32

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

APPENDIX A: SEARCH STRATEGY

Primary Literature (January 2009 through July 2010)

Final limits: Human, Adult, 19+ years, English, Randomized Controlled Trial, Publication date 

from January 1, 2009 to July 31, 2010.

Step Terms Result

1. Replication of Cuijpers 

database therapy terms

Behavior therapy OR biofeedback OR cognitive analytic therapy PR 

counseling OR family therapy PR marital therapy PR psychoanalytic 

therapy OR psychotherapy PR relaxation therapy

1822

2. Replication of Cuijpers 

database depression terms

“depressive disorder”[MeSH Terms] OR (“depressive”[All Fields] 

AND “disorder”[All Fields]) OR “depressive disorder”[All Fields] 

OR “depression”[All Fields] OR “depression”[MeSH Terms] OR 

depressive[All Fields]

1152

3. Addition of other terms for 

types of therapy of interest 

for this report

Interpersonal therapy OR problem-solving therapy OR mindfulnessbased cognitive therapy OR cognitive behavioral analysis system 

of psychotherapy OR dialectical behavior therapy OR functional 

analytic psychotherapy OR acceptance and commitment therapy

178

4. Final search (#1 OR #3) AND #2 383

Systematic Reviews 

Final limits: English, All Adult: 19+ years, Systematic Reviews, Publication date from 2000.

Step Terms Result

1 Search ((“depressive symptoms”[All Fields]) OR (“Depression”[Mesh] OR “Depressive 

Disorder”[Mesh]) OR (depression)) 

51523

2 Search (minor AND depression) OR (subthreshold AND depression) OR (subsyndromal 

AND depression)

3689

3 Search major depressive disorder[mesh] 64244

4 Search dysthymia OR dysthymic disorder[mesh] 2407

5 Search adjustment disorder[mesh] 3615

6 Search 1 OR 2 OR 3 OR 4 OR 5 69903

7 Search ((cognitive behavioral therapy OR CBT OR cognitive therapy OR behavior 

therapy OR interpersonal therapy OR IPT OR problem-solving therapy OR PST OR 

mindfulness-based cognitive therapy OR MBCT OR (“cognitive behavioral analysis 

system” AND therapy) OR CBASP OR dialectical behavioral therapy OR DBT 

OR functional analytic psychotherapy OR FAP OR (acceptance AND commitment 

AND therapy) OR ACT OR short-term psychodynamic therapy) OR (psychotherapy, 

brief[mesh]))

297485

8 Search Cochrane Database Syst Rev [TA] OR search[Title/Abstract] OR metaanalysis[Publication Type] OR MEDLINE[Title/abstract] OR (systematic[Title/Abstract] 

AND review[Title/Abstract])

159125

9 Search 6 AND 7 AND 8 341
33

sion in Primary Care Evidence-based Synthesis Program

DENCE TABLES

sychotherapy for Depression in Primary Care

argus, et al., 2009

ants Interventions Results and Adverse Effects

Comments/Quality Scoring

D): 42

 42.07 (11.34)

1.79 (9.52)

NR

8 to 65

on: 

D)

 16.38 (3.04)

5.21 (3.19)

n (%): 19 of 28 (68%)

 10 of 14 (71%)

 of 14 (64%)

hnicity: NR

s: NR

e depression assessment(s): 

: DSM-IV: Chronic MDD n (%) 

 7 (50%)

2 (85%)

 100% score: mean (SD)

T: 29.36 (9.66)

31.32 (10.79)

ty: 20+ years for current

sodes: At least 3 prior episodes 

yr

Intervention description:RCT of 2 arms:

1. MBCT: 14 participants2. TAU: 14 participants

Depression intervention(s):Behavioral interventionType: MBCT for 8 sessions of 2-hr duration delivered via manual (Segal, 2002) modified for suicidality with homework of mindfulness practice 1 hr per day, 6 days per wkDelivery: GroupIntensity: 8 weekly 2 hrFidelity monitoring: YesOther notes about intervention:All on some type of antidepressantTherapistDiscipline: CBTExperience: NRTraining: internship at the Center for Mindfulness in Medicine, University of MassachusettsComparator: Behavioral controlType: TAUDelivery: MixedIntensity: MixedFidelity monitoring: NoOther notes about control: All on some type of antidepressantCointervention—psychotropic drugs: None

Eligible randomized: 31 of 34 (91%)Followup rate: Total: 28 of 31 (90%) MCBT: 14 of 16 (86%) TAU: 15 of 16 (94%)Important baseline differences:Presence of chronic depression higher in TAU (n = 12) versus MBCT (n = 7), p = 0.04Depression outcomes:BDI-IIResponse rates n (%):BDI fell to < 13

MBCT: 6 (37)

 TAU: 1 (6) P = 0.04Change in diagnosis:

MBCT: 7 of 10

 TAU: 2 of 11 P = 0.03Severity score: mean (SD) MBCT: 17.62 (10.94) TAU: 28.86 (12.97)HRQOL outcomes: NROther outcomes: Social: NoOccupational: NoSatisfaction: NoSuicidal ideation: Yes 

Generalcomments:Stats were LOCF – now frowned upon in favor of modeling or imputationStudy-level quality assessment: GoodAssessment of adverse effects adequate? YesApplicability:- High education- Mostly women
34

sion in Primary Care Evidence-based Synthesis Program

argus, et al., 2009

ants Interventions Results and Adverse Effects

Comments/Quality Scoring

d psychiatric conditions: 

ubstance abuse: Excluded

sorder: 

: 4 (28%)

6 (42%)

R

e attempt: 8 (56%)

: 4 (28%)

4 (28%)

d chronic medical conditions: 

n criteria: 

y of 3 episodes MDD 

nt MDD or subthreshold MDD

y of suicidality

nce of other severe mental 

 diagnosis, especially self-harm

uate written and oral English

urrently in treatment

18 to 65

n criteria: NR

Treatment discontinuation rate: 3 (9.7%)Adverse effects: None reported related to intervention
35

sion in Primary Care Evidence-based Synthesis Program

Toner, et al., 2008

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

D)

4 (8.39)

4.05 (7.62)

NR

NR

n:

D)

0.10 (1.74)

9 (1.29)

 (%):

 (60%)

8 (85%) 

nicity: NR

: NR

 depression 

ent(s): 

9.6 (5.22)

9.5 (5.48)

6 (2.7)

5 (3.55)

s

.4 (3.08)

.8 (2.84)

 MDD

NR

y: NR

odes: NR

Intervention description:Two arms:

1. CBT: 21 participants2. TAU: 23 participants

CBT followed conceptual model and protocol developed by Beck. TAU was as close to standard care as possible. No restrictions on type of treatment; also, no treatment was allowed if GP thought appropriate.Depression intervention(s):Behavioral interventionType: CBTDelivery: Mean 8 sessions (SD = 4.7, range 2 to 17)Intensity: NR (assumed weekly since adhering to Beck’s protocol)Fidelity monitoring: Yes, audiotaped and rated with Cognitive Therapy Rating Scale by cognitive therapy expertsOther notes about intervention: Assumption is that the sessions were weekly given that they said they adhered to Beck’s model, in which case post results should approximate 8 sessions; however, frequency of sessions not provided.TherapistDiscipline: PsychologyExperience: NRTraining: Master’s level (except for one who was graduate level with several years of experience)

Eligible randomized: 61% (based 

on Figure 1, 115 referred, 28 + 44 eligible, 44 randomized)Followup rate: 40 (90.9%)Important baseline differences:Gender (TAU had higher percentage of female; CBT had higher percentage of male)Depression outcomes:Response rates:  CBT: 20 TAU: 20

BDI

CBT TAU F, p

Post treatment

9.4 (8.56)

13.25 (10.3)

1.65 0.21

3 mo 9 

(8.16)

12.9 (9.34)

1.98 0.17

6 mo 10.55 

(9.05)

15.10 (11.83)

1.87 0.18

GDS

CBT TAU F, p

Post treatment

3.85 (3.83)

5.3 (3.48)

1.570.22

3 mo 5 

(3.71)

4.9 (3.35)

0.0080.93

6 mo 5.05 

(3.46)

5.75 (3.72)

0.380.54

General comments:

- Adequate randomization- Missing data adequately addressed- Blinding not possible given intervention but assessors were blinded- No concerns regarding selective outcome reporting- No conflicts of interestStudy-level quality assessment FairComments: - Small sample size- Missing information from the protocol that would allow evaluation of applicability to our questionAssessment of adverse effects adequate? UnclearApplicability:

To general population:YesTo Veterans: YesLimitations: - Not enough information on disease severity- Intensity of therapy not given- UK primary care may differ from US
36

sion in Primary Care Evidence-based Synthesis Program

Toner, et al., 2008

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

d psychiatric 

ns: 

ubstance abuse: NR

R

xiety disorder: NR

is I disorder: CBT-2 

(30%)

d chronic medical 

ns: 

D)

.26 (1.2)

.2 (0.83)

s not specified

n criteria: 

60 or over

DSM-IV criteria for 

 using the SADS-L 

ured interview

-D = 7-24

I = 13 to 28

provide written consent

prescribed 

epression medication 

n 3 mo of referral to 

n criteria:

ficient knowledge of 

sh

E < 22

ived more than 6 

ons of CBT in the 

or currently receiving 

hological therapy

Comparator: Behavioral controlType: TAUDelivery: Standard careIntensity: At GP’s discretionFidelity monitoring: Yes, checking GP notes at the end of study and asking participants about treatment received; however, no adherence data since there were guidelines given to GPsOther notes about control: 16 (80%) received medicationsCointervention—psychotropic drugs:Drug name/dose: None provided by the studyClinician discipline: NA

HAM-D

CBT TAU F, p

Post treatment

5.25 (4.48)

7.75 (6.05)

2.20.15

3 mo 5.15 

(4.75)

6.7 (6.23)

.780.38

6 mo 6.7 

(5.03)

7.55 (6.13)

.230.63

HRQOL outcomes:WHOQOL Physical Subscale

CBT TAU F, p

Post treatment

22.4 (5.02)

19.85 (4.34)

0.29 0.59

3 mo 21.6 

(3.66)

20.75 (5.3)

0.020.9

6 mo 21.35 

(5.34)

20 (5.69)

.0.75 0.39

WHOQOL Psychological Subscale

CBT TAU F, p

Post treatment

20.65 (3.13)

18.15 (3.66)

0.14 0.71

3 mo 19.65 

(2.62)

19.15 (3.13)

0.080.78

6 mo 19.2 

(3.43)

17.75 (3.99)

2.39 0.13

Other outcomes:Social: WHOQOL Social Relationships

CBT TAU F, p

Post treatment

10.05 (2.66)

9.95 (1.4)

1.72 0.09

3 mo 11 

(1.26)

10.55 (1.23)

0.35 0.56

6 mo 10.5 

(1.4)

10.2 (1.47)

0.77 0.44
37

sion in Primary Care Evidence-based Synthesis Program

Toner, et al., 2008

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

Occupational: NR

Satisfaction: NRTreatment discontinuation rate:Withdrew from study at 6 mo followup: CBT: 2 TAU: 4 Adverse effects: NR
38

sion in Primary Care Evidence-based Synthesis Program

h, Day, et al., 2000

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

D)

4 (NR)

T: 35 (NR)NR

nge: 19 to 58

T range: 19 to 62

n:

(25%) > 16 yr

T: 8 (23%) > 16 yr

 (%)

 (86%)

T: 24 (69%)

nicity:

%)

2 (89%)

T: 34 (97%)

: No

 depression 

ent(s): 

 HRSD ≥ 13 71 (100%) probable 

e MDD

ean (95% CI)

0.2 (19.1 to 21.4)

T: 19.8 (18.5 to 21.1)

n (95% CI)

0.2 (27.7 to 32.7)

T: 30.0 (27.3 to 32.6)

Intervention description:Four arms: 

1. Problem-solving treatment 

(PST) alone provided by GP (excluded from this analysis): 39 participants

2. PST alone provided by nurse 

(excluded from this analysis): 41 participants

3. Medication alone (Med): 36 

participants 

4. Medication + PST (MedPST) 

provided by nurse: 35 participants 

Depression intervention(s):Behavioral interventionType: MedPST; PST for use in primary care settings was added to GP prescription of fluvoxamine or paroxetineDelivery: IndividualIntensity: 6 sessions (first session, 1 hr; rest 30 min) over 12 wkFidelity monitoring: NoTherapistDiscipline: Research practice nurseExperience: Participated in previous study as problem-solving therapistTraining: Nursing; trained in PST by study investigatorComparator: Behavioral controlType: Med; GP prescribed fluvoxamine or paroxetine in accordance with practice guidelinesDelivery: IndividualIntensity: NRFidelity monitoring: No

Eligible randomized: 83%

Followup rate: 

N (%) Med 6 wk: 34 of 36 (94%) MedPST 6 wk: 34 of 35 (97%) Med 12 wk: 34 of 36 (94%) MedPST 12 wk: 31 of 35 (89%) Med 52 wk: 30 of 36 (83%) MedPST 52 wk: 30 of 35 (86%)Important baseline differences:NoneDepression outcomes:HRSD Recovered (HRSD ≤ 7): Med 12 wk: 24 (67%) MedPST 12 wk: 21 (60%) Med 52 wk: 20 (56%) MedPST 52 wk: 23 (66%) Severity score mean (95% CI): Med 12 wk: 6.2 (3.7 to 8.6) MedPST 12 wk: 7.5 (5.2 to 9.9) Med 52 wk: 7.2 (5.1 to 9.2) MedPST 52 wk: 5.7 (3.4 to 7.9)BDI mean (95% CI) Med 12 wk: 11.8 (7.8 to 15.8) MedPST 12 wk: 9.3 (6.6 to 12.0) Med 52 wk: 11.5 (6.9 to 16.2) MedPST 52 wk: 8.6 (5.3 to 11.9)CIS mean (95% CI) Med 12 wk: 9.8 (6.1 to 13.5) MedPST 12 wk: 9.6 (6.3 to 12.9) Med 52 wk: 11.5 (7.3 to 5.6) MedPST 52 wk: 9.7 (5.9 to 13.6)

General comments:

PST alone (provided by either GP or nurse) found to be equally efficacious to medication alone, and addition of PST to medication did not result in significant benefitStudy-level quality assessment GoodAssessment of adverse effects adequate? Yes; research interviewers were blindApplicability:

To general population: - Comorbid conditions not reported- Therapists likely more skilled than typical providers- UK treatment settings different than typical US primary careTo Veterans: - Patient sample predominantly female- From UK- Treatment often provided in home
39

sion in Primary Care Evidence-based Synthesis Program

h, Day, et al., 2000

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

ean (95% CI)

9.3 (27.3 to 31.2)

T: 29.0 (26.5 to 31.5)

y:

 (33%) > 6 mo

T: 13 (37%) > 6mo

odes:

: 19(53%)

T ≥ 1: 19(54%)

d psychiatric 

ns: 

ubstance abuse: NR 

)

R (excluded)

xiety disorder: NR 

)

d chronic medical 

ns: NR

n criteria:

spected MDD

ble or definite MDD 

earch diagnostic 

a

D ≥ 13

duration ≥ 4 wk

n criteria:

iatric disorder 

ding MDD onset

urrent MDD treatment

damage

ng difficulties

ophreniadependence

nt alcohol abuse

cal illness 

with psychotic 

es or suicidal intent

Cointervention—psychotropic drugs :Drug name/dose : Fluvoxamine/initial dose 100 mg ; or paroxetine/initial dose 20 mgClinician discipline : GP

HRQOL outcomes: NoneOther outcomes: Social: Yes (social adjustment scale)Occupational: NoSatisfaction: NoTreatment discontinuation rate:  Med: 6 (17%) MedPST: 6 (17%)Adverse effects: N (%) 

 Med medication side effects: 2 (6%) MedPST medication side effects: 4 

(11%)
40

sion in Primary Care Evidence-based Synthesis Program

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

D): 41.73 (12.81)

NR

NR 

on: 

D):15.96 (2.59) yr

n (%)

0 (83%)

7 (78%)

hnicity: NR

s: No

e depression 

ment(s): 

 Research Diagnostic  21 (100%) MDD

3.91 (7.09)

20.67 (5.39)

1.36 (8.12)

78.76 (7.05)

y: NR

sodes: NR

id psychiatric 

ns: 

ubstance abuse: NR 

n criterion)R

xiety disorder: NR

R

Intervention description:Three arms: 

1. Problem-focused therapy (PFT) 

(excluded from this analysis): 11 participants

2. Problem-solving therapy (PST): 

12 participants

3. Waitlist control (WLC): 9 

participants

Depression intervention(s):Behavioral interventionType: PST based on D’Zurrila and Nezu’s (1982) five-component modelDelivery: GroupIntensity: 8 weekly 1.5 to 2 hr sessionsFidelity monitoring: Partial (weekly supervision to ensure adherence to relevant treatment manuals)Other notes about behavioral intervention: Therapist allegiance very likely a confound for PST vs PFT but not for PST vs waitlistTherapistDiscipline: Two psychology graduate studentsExperience: Average 4.5 years supervised psychotherapy experienceTraining: Prior training in group therapy and PST model; weekly supervision from author during treatment period

Eligible randomized: 78%

Followup rate:N (%)  PST 8 wk: 11 of 12 (92%) WLC 8 wk: 6 of 9 (67%) (3 

excluded because entered therapy in interim)

 PST 6 mo: 10 of 12 (83%)Important baseline differences:NoneDepression outcomes:BDI PST 8 wk: 9.82 (4.71) WLC 8 wk: 21.00 (6.27) PST 6 mo: 9.50 (3.64)MMPI-D PST 8 wk: 54.27 (4.62) WLC 8 wk: 76.33 (4.89) PST 6 mo: 52.50 (6.89)HRQOL outcomes: NoneOther outcomes:Social: NoOccupational: NoSatisfaction: NoTreatment discontinuation rate:  PST: 1 (8%)Adverse effects: NR

General comments:

Therapist allegiance to and experience in PST both very highStudy-level quality assessment FairComments: - 33% of WLC excluded from analysis because sought treatment- Outcome assessors were not blind (although clinical interview not used as outcome measure)- Therapist allegiance to PST likely very highAssessment of adverse effects adequate? NoApplicability:

To general population: - Patients recruited through newspaper ads- Therapist skill in and adherence to PST higher than typical clinician- Intensive treatment for PC setting
41

sion in Primary Care Evidence-based Synthesis Program

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

d chronic medical 

ns: NR

n criteria:

ponded to 

rtisement

≥ 16

essive episode ≥ 4 

ks

 Research Diagnostic 

ria for MDD

PI-D T score > 70

n criteria: 

al retardation

hotic symptomatologye substance use

nic brain syndrome

ent MDD treatment

Comparator: Behavioral controlType: WLC invited to receive treatment at the end of 8-wk programDelivery: NAIntensity: NAFidelity monitoring: NoCointervention—psychotropic drugs: None

To Veterans: - Patient sample predominantly female- Comorbid conditions not reported- University psychology clinic setting
42

sion in Primary Care Evidence-based Synthesis Program

tty, et al., 2004, and Simon, Ludman, and Rutter, 2009

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

D)

care: 44.0 (16.0)

anagement (CM): 

 (15.3)

otherapy + CM: 44.7 

7) 

NR

NR

on: 

graduate: 39.3%

74.33%

hnicity: 

0%

s: NR

e depression 

ment: 

 Hopkins Symptom 

list (SCL)

 NR

 mean (SD)

Care: 1.55 (0.62)

54 (0.61)

otherapy + CM: 1.52 

9) 

y: NR

sodes: NR

d psychiatric 

ns: NR

ubstance abuse: NR

isorder: NR

R

R

Intervention description:Three arms: 

1. Telephone-based 

psychotherapy (CBT) + CM: 195 participants

2. Telephone CM: 207 

participants 

3. Usual care: 195 participants 

Depression intervention(s):Behavioral interventionType: CBT; 8 sessions structured assessment, motivational enhancement, behavioral activation, cognitive restructuring, self-care planDelivery: TelephoneIntensity: 8 sessions 30 to 40 min; first four sessions every wk, second four 1 to 4 wk apartFidelity monitoring: NoOther notes about intervention:Psychotherapy was in addition to CMTherapistDiscipline: Master’s-level psychologistExperience: At least 1 yr clinical experienceTraining: 12 hr didactic and role play, observation, and audiotaping of 6 sessions each, 1 hr weekly supervision, twice monthly motivational interviewing seminar

Eligible randomized: 95%

Followup rate: N (%) 578 (96%) had 1 followup 532 (89%) completed 6 month 

followup

CM: 97% had 1 contact 85% had 3 contactsPsychotherapy + CM: 14 (7%) had no sessions 2 (1%) had 1 session only 167 (84%) had ≥ 4 sessions 125 (25%) had ≥ 7 sessionsImportant baseline differences:NoneDepression outcomes: 6-mo followup using SCL (50% reduction)Response rates n (%): Usual care: 76 of 176 (43%) CM: 94 of 184 (51%) Psychotherapy + CM: 100 of 172 

(58%)

Severity score: NR 

General comments:NoneStudy-level quality assessment: GoodComments:- Comparable groups- Little missing data - Outcome assessors blinded  - Not free of selective outcome reporting- PHQ results not reported- SCL scores at outcome not reported Assessment of adverse effects adequate? NRApplicability:-Severity of baseline depression, chronicity and comorbid condition not given- Sample was from a group model primary care clinic who did not want referral to mental health clinic- CM involved significant outreach (at least 5 phone calls) per participant, which is not routine clinical practice
43

sion in Primary Care Evidence-based Synthesis Program

tty, et al., 2004, and Simon, Ludman, and Rutter, 2009

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

d chronic medical 

ns: NR

n criteria: 

ning antidepressant

Score > 0.5

on criteria: 

 new episode of 

epressant treatment

ar

ophrenia

ing or receiving 

hotherapy

itive, language, or 

ng impairment

Comparator 1: Behavioral controlType: Usual care; any treatment normally available including primary care physician visits and referral to mental healthDelivery: NRIntensity: NRFidelity monitoring: NoComparator 2: Behavioral controlType: Telephone CM; assessment of depression, antidepressant use, and adverse effects. Scripts for addressing concerns and motivational enhancement. Primary care physicians received summary and computer-generated recommendations. Also care coordination, outreach, and asneeded crisis intervention.Delivery: TelephoneIntensity: Wk 4, 12, 20Fidelity monitoring: NoCointervention—psychotropic drugs: NR

HRQOL outcomes: NROther outcomes: NNT 6.4 for 50% reduction in SCL psychotherapy + CM versus usual care Social: NROccupational: NRSatisfaction: Self-rated “very satisfied”— Usual care: 50 of 176 (29%) CM: 85 of 184 (47%) Psychotherapy + CM: 101 of 172 

(59%)

Self-rated “much improved”— Usual care: 97 of 176 (55%) CM: 121 of 184 (66%) Psychotherapy + CM: 100 of 172 

(58%)

Total depression costs:$ Mean (SD) Usual care: 1020 (1009) CM: 1485 (1258) Psychotherapy + CM:1670 (1110)Total health care costs $ Mean (SD) Usual care: 9406 (10554) CM: 10268 (9773) Psychotherapy + CM: 9334 (8432)Treatment discontinuation rate: N (%) 14 (7%) had no sessions 2 (1%) had 1 session only 167 (84%) had ≥ 4 sessions 125 (25%) had ≥ 7 sessionsAdverse effects: NR
44

sion in Primary Care Evidence-based Synthesis Program

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

D): 38.8 (NR)

NR

0 to 55

n: NR

42 (65.6%)

nicity: NR

: None

 depression 

ent(s): 

 BDI NR 

yline +task 

nment: 26.08 (7.61)

yline + relaxation 

py: 23.10 (3.51)

yline+ minimal 

act: 25.8 (5.12)

o +task assignment: 

2 (4.87)

o+ relaxation therapy: 

2 (4.47)

o + minimal contact: 

0 (5.77)

y: NR

odes: “Past 

hological issues in 

d psychiatric 

ns: NR

d chronic medical 

ns: NR

Intervention description: Patients randomly allocated within sex to:

1. Amitriptyline +task assignment2. Amitriptyline + relaxation therapy3. Amitriptyline+ minimal contact4. Placebo +task assignment5. Placebo+ relaxation therapy6. Placebo + minimal contact

Depression intervention(s):Behavioral interventionType: Behavioral therapy, 7 sessions over 1 hr Delivery: IndividualIntensity: NRFidelity monitoring: NROther notes about intervention:Adapted from MacPhillamy and Lewinsohn therapyTherapistDiscipline: PsychologyExperience: Graduate studentsTraining: Previous experience with behavioral treatments (experimental and clinical) not specified furtherComparator: Behavioral control Type: Minimal contact, participants described their problems, nondirective and no specific suggestionsDelivery: IndividualIntensity: Two 1-hr sessionsFidelity monitoring: NR

Eligible randomized: 97; 64 analyzed 

in completers analysisFollowup rate: 64 (65.9%)Important baseline differences:NoneDepression outcomes:8 wk:Placebo +task assignment: 11.89 

(10.87)

Placebo+ relaxation therapy: 16.55 

(10.36)

Placebo + minimal contact: 14.67 

(11.12)

6 mo:Placebo +task assignment: 10.00 

(8.14)

Placebo+ relaxation therapy: 11.27 

(7.98)

Placebo + minimal contact: 15.18 

(10.86)

Response rates: NRSeverity score: NRHRQOL outcomes: NROther outcomes: Social: NoOccupational: NoSatisfaction: NoTreatment discontinuation rate: NRAdverse effects: NR

General comments:

NoneStudy-level quality assessment PoorComments:- Unclear randomization - Unclear allocation concealment- Incomplete data not addressed - Unclear blinding (not blinded to drug)- Selective outcome reporting Assessment of adverse effects adequate? NoApplicability:To general population:

- Done in Australia- University setting- Recruitment via advertising

To Veterans:

- 65% women- Comorbidities NR

- Chronicity NR
45

sion in Primary Care Evidence-based Synthesis Program

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

n criteria: 

20

ssion ≥ 2 months 

eport)

n criteria:

her major psychiatric 

ers 

etting any 

ological or 

acological ents (apart from 

 tranquilizers)

ntraindications to 

ptyline

Other notes about control: Described as a way for subjects to talk about their problems and see a solution to it themselvesCointervention—psychotropic drugs:Drug name/dose: Randomized to drug or placebo. Amitriptyline 50 mg titrated to 150 mg over 6 wk and then titrated off over 6 daysClinician discipline: NR
46

sion in Primary Care Evidence-based Synthesis Program

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

9.5 

NR

0 to 58

n: 

 completed at least 

ondary school

20 (80%)

nicity: NR

: No

 depression 

ent(s):

pants had past 

ation

idepressants 

nor tranquilizers

al therapy arm

n: BDI

r: NR

y: 21.13 (7.62)

ity: At least 3 mo

isodes: NR

n: HAM-D (17 item)

r: NR

y: 13.89 (3.22)

ity: at least 3 mo

isodes: NR

Intervention description:

1. Behavioral therapy: 8 participants2. Cognitive therapy: 8 participants3. Waitlist: 9 participants

Depression intervention 1:Behavioral interventionType: Behavioral activation based on Lewinsohn et al. To increase the frequency, quality, and range of activities and social interactions; mood record also maintained.Delivery: IndividualIntensity: Eight 1-hr weekly sessions Fidelity monitoring: NoDepression intervention 2:Cognitive interventionType: Cognitive restructuring based on Beck et al. Negative cognitive distortions and irrational beliefs evaluated and positive thought schedule developed for 3 times a day use; thought record also maintained.Delivery: IndividualIntensity: Eight 1-hr weekly sessions Fidelity monitoring: NoTherapistDiscipline: NRExperience: NRTraining: NRComparator: Behavioral controlType: Waitlist only; no interactionDelivery: NoneIntensity: NoneFidelity monitoring: NoCointervention—psychotropic drugs: NR

Eligible randomized: 29

Followup rate: NA;3 participants in behavioral treatment and 1 in cognitive treatment dropped out and were replaced by new participantsImportant baseline differences: NRDepression outcomes:Response rates: NRSeverity scores: BDI Behavioral therapy Pre Rx: 21.13 (7.62) Post Rx: 7.50 (4.55) Cognitive therapy Pre Rx: 27.25 (3.80)

Post Rx : 9.00 (6.82)

 Waitlist Pre Rx : 23.66 (7.45)

Post Rx: 21.44 (5.52)

HAM-D Behavioral therapy Pre Rx: 13.89 (3.22) Post Rx: 5.25 (3.46) Cognitive therapy Pre Rx: 13.62 (2.40) Post Rx: 5.88 (5.01) Waitlist Pre Rx: 13.22 (4.08) Post Rx: 14.78 (5.96)HRQOL outcomes: NROther outcomes: Social: NoOccupational: NoSatisfaction: No

General comments:NoneStudy-level quality assessment FairComments: - Unclear randomization - Unclear allocation concealment - Unclear blinding - No selective outcome reporting- Patients who dropped out were replaced; possibly not randomized- Comorbidities NR- Limited information reported, but an old studyAssessment of adverse effects adequate? NoApplicability:To general population:

- Recruited via advertising

- Treated in Australia- Treatment in a university settingTo Veterans:

- 80% women- No comorbidities reported including substance abuse

- Dropouts replaced
47

sion in Primary Care Evidence-based Synthesis Program

ants Interventions Results and Adverse Effects Comments/ Quality Scoring

e therapy arm

n: BDI

er: NR

y: 27.25 (3.80)

city: At least 3 mopisodes: NR

n: HAM-D (17 item)

er: NR

y: 13.62 (2.40)

city: At least 3 mopisodes: NR

Waitlist Criterion: BDI Disorder: NR Severity: 23.66 (7.45) Chronicity: at least 3 mo Prior episodes: NR Criterion: HAM-D (17 item) Disorder: NR Severity: 13.62 (4.08) Chronicity: At least 3 mo Prior episodes: NRComorbid psychiatric conditions: ExcludedAlcohol/substance abuse: NRPTSD: NROther anxiety disorder: NROther: NRComorbid chronic medical conditions: NRInclusion criteria: 

1. BDI ≥ 172. Frequent episodes of depression 

(self-report)

3. Depression for at least 3 mo (selfreport)

Exclusion criteria:

1. Previous/concurrent use of major 

tranquilizers or lithium

2. No other major physical or 

psychiatric disorders

3. No suicidal ideation

Treatment discontinuation rate: 3 of 8 (37.5%) participants in behavioral treatment and 1 of 8 (12%) in cognitive treatment dropped out and were replaced by new participantsAdverse effects: NR

 BDI-II = Beck Depression Inventory-II, CBT = cognitive behavioral therapy, CES-D = Center for Epidemiologic Studies-Depression Scale, CI 

stic Interview Schedule, HDRS = Hamilton Depression Rating Scale, MDD = major depressive disorder, n = number, NA = not applicable, NR = 

R = odds ratio, p = probability, PHQ = Patient Health Questionnaire, RCT = randomized controlled trial, SD = standard deviation, SE = standard 

 versus, wk = week/weeks, yr = year/years
48

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

LIST OF INCLUDED STUDIES from primary literature IN 

ALPHABETICAL ORDER

Barnhofer T, Crane C, Hargus E, et al. Mindfulness-based cognitive therapy as a treatment for 

chronic depression: A preliminary study. Behav Res Ther 2009;47(5):366-73.

Laidlaw K, Davidson K, Toner H, et al. A randomised controlled trial of cognitive behaviour 

therapy vs treatment as usual in the treatment of mild to moderate late life depression. Int J 

Geriatr Psychiatry 2008;23(8):843-50.

Mynors-Wallis LM, Gath DH, Day A, et al. Randomised controlled trial of problem solving 

treatment, antidepressant medication, and combined treatment for major depression in primary 

care. BMJ 2000;320(7226):26-30.

Nezu AM. Efficacy of a social problem-solving therapy approach for unipolar depression. J Consult Clin Psychol 1986;54(2):196-202.

Simon GE, Ludman EJ, Tutty S, et al. Telephone psychotherapy and telephone care management 

for primary care patients starting antidepressant treatment: a randomized controlled trial. JAMA 

2004;292(8):935-42.

Simon GE, Ludman EJ, Rutter CM. Incremental benefit and cost of telephone care management and telephone psychotherapy for depression in primary care. Arch Gen Psychiatry 

2009;66(10):1081-9.

Wilson PH. Combined pharmacological and behavioural treatment of depression. Behav Res 

Ther 1982;20(2):173-84.

Wilson PH. Comparative efficacy of behavioral and cognitive therapies of depression. Cognit 

Ther Res 1983;7(2):111-124
49

sion in Primary Care Evidence-based Synthesis Program

EWER COMMENTS AND RESPONSES

Response

pe, and methods for this review clearly described?

 literature review here or in the text. KQ 1 involves evaluation of “brief 

 to be defined as 8 or fewer sessions. 

We have added further explanation to both the Methods and Results sections of our overall approach and more explanation of what constitutes a “complex systematic review.” We have also clearly delineated that, for the purposes of this review, ≤ 8 sessions are defined as “brief,” 12 to 20 sessions are described as “standard,” and psychotherapies of other durations are specifically designated.

get the Results for KQ1. I wonder if organizing your results by type of therapy 

 For example, “We identified X articles evaluating CBT: X were from the 

w and X were identified from the systematic reviews. 

We have further clarified our overall approach and portions of KQ 1 to make apparent our structure of discussing systematic review findings prior to primary literature findings. 

s 3 times and still cannot follow the flow of literature. This needs to be clarified. 

clarified by adding 2 boxes below the one describing the 2 SR’s which shows 

me from each of the SR’s and then connecting it to the very bottom box.

We have altered the literature flow figure to better indicate how we used the primary literature and systematic reviews.

cussion. Thank you.

oint that most of these studies involve women deserves more than a line in 

 This is a huge issue for the VA. Were you able to tease out any gender sub

 or the original articles?

We agree and have added consideration of this point to the discussion section. While we agree that a subanalysis would be interesting, we have not conducted such an analysis because the data are not adequate or appropriate, and AHRQ guidelines recommend against such analyses.

objectives, scope, and methods are clearly described. However, it is 

itional specificity be provided in references to “brief” versus “longer duration” 

ghout the manuscript, including the executive summary (e.g., p. 1, lines 14-15: 

rapies compared to longer duration psychotherapies had similar effect sizes.”) 

duration” is often used in the report to refer to psychotherapy lengths that are 

8+ sessions). Because this term is typically associated with psychotherapies 

 12-16+ sessions), it would likely be helpful to be specific in such references to 

hermore, there was a finding of a larger effect for the somewhat longer duration 

ing confidence intervals led to the conclusion that the evidence was inadequate 

termination. Thus, it is somewhat unclear what led to the statement above of 

brief vs. “longer” duration psychotherapies.

We have now clearly delineated that, for the purposes of this review, ≤ 8 sessions are defined as “brief,” 12 to 20 sessions are described as “standard,” and psychotherapies of other durations are specifically designated. We have also clarified our interpretation of overlapping confidence intervals for “brief” versus “standard” length psychotherapy.Acknowledged

 focusing the review on brief (8 or fewer sessions) is clear. The methodology 

w is well described. It was somewhat surprising that there was not a key question 

n a comparison of brief versus slightly longer standard psychotherapy (e.g., 

imary care. The authors note on Page 1, line 10 that there are guidelines 

6 one-hour sessions. For this reviewer, this number of sessions is the usual “gold 

reatment and for clinical research in this area. Thus it would have been helpful 

r there is evidence that briefer treatment (8 or fewer sessions) is as efficacious as 

The review that we originally proposed to conduct would have made this comparison. However, a variety of reasons contributed to our VA stakeholders recommending against conducting this comparison. Fortunately, the Cuijpers’ systematic review addresses this comparison and allows us to make some tentative conclusions about comparative efficacy.

nd scope are very clearly described and this review adheres nicely to its 

The description of the search strategy (page 14) was somewhat confusing, 

ds to the selection of the specific dates to include in the Jan 2009-Aug 2010 

PsycINFO, Embase. After reading it a few times, I think I understand why those 

 am still not entirely confident.

We have reworked this section to provide clarification on our search strategy.
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sion in Primary Care Evidence-based Synthesis Program

Response

of bias in our synthesis of the evidence?

omments. Acknowledged

AcknowledgedAcknowledged

e an exhaustive search of the literature, and the synthesis of the available data is 

Thank you.Acknowledged

f interest to the VA that we have overlooked?

not addressed Acknowledged

AcknowledgedAcknowledged

viewer is aware of. Acknowledged

Acknowledged

 suggestions or comments below. If applicable, please indicate the page and line numbers from the draft report.

7. 15 articles are described. We have clarified the number of articles being described.

6 is a description of findings from the systematic reviews of 6-16 sessions but I 

on brief interventions? 

The reference to 6-16 sessions has been deleted so that the focus of this section of the Executive Summary is exclusively on brief psychotherapies.

ut a meta-analysis of 6 trials. Where did 6 come from? This sentence was reworded to indicate that the 6 trials were a subset of 

CBT trials that we examined.

about the other systematic review? Any data on number of sessions from it? The other systematic review was limited exclusively to brief 

psychotherapies, so no comparison could be made between brief psychotherapies and standard-length psychotherapies.

ontain information that should be presented earlier in the Results section (perhaps 

 This limitation should still be discussed in the conclusions.

This information is now also presented early in the Results section of the Executive Summary.

s 9 on—This paragraph needs to be clearer and for clarity, each search strategy 

ts own paragraph. I believe lines 11-14 belong in the Results section.

Separate paragraphs have been created to enhance clarity, and the referenced lines have been moved to appropriate places in the Results section.

sis—Clarify what you mean in line 20 page 17. Which findings are you 

que studies or the reviews findings?

We have clarified that we summarize in narrative form the systematic review findings.

2 systematic reviews are described and the authors identify 7 articles that are 

Next, on page 24 line 1, the authors describe a systematic review including 34 

learly however, that 14 of them contribute to the KQ addressed in this review. 

34 articles to the 9 articles described on page 23 and in Figure 2? How many 

view? The entire paragraph describing the Cape review needs to be clarified. 

The reason for this discrepancy is that the Cuijpers review was described on page 22, while the Cape review was described on page 24. We have made changes throughout the document to more fully describe the “complex systematic review” that we conducted, including why we report on reviews that cover some articles that did not meet our inclusion criteria for individual studies (i.e., a systematic review could meet our inclusion criteria for systematic reviews even if not every article covered in a review met our inclusion criteria for primary literature). 

 already in Methods. This section has been modified to parallel our description results for the 

systematic review search.

are helpful. Acknowledged

ld be helpful to begin, “Of the 15 unique studies, six studies...” so that it is clear 

ith this paragraph. 

Change made as suggested.
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sion in Primary Care Evidence-based Synthesis Program

Response

uld begin a new paragraph with, “The intervention...” Change made as suggested.

 15 RCT’s? I though you only found 8? Help! Why are you reporting the 

iew when it does not address KQ1 dealing with brief therapies? This is confusing!

Please see above response for how we clarified this apparent discrepancy. 

dies? You just talked for a few pages about how you got to 15. Clarify. Please see above response for how we clarified this apparent 

discrepancy.

ed to be clarified. Perhaps using subtitles such as CBT or MBCT would be helpful? We have altered the position of CBT in the initial sentence to help clarify 

that this paragraph is exclusively about CBT.

sessions? We have changed “fewer than 9” to “≤ 8.”

dical therapy among the controls in the 15 studies this would be very helpful. 

ols treated with medicine or just followed? Since this is the comparison most 

n, it seems to me that it deserves more discussion

For the purposes of this review, we intentionally excluded trials that used standardized medication protocols (i.e., what we considered a separate active treatment condition). Many of the control groups were “usual care,” which could possibly entail patients receiving medication, but usual care was highly variable.

ef EBPs are efficacious is somewhat tenuous, given the limited state of the research 

tations of many of the studies (e.g., many low quality studies, high heterogeneity, 

ual care comparison groups, small effect sizes), methodology required for the review 

and significant differences between the samples included in the reviewed studies 

ion. While the report notes many of these limitations, it is recommended that the 

ssion (p. 40, lines 2-3; “We conclude that brief psychotherapy is an efficacious 

ients with depression in VA primary care settings”) be qualified somewhat. Further, 

the finding of a significant effect for brief EBPs was only seen for studies in which 

y their GP for treatment but not for those recruited through systematic screening. 

f the differential effect, it may be worth noting this more directly in response 

cussion. Moreover, while it may very well be that brief EBP is an efficacious 

A primary care settings, the reviewed studies were conducted overwhelmingly on non

e significant, many of the studies had diagnoses commonly seen in Veteran primary 

onary criteria (e.g., substance abuse, psychosis, suicidality). This is worth explicitly 

 discussing and perhaps qualifying the conclusions somewhat. There is brief, one

 Limitations section that the studies in the review was composed primarily middle

s, which does not seem sufficient. 

We concur with many of these points and have qualified the statement. We have now commented on the differential effect between GP referral and systematic screening in the Discussion of KQ 1. We have more overtly acknowledged the limitations for the Veteran population, including the low representation of Veterans in the studies we reviewed, lack of comorbidity, and overrepresentation by middle-aged Caucasian females.

ke highly meaningful interpretations of the results of many of the treatment group 

f EBP vs. usual care), since usual care was poorly described and variable in the 

hermore, it is safe to assume that care as usual in many of most of the reviewed 

of evidence-based “care management,” as is now implemented in most VA primary 

 likely be valuable to note this in the Discussion. 

We have commented on the VA’s commitment to evidence-based care management in the Discussion. To our knowledge, the data remain out on whether VA’s investment in evidence-based care management has in practice resulted in significantly better usual care than was received in the studies we reviewed. 

rch comparing brief EBPs with full course EBPs, it is important that the 

f EBPs not come at the expense or replacement of full course EBPs (which could 

ership perception that brief EBPs are effective and a desire for efficiency). The 

parison of brief EBPs with full course EBPs was not directly tested in the studies and suggests this, appropriately so, as an area of future inquiry. While direct 

 full course EBPs was not tested in the studies included in the review, it might be 

fect sizes commonly found in reviews of full course CBT and PST, or to consider 

We sympathize with these concerns. After careful consideration, we have decided not to cite effect sizes for evidence-based psychotherapies from other reviews, as these effect sizes could be misleading should the reader compare them to the effect sizes we report for brief psychotherapy. Fortunately, the Cuijpers review makes this comparison in a subset of carefully selected trials, and we have elaborated on the caution warranted in interpreting their comparison because it is indirect and large Cis are involved.
52

sion in Primary Care Evidence-based Synthesis Program

Response

re does not seem to be sufficient evidence to support the conclusion that “broad 

th may not be necessary to provide these therapies.” It is noted in the manuscript 

s included therapists who were “graduate students, nurses, general practitioners, 

professionals.” It is further suggested that “Within the VA, a range of providers 

cluding nurses, nurse practitioners, primary care physicians, social workers, and 

rief EBPs. However, the inclusion of some non-MH providers in some studies does 

determining that individuals without background in mental health could deliver 

vely (or as effectively) as mental health professionals, and there is no data to 

which mental health training had an impact on, or moderated, outcomes. In fact, 

e pooled across different provider types, it is quite possible that effects would 

 treatments were delivered by mental health providers. It is also possible that 

ant effect for CBT or PST when delivered by non-MH providers. Were results 

 by provider-type? In addition, GPs and others noted above were identified in 

s; were these provider-types also included for CBT? Furthermore, VA patients 

plex and often have comorbidities (substance abuse, suicidality, psychosis) that 

y of the reviewed studies and would often require a higher level professional to 

s adapt treatment for. In addition, several of provider-types noted above are not 

deliver brief EBPs in VHA. It is also worth noting that graduate students and 

(as well as nurses with background in mental health) are considered mental health 

often do deliver EBPs, along with psychologists and psychiatrists. 

We have tempered our statements regarding necessary training and emphasized the need for more research on the use of “non–mental health professionals” to provide brief EBPs.

shown to more efficacious in treating major depression than dysthymia. It may be 

ults for different types of depression to the extent that this is possible (i.e., if there 

f studies/participants without mixed diagnostic groups).

We have now included in our KQ 1 Results information from the Cuijpers review on MDD versus “other” diagnoses. 

 a large effect size for treatment of anxiety is interesting and significantly higher 

r mixed anxiety and depression and depression only. Although anxiety is beyond 

t review, it would be interesting to know what type of anxiety this included (e.g., 

other specific forms of anxiety?). Might this finding be an artifact of the research 

ze), rather than the being a true differential effect for this condition?

We now note that “anxiety” refers predominantly to diagnoses of panic and generalized anxiety disorder. Although we do not expound on this finding because it is beyond the scope of this review, we would caution interpretation of the difference due to the indirect comparison methodology, but we would also suggest that the finding may represent a true difference and is of value as a hypothesis generating finding.

iew. Methods used to identify studies were appropriate. Decision to review 

eviews and add additional studies not included in those reviews seems a good one. 

e job of summarizing the included studies – they are well organized and easy to 

Thank you.

ze in relation to usual care was noted. I wonder if an analysis could be done 

ociation between depression severity and effect size. I would hypothesize that 

be most effective for those with moderate symptoms, less effective for those with 

ast effective (at least as monotherapy) for those with severe symptoms. It would be 

terature supports targeting any subgroups of patients as the best candidates for brief 

Such an analysis was not possible with the data obtained from the primary literature. However, we have added as a limitation our inability to answer this question.

rs of older veterans receiving care in the VA system, some mention of 

acy of brief psychotherapies in older adults would help the discussion. Several 

clude or are entirely focused on older adults, so some specific comment on this 

 This is particularly relevant since older white males have among the highest 

ide, and studies have shown that a large proportion of completed suicide victims 

recently seen a primary care physician. In sum, the inclusion of a discussion of 

sion in older veterans would add much to the report.

The 2 out of 15 studies that contained elderly participant samples are now separately examined in the Results. Also, additional mention on lack of data in Veteran samples (or male/elderly samples) is now made in the Discussion.
53

sion in Primary Care Evidence-based Synthesis Program

Response

written report that does a nice job utilizing the available research literature to 

ns it sets out to answer. The ability of this review to identify and outline some 

rrent knowledge base will provide an important foundation for future research 

es for depression and the use of psychotherapy in primary care settings. A study 

t addressed in this review, but may be useful to consider, or at least mention, is 

Thank you. We have revised a column heading in Table 4 to “Therapy completed” to indicate the number patients retained in the treatment condition (i.e., those that did not dropout).

omments consist of minor wording suggestions or clarifications:

ent, the word “Veteran” should be consistently capitalized. I would also suggest 

 quality of life has hyphens between the words (i.e. quality-of-life) or not (i.e. 

“Veteran” and “Veterans” have been capitalized throughout. The phrase “quality of life” appears with hyphens when used as a unit modifier, as in “quality-of-life measures.” Most instances in the report are not this usage, so we have left those without hyphens.

ne 11: the suggestion that “broad” training in mental health may not be necessary. 

f the other non-mental health specialists being discussed here probably do in fact 

n mental health, but may not have “extensive” or “specialized” training in mental 

 a more accurate way to capture what you are trying to say here.

We have tempered our statements to more strictly state what we found in the review and to emphasize the need for more research on the use of “non–mental health professionals” to provide brief EBPs.

st using “intensive” rather than “demanding” Changed as suggested.

the wording of this sentence is awkward and therefore does not convey the 

ew as clearly and strongly as possible.

The sentence has been split into two sentences and reworded.

e description of the Cuijpers review, p21, line 17 refers to 15 studies, but p 22, line 

s...”

16 was a mistake; we have changed to 15.

the sentence about what countries the studies were conducted in is confusing. 

is paragraph the authors are talking about the “14 depression studies” but then say 

were conducted in the US. Does this mean 2 of the 14 were conducted in the US? 

Yes, that is what was meant. We have reworded the sentence to enhance clarity.

istal follow up” time period refer to the length of time between baseline and most 

ween the end of treatment and the most distal follow up? It would be helpful to 

(even if it is described in the text).

A footnote has been added to the table for clarification.

est moving the sample size to Table 3, since it seems more like a characteristic 

 intervention. I would also suggest using “intervention n” or “treatment n” (and 

means) for that column rather than “completed n” and “control n”. It would make 

letion rates for the intervention arm as a column in Table 4. The therapy intensity 

little difficult to digest. Perhaps having separate columns for session length and 

would make it easier to understand?

We have split the therapy intensity column into two columns as suggested and have changed the column heading for “completed n.” We concur with the reviewer’s sentiment that sample size is more a characteristic of the study than the intervention, but we decided not to move this information in order to consolidate information in Table 4 and to cut down on clutter in Table 3.

I would suggest re-wording this sentence to something like, “Follow-up duration 

 for 7 studies 6 months or greater for 8 studies.”

Sentence has been reworded as suggested.

to the fact that only 2 study samples included any Veteran representation. It 

d a little more detail about what proportion of the samples were Veterans in those 2 

 studies specifically of Veterans, etc.

Additional detail has been added here and throughout the report.

 was the ES for < 6 sessions smaller than it was for interventions that included 

Page 31, line 3, reports that brief psychotherapies had a small but significant 

ment of depression in primary care – did Cuijpers examine whether this ES of 

smaller than that for the full range of studies they looked at (ES -0.31 reported on 

The Cuijpers review does make a comparison between ≤ 6 sessions and > 6 sessions, and they did not find a statistically significant difference. We report these findings in KQ 2 because the comparison between brief and standard-duration psychotherapies is the focus of KQ 2.

sis, is the ES of -0.21 reported on page 31, line 11 referring to the combined ES for 

d anxiety and depression?

Yes. We have clarified by identifying the different diagnostic categories from the outset of this paragraph and by pointing out that the authors combined diagnostic categories for some of their analyses.
54

sion in Primary Care Evidence-based Synthesis Program

Response

The sentences describing the ES for brief psychotherapies specifically for 

t contradictory. On the one hand, the authors report a “slightly smaller” effect 

care (as compared to the effect for CBT over usual GP care), but then report 

ces in efficacy between CBT and PST. This could possibly be re-worded to say 

y smaller, but not significantly different, for PST, but even this is still somewhat 

’s not statistically significantly smaller, can it be called smaller?)

The issue here is that at the p = 0.05 level, CBT demonstrated statistical significance and PST did not. Because there was no statistically significant difference between CBT and PST, because CBT narrowly demonstrated statistical significance at the p = 0.05 level, and because PST would demonstrate statistical significance at a slightly more lenient p level (e.g., p = 0.06 or 0.07), we feel that it would be misleading to draw too much attention to the fact that CBT achieved significance (narrowly) at the arbitrary 0.05 mark and PST did not (narrowly). We have reworded this sentence to remove the contradiction.

uld suggest replacing “judged to” with “rated as” Changed as suggested.

ou want to add (n=1) after the word antidepressant? Yes, changed as suggested.

unsure of exactly what the term “irregular comparator condition” means. We have clarified this sentence by replacing the term “irregular 

comparator” with a more accurate description of the control condition.

 under the Sd diff in means and 95% CI, do the authors intentionally use “Favours” 

The British spelling has been changed to “Favors.”

Stating that “These results are consistent with both Cape’s and Cuijpers’ conclusion 

us option for the treatment of depression.” may be slightly overstating it, since one 

d a difference and the other did not, especially since the better quality trial did not 

d outcomes.

We have altered a sentence to clarify that although the Mynors-Wallis study found PST+Med no better than Med alone, they also found that PST alone was equally as effective as Med alone. On this basis, we still conclude that the results are consistent with the conclusion that PST is an efficacious treatment option.

The authors could put the number of studies with each type of provider in 

 as they did on page 32 (lines 11-14)

We retained the sentence structure to avoid ambiguity (e.g., n = 3 could be interpreted as 3 studies or as 3 psychologists).

uggest adding a sentence after line 3 noting that the numbers of studies in each sub

o conduct quantitative analyses of provider type, individual vs. group, telephone vs. 

intensity. Though this is fairly obvious, it would make it explicit and also make it 

ections of the review in which similar decisions were made.

Changed as suggested.

 would suggest saying more about the statement, “However, usual care may 

t control condition than placebo controls used in antidepressant trials.” What do 

at makes them think this could be the case?

We have expounded on this statement to describe that it may be the case that usual care is more effective than placebo control because patients treated with usual care are receiving what is intended to be an active treatment and could even be a “best practice” treatment.

uld suggest changing the phrase “appropriate training and supervision” to 

g and supervision specific to the intervention being conducted”. Since many 

ch detail about the training provided, and since we really don’t have data that tells 

kind of training is needed to implement these interventions, I’m not sure it can be 

(or inappropriate) based on the information provided in each study.

Changed as suggested. We have also tempered our statements to more strictly state what we found in the review and to emphasize the need for more research on the use of “non–mental health professionals” to provide brief EBPs.

gest using the term “screened” rather than “selected” in reference to identifying 

 appropriate for brief psychotherapy 

Changed as suggested.

uld suggest replacing “appropriate” (in reference to the quantitative synthesis 

ng like “rigorous” or “robust” to convey that you not only chose analyses that were 

ou chose the best available methods. This is indeed a strength of this review and 

g change conveys that in a stronger manner.

Changed as suggested.
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sion in Primary Care Evidence-based Synthesis Program

LUDED STUDIES

eviewed in their full-text version and excluded for the reason indicated. An alphabetical reference list follows the table.

Population not appropriate Intervention not of interest Comparator not appropriate Not SR or RCT > 8 therapy sessions planned Main outcome not of interest

X

XX

X

X

XX

XX

X

X

X

X

X

X

XX

X

X

XX

X

X

X

X

X

X

X

XX

X

XX
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Population not appropriate Intervention not of interest Comparator not appropriate Not SR or RCT > 8 therapy sessions planned Main outcome not of interest

X

X

X

XXX

X

X

X

X

X

X

X

XX

X

X

X

XX

X

X

XXX

X

X

XX

X

XXX

X

X

X

X
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sion in Primary Care Evidence-based Synthesis Program

Population not appropriate Intervention not of interest Comparator not appropriate Not SR or RCT > 8 therapy sessions planned Main outcome not of interest

XXXX

XX

XX

X

X

X

X

X

X

X

X

XXX

X

XX

X
58

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

LIST OF EXCLUDED STUDIES 

Abbass Allan A, Hancock Jeffrey T, Henderson J, et al. 

Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews 2006(4).

Abraham IL, Neundorfer MM, Currie LJ. Effects of 

group interventions on cognition and depression in 

nursing home residents. Nurs Res 1992;41(4):196-202.

Alexopoulos GS, Raue P, Arean P. Problem-solving 

therapy versus supportive therapy in geriatric major 

depression with executive dysfunction. Am J Geriatr 

Psychiatry 2003;11(1):46-52.

Anonymous. Cognitive Behavioral Therapy Effective for Depressed Elderly. J Natl Med Assoc 

2010;102(4):358.

Arean PA, Perri MG, Nezu AM, et al. Comparative 

effectiveness of social problem-solving therapy and 

reminiscence therapy as treatments for depression in 

older adults. J Consult Clin Psychol 1993;61(6):1003-

10.

Barrera M, Jr. An evaluation of a brief group therapy 

for depression. J Consult Clin Psychol 1979;47(2):413-

5.

Bedi N, Chilvers C, Churchill R, et al. Assessing effectiveness of treatment of depression in primary care. 

Partially randomised preference trial. Br J Psychiatry 

2000;177:312-8.

Bee PE, Bower P, Gilbody S, et al. Improving health 

and productivity of depressed workers: a pilot randomized controlled trial of telephone cognitive behavioral 

therapy delivery in workplace settings. Gen Hosp 

Psychiatry 2010;32(3):337-40.

Bell AC, D’Zurilla TJ. Problem-solving therapy 

for depression: A meta-analysis. Clin Psychol Rev 

2009;29(4):348-353.

Beutler LE, Scogin F, Kirkish P, et al. Group cognitive 

therapy and alprazolam in the treatment of depression 

in older adults. J Consult Clin Psychol 1987;55(4):550-

6.

Boer Peter CAM, Wiersma D, Russo S, et al. Paraprofessionals for anxiety and depressive disorders. 

Cochrane Database of Systematic Reviews 2005(2).

Bortolotti B, Menchetti M, Bellini F, et al. Psychological interventions for major depression in primary care: 

a meta-analytic review of randomized controlled trials. 

Gen Hosp Psychiatry 2008;30(4):293-302.

Campbell JM. Treating depression in well older adults: 

use of diaries in cognitive therapy. Issues Ment Health 

Nurs 1992;13(1):19-29.

Catalan J, Gath DH, Anastasiades P, et al. Evaluation 

of a brief psychological treatment for emotional disorders in primary care. Psychol Med 1991;21(4):1013-8.

Ciechanowski P, Wagner E, Schmaling K, et al. Community-integrated home-based depression treatment 

in older adults: a randomized controlled trial. JAMA 

2004;291(13):1569-77.

Coelho HF, Canter PH, Ernst E. Mindfulness-based 

cognitive therapy: Evaluating current evidence and 

informing future research. J Consult Clin Psychol 

2007;75(6):1000-1005.

Cole MG. Brief interventions to prevent depression in 

older subjects: a systematic review of feasibility and 

effectiveness. Am J Geriatr Psychiatry 2008;16(6):435-

43.

Comas-Diaz L. Effects of cognitive and behavioral 

group treatment on the depressive symptomatology of Puerto Rican women. J Consult Clin Psychol 

1981 ;49(5) :627-32.

Cuijpers P, van Straten A, Andersson G, et al. Psychotherapy for depression in adults: A meta-analysis of 

comparative outcome studies. J Consult Clin Psychol 

2008 ;76(6) :909-922.

Cuijpers P, van Straten A, Bohlmeijer E, et al. The 

effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect 

size. Psychol Med 2010;40(2):211-23.

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APPENDIX E: ACRONYMS AND ABBREVIATIONS

ACT acceptance and commitment 

therapy

AE adverse effects

BDI-II Beck Depression Inventory-II

CBASP cognitive behavioral analysis 

system of psychotherapy

CBT cognitive behavioral therapy

CES-D Center for Epidemiologic StudiesDepression

CI confidence interval

CM care management

DBT dialectical behavioral therapy

DHP Diabetes Health Profile

DIS Diagnostic Interview Schedule

DSM-IV Diagnostic and Statistical Manual 

of Mental Disorders

FAP functional analytic psychotherapy

GP general practitioner

HAM-D Hamilton Depression Scale

HRSD Hamilton Rating Scale for 

Depression

HSLC-D Headache Specific Locus of 

Control-Depression

IPT interpersonal therapy

LOCF last observation carried forward

MBCT mindfulness-based cognitive 

therapy

MDD major depressive disorder

MDE major depressive episode

MH mental health

MMPI-D Minnesota Multiphasic Personality 

Inventory-Depression

MMSE Mini Mental State Examination

MOS-D Medical Outcomes StudyDepression

N or n number

NA not applicable

NNT number needed to treat

NR not reported

NS or ns not significant

OR odds ratio

p probability

PC primary care

PFT problem-focused therapy

PHQ Patient Health Questionnaire

PRIME-MD Primary Care Evaluation of Mental 

Disorders

PST problem-solving treatment

PTSD posttraumatic stress disorder

RCT randomized controlled trial

RDC Research Diagnostic Criteria

Rx medicine prescription

SADS-L Schedule for Affective Disorders 

and Schizophrenia-Lifetime Version

SCAN Schedules for Clinical Assessment 

in Neuropsychiatry

SCL Symptom Checklist

SD standard deviation

SE standard error

ST standard treatment

TAU treatment as usual

vs versus

WHOQOL World Health Organization Quality 

of Life

wk week or weeks

WLC waitlist control

yr year or years