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

EXECUTIVE SUMMARY

BACKGROUND

The individual and societal burden of depressive disorders is widely acknowledged, but treating 

these disorders remains challenging. Clinical guidelines recommend that both pharmacotherapy 

and psychotherapy should be considered as first-line treatments. Yet, because primary care 

settings are often the frontline of treatment, pharmacological treatments take precedence. In 

part, this may be due to the perception that psychotherapy is lengthy and time intensive, with 

guidelines recommending 12 to 20 1-hour sessions for most evidence-based psychotherapies. 

However, recent evidence seems to suggest that psychotherapies that are briefer in both duration 

and intensity may be efficacious in acute-phase treatment. If true, these briefer psychotherapies 

may be more easily integrated in primary care settings. Thus, we conducted a systematic review 

of the peer-reviewed literature to answer the following key questions:

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?

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. 

METHODS

We utilized a combined approach, identifying and evaluating existing systematic reviews and 

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

in these reviews. First, we searched for relevant, good-quality, English-language systematic 

reviews in MEDLINE® (via PubMed®), Embase®, and PsycINFO® from database inception 

through May 2010. Two good-quality systematic reviews were identified and evaluated for this 

report. Second, we used a well-documented Internet-accessible database of psychotherapy trials 

(www.psychotherapyrcts.org/index.php?id=3) that was current through January 2010. We used 
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

this database of 243 trials as a data source for original research, searching 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. Finally, we searched for English-language publications in MEDLINE 

(via PubMed), PsycINFO, and Embase, from January 2009 (one year prior to the search date 

of the online database) through August 1, 2010. We supplemented electronic searching by 

examining the bibliographies of included studies and review articles. 

Primary research articles were included if they were RCTs and included adults with major 

depressive disorder (MDD), dysthymic disorder, or subthreshold (minor) depressive disorder in 

acute-phase treatment. Relevant psychotherapy modalities included cognitive behavioral therapy 

(CBT) (including cognitive therapy and behavior therapy), interpersonal therapy (IPT), problemsolving 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 eight or fewer planned sessions. Eligible comparators of active 

treatment included waitlist control, attention control, usual care, or antidepressant medication 

if the intervention included a combination of psychotherapy and an antidepressant medication. 

Patients had to be recruited from outpatient general medical or mental health clinics located in 

North America, Western Europe, New Zealand, or Australia for the greatest generalizability to 

the Veteran population. Finally, RCTs were required to measure depressive symptoms using a 

validated instrument reported at 6 weeks or more after randomization.

Quality of the systematic reviews was rated using 12 design-and-reporting characteristics and 

summarized as “good,” “fair,” or “poor.” Quality and risk of bias of the RCTs were rated good, 

fair, or poor using the Agency for Healthcare Research and Quality (AHRQ) criteria. Data 

were synthesized both in narrative form and via updated meta-analysis where it appeared that 

the primary literature was sufficient to facilitate an updated effect size. All results are reported 

such that a negative effect size indicates greater reduction in depressive symptoms for the 

intervention compared to the control condition. We graded the strength of evidence for each key 

question using principles from the Grades of Recommendation, Assessment, Development, and 

Evaluation (GRADE) Working Group. 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.

RESULTS

Using the combined literature search, 560 potential systematic reviews were identified. From 

these, two eligible reviews were retained. The first review completed a good-quality metaanalysis of 15 studies that examined psychotherapeutic interventions for depression in primary 

care. The second review 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.

Our search of the primary literature yielded 243 references from the Internet-accessible database 
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Brief Psychotherapy for Depression in Primary Care Evidence-based Synthesis Program

of psychotherapy trials and 516 citations from the search of PubMed, PsycINFO, and Embase. 

After excluding ineligible articles, our search identified eight unique trials from the two included 

systematic reviews and seven unique trials from our primary literature search. The brief therapies 

evaluated were PST (eight studies), CBT (six studies), and MBCT (one study). Interventions 

were monitored for treatment fidelity in nine studies. Study participants were predominantly 

middle-aged, female, and Caucasian.

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)?

The systematic reviews found that, compared to control, brief psychotherapies had a small but 

statistically significant benefit, with effect size estimates ranging from -0.33 to -0.25. Only CBT 

and PST were evaluated as brief therapies. Findings from the systematic reviews were consistent 

with the meta-analysis that we conducted on six trials of CBT, which showed that six to eight 

CBT sessions were more efficacious than control (ES -0.42, 95% CI -074 to -0.10), but results 

were statistically heterogeneous (I2 = 56%). A sensitivity analysis excluding a poor-quality 

study and one with a waitlist control showed homogeneous but smaller treatment effects (ES 

-0.24, 95% CI -0.42 to -0.06, I2 = 0%). Health-related quality of life (HRQOL) was reported too 

infrequently to synthesize quantitatively.

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?

One of the systematic reviews completed a meta-analysis showing no statistically significant 

difference in efficacy between psychotherapies of more than six sessions (ES -0.36, 95% CI 

-0.54 to -0.17) compared to those of six or fewer sessions (ES -0.25, 95% CI -0.48 to -0.02). 

Because confidence intervals overlapped and comparisons were indirect, there remains the 

possibility that a true difference in efficacy between brief and standard-duration psychotherapies 

(i.e., 12 to 20 sessions) could exist and that it could be clinically meaningful. Current evidence is 

inadequate to answer this question. 

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)?

Treatment providers and modalities varied across studies. Providers included clinical psychologists, 

social workers, nurses, general practitioners, and graduate students trained specifically to deliver 

the treatment as prescribed in the study protocol. Length of treatment varied from 3.5 hours of 

PST (delivered across six sessions) to 18 hours of MBCT (delivered across eight sessions). Finally, 

treatments were delivered primarily in individual, face-to-face sessions; however, two studies relied 

on group therapy, and one trial relied on telephone-based psychotherapy. 

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

Of the 15 RCTs evaluating brief psychotherapies, 5 reported HRQOL, 5 reported social 

functioning, 0 reported occupational status, 2 reported patient satisfaction with treatment, and 

1 reported adverse treatment effects. 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.

FUTURE RESEARCH RECOMMENDATIONS

Several questions may be answered by future studies. First, brief psychotherapies (i.e., ≤ 

8 sessions) compared to standard-duration psychotherapies (i.e., 12 to 20 sessions) did not 

significantly differ in their effect sizes, but these comparisons were based on relatively few 

studies and indirect comparisons, and thus direct comparisons in RCTs would be needed 

to answer this question definitively. Second, our review found that brief psychotherapies 

have been provided by an array of trained health care professionals, including non–mental 

health professionals. Because descriptions of training were incomplete, the degree of training 

necessary to replicate findings from these studies is uncertain. Third, 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. Therefore, future research should 

aim to include these secondary but important clinical outcomes. Fourth, evidence regarding brief 

therapies other than CBT and PST was nonexistent or sparse. Finally, further research needs 

to expand participants beyond the mostly middle-aged, female, Caucasian subjects included in 

studies to date. 

CONCLUSIONS

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

RCTs, the collective evidence suggests that six to eight sessions of brief CBT or PST are more 

efficacious than control for the treatment of depression in primary care; however, the effects 

are modest (moderate strength of evidence). Current evidence suggests that these treatments 

might be effectively delivered by providers of various professional disciplines, provided they 

receive adequate training and supervision. This may be important in terms of balancing cost to 

the Veterans Health Administration with access to mental health treatment among Veterans. As 

the VA moves to the Patient-Aligned Care Team model of the patient-centered medical home, 

it is encouraging to find empirical evidence to support the provision of brief psychotherapy in 

primary care.