7. Peer Review
Evidence-based Synthesis Progra

(ESP)

Key Questions

• Key Question 1: For primary care patients with de

disorders, are brief, evidence-based psychotherap

durations of up to eight sessions more efficacious durations of up to eight sessions more efficacious 

control for depressive symptoms (i.e., on self-repclinician-administered measures) and quality of li

functional status and/or health functional status and/or health

-related quality of 

related quality of 

• Key Question 2: For primary care patients with de

di d t t d ith b i f id disor

ders 

trea

t

e

d with a 

b

rie

f, evidence-b d ase

d

psychotherapy, is there evidence that treatment evary by the number of sessions delivered? 
Evidence-based Synthesis Progra

(ESP)

Key Questions

• Key Question 3: For psychotherapies demonstrat

clinically significant treatment effects, what are t

characteristics of treatment providers (i.e., type ocharacteristics of treatment providers (i.e., type o

and training), and what are the modalities of therindividual/group, face-to-face/teletherapy/Inter

• Key Question 4: How commonly reported are the 

outcomes of quality of life, social functioning, occ

st t ti t ti f ti d d t t 

t

a

tus, patien

t sati

s

faction, an

d a

dverse 

trea

tmen

randomized trials of psychotherapy? 
Evidence-based Synthesis Progra

(ESP)

Literature Flow: Systematic Revi

560 references identified by literature search for systematic reviews (S

32 references identified for full-text review 

528 excluded at title/abstract level

30 excluded:

Population not of interest (15)Intervention not of interest (11)

N t SR RCT (3)

2 SRs identified for inclusion

N

ot SR or RCT (3)

Comparator not appropriate (1)

2 SRs identified for inclusion
Evidence-based Synthesis Progra

(ESP)

Literature Flow: Randomized Controll

866 references identified by literature search for RCTs

Internet databasea (243)

Online databasesb (516)

Bibliographies (107)

774 excluded at title/abstract level

(for Internet database, 185 excluded using database 

variables, and 27 excluded using title/abstract)

92 references identified for full-text review 

74 excluded:

Population not appropriate (22)

Comparator not appropriate (16) Comparator not appropriate (16)More than 8 sessions (19)Intervention not of interest (11)Not RCT or peer-reviewed (3)Outcome not appropriate (3)

18 articles representing 15 unique studies
Evidence-based Synthesis Progra

(ESP)

Inclusion/Exclusion Criteria
Evidence-based Synthesis Progra

(ESP)

Results: Study Characteristic

• Systematic Reviews (2)

o Cuijpers et al. (2009) reviewed 15 RCTs, 7 of which exam

p y py s

ychotherapy of 

≤ 6 sessions

o Cape et al. (2010) reviewed 34 RCTs, all of which examine

psychotherapy of < 10 sessions

• Randomized Controlled Trials (15 total, 7 new)

o 8 PST, 6 CBT, & 1 MBCTo 6-8 sessionso Conducted mainly in U.S. & U.K.o 11 in PC and 4 in MH outpatiento Middle-aged, Caucasian females with mixed depression
Evidence-based Synthesis Progra

(ESP)

KQ #1 Results: Efficacy

• CBT and PST had small but statistically significan• Health

-related quality of life (HRQOL) was report

related quality of life (HRQOL) was report

infrequently to synthesize quantitatively.

• A new meta A new meta

-analysis of CBT for depression was ju

analysis of CBT for depression was ju

• Systematic Reviews:

o B th b t d fi di i f f CBT d PST B

oth corro

bora

t

e

d fi

ndi

n

gs in 

favor o

f CBT an

d PST.

o Cuijpers et al. (2009): GP referral > systematic screeningo Cape et al. (2010): CBT for anxiety > CBT for mixed depre

anxiety
Evidence-based Synthesis Progra

(ESP)

Meta-Analysis of CBT

All t di ES 0 42 (95% CI 0 74 t 0 10 NNT

4 

All s

t

udies: ES -

0.42 (95% CI -

0.74

to -

0.10; NNT

≈

4

Minus Wilsons: ES -0.24 (95% CI -0.42 to -0.06; NNT 
Evidence-based Synthesis Progra

(ESP)

KQ #2 Results: Number of Sessi

• Range too limited on 15 included RCTs.• C ij t l (2009) C

uijpers e

t al. (2009):

o No statistically significant difference between 6 or less (ES 

CI -0.48 to -0.02

)p ( com

pared to 7 or more 

(ES -0.36, 95% 

0.17).

o Comparisons were indirect.o

There remains the possibility that a true and clinically mea

difference exists between brief psychotherapy (i.e., 6 to 8 standard duration psychotherapy (i.e., 12 to 20 sessions).
Evidence-based Synthesis Progra

(ESP)

KQ #3 Results: Providers & Interve

• Providers included psychologists, social workers, n

general practitioners, graduate students, and allied 

profi l ess onals.

o Only PST included non mental health providerso Current evidence does not suggest than non MH are less ef

Current evidence does not suggest than non MH are less ef

• Length of treatment varied from 3.5 hours of PST (

across 6 sessions) to 18 hours of MBCT (delivered across

6 sessions) to 18 hours of MBCT (delivered 

sessions). 

• Treatments were delivered 

primaril

y in individual

, 

py ,

sessions; however, two studies used group therapystudies use telephone-based psychotherapy. 
Evidence-based Synthesis Progra

(ESP)

KQ #4 Results: Outcome Measu

1214

8

10

4602

Quality of Social Occupational Patient AdQuality of

life

Social

functioning

Occupational

status

Patient

satisfaction

Ad

trea

ef
Evidence-based Synthesis Progra

(ESP)

Discussion

• CBT and PST more efficacious than usual care• Comparator conditions may partially account for 

eff t i ec

t sizes

• GP referral rather than depression screening

• VA i i t d t d lit f MH 

VA mission 

to expan

d access 

to an

d quality o

f MH

o Brief psychotherapy consistent with aims of PCMHI o Fewer sessions means same workforce can treat more pat

Fewer sessions means same workforce can treat more pat

more patients may be willing to accept psychotherapy

o A range of providers, sufficiently trained and supervised, c

considered for work with appropriate patient populations
Evidence-based Synthesis Progra

(ESP)

Conclusions

• Identified 2 systematic reviews and 15 RCTs of br

psychotherapy (i.e., 

≤ 8 sessions) for depression

• 1716 patients included
Evidence-based Synthesis Progra

(ESP)

Limitations

• Indirect comparisons

o Number of treatment sessionso Types of providero Types of psychotherapy

• Only two psychotherapies reviewed• Demographically homogeneous• Missing key clinical outcome measures
Evidence-based Synthesis Progra

(ESP)

Future Research

• Head-to-head brief vs. standard duration psychot• Head-to-head for depression severities• Beyond middle Beyond middle

-aged Caucasian females aged Caucasian females

• Beyond CBT and PST• Be

y p yp y ond measures of de

pressive s

y

m

ptom severity

• Training & supervision needed for non MH profess• Do brief psychotherapies deliver as promised?

o Reduce sti

gma in PC?

o Broaden pt population?o Increase cost-effectiveness?

o Prevent development of MDD?
Evidence-based Synthesis Progra

(ESP)

Questions?

If you have further questions, 

feel free to contact:

Jason A. Nieuwsma, PhD

919

-286

-0411 x6436 0411 x6436

Jason.Nieuwsma@va.gov

The full report and cyberseminar presentation is available on the 

http://www.hsrd.research.va.gov/publications/esp/