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Behavioural therapies versus other psychological therapies for depression

  1. Kiyomi Shinohara1,
  2. Mina Honyashiki1,
  3. Hissei Imai2,
  4. Vivien Hunot3,
  5. Deborah M Caldwell4,
  6. Philippa Davies4,
  7. Theresa HM Moore4,
  8. Toshi A Furukawa5,
  9. Rachel Churchill3,*

Editorial Group: Cochrane Depression, Anxiety and Neurosis Group

Published Online: 16 OCT 2013

Assessed as up-to-date: 31 JUL 2013

DOI: 10.1002/14651858.CD008696.pub2


How to Cite

Shinohara K, Honyashiki M, Imai H, Hunot V, Caldwell DM, Davies P, Moore THM, Furukawa TA, Churchill R. Behavioural therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD008696. DOI: 10.1002/14651858.CD008696.pub2.

Author Information

  1. 1

    Kyoto University Graduate School of Medicine / School of Public Health, Department of Health Promotion and Human Behavior, Kyoto, Japan

  2. 2

    Kyoto University Graduate School of Medicine / School of Public Health, Department of Field Medicine, Kyoto, Japan

  3. 3

    University of Bristol, Centre for Academic Mental Health, School of Social and Community Medicine, Bristol, Avon, UK

  4. 4

    University of Bristol, School of Social and Community Medicine, Bristol, Avon, UK

  5. 5

    Kyoto University Graduate School of Medicine / School of Public Health, Departments of Health Promotion and Behavior Change and of Clinical Epidemiology, Kyoto, Japan

*Rachel Churchill, Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Bristol, Avon, BS8 2BN, UK. rachel.churchill@ccdan.org. rachel.churchill@bristol.ac.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 16 OCT 2013

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Characteristics of included studies [ordered by study ID]
Bellack 1981

MethodsDesign: RCT.
Study duration: 12 weeks of initial therapy and 6 months of maintenance treatment
Follow-up: 6 months (end of 6 months' maintenance treatment)


ParticipantsSample size: 125 individuals eligible and randomly assigned into four groups    

Recruitment: media advertisements and others (participants referred but did not mention from where they were referred)

Inclusion criteria: diagnostic classification criteria: DSM-III

Inclusion criteria: rating scales: scores of 7 or higher on Raskin Eligibility Depression Scale

Included disorders: major depressive disorder

Gender: 125 women

Mean age: 30.4 years

Country/Ethnicity: USA/90% of samples: white

Pharmacotherapy during the study: allowed


InterventionsGroup 1: BT-social skills training/assertiveness training plus pill placebo.

  • n = 33.
  • Participants received 12 weekly 1-hour group sessions of social skills training during initial treatment and six to eight 1-hour sessions during 6 months of maintenance treatment
  • In addition, they were seen concurrently in "drug evaluation" sessions for administration of pill placebos
  • Social skills training involved identification of skill deficits in three to four problem areas (interaction with strangers, friends and family members and at work), specific therapeutic instructions, feedback, practice in the environment, social perception training and self-evaluation and self-reinforcement


Group 2: social skill training plus amitriptyline: n = 31

Group 3: amitriptyline only: n = 30

Group 4: psychodynamic-other psychodynamic therapies plus pill placebo

  • n = 31
  • Participants received 12 weekly 1-hour individual time-limited dynamic therapy sessions during initial treatment and six to eight sessions during 6 months of maintenance treatment
  • In addition, they were seen concurrently for "drug evaluation" sessions for administration of pill placebos
  • Time-limited dynamic therapy focused on the individual's current concern rather than on in-depth exploration or personality reorganization. Therapist activity involved support, warmth, empathy, reflection, interpretation and clarification


OutcomesBDI

24-Item NIMH version of HAM-D       

Raskin Depression Scale (for eligibility)  

Lubin Depression Adjective Checklist           

Hopkins Symptom Checklist     

Social Ajustment Scale   

Eysenck Personality Inventory

Wolpe-Lazarus Assertiveness Scale


NotesWe extracted data mainly from Hersen 1984. We analysed outcomes only for group 1 and group 4 in this trial


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided     

Allocation concealment (selection bias)Unclear risk    

No information provided     

Blinding of participants and personnel (performance bias)
All outcomes
High risk    

Impossible to blind participants in a psychological therapy trial     

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Low riskAssessments performed by Independent researchers 

  

"Assessments were conducted by members of research staff who were blind to group assignment"—page 25, 1st paragraph, last sentence

Incomplete outcome data (attrition bias)
All outcomes
High riskCompleter analysis performed but high attrition rate and imbalance in attrition rates among arms 

Selective reporting (reporting bias)High riskNot all outcomes reported (Social Ajustment Scale) 

Researcher allegiance and other conflicts of interest (financial or other)High riskSocial skill training manual developed by author

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsUnclear riskTherapists qualified: yes

Received specialist training: unclear

"Social skill training was administered by one of two Ph.D. psychologists"—page 25, 5th paragraph

"Therapy was conducted by one of three Ph.D. psychologists"—page 27, 2nd paragraph

Treatment fidelityUnclear riskNo information about monitoring provided

Other biasUnclear riskNot enough information provided

Breckenridge 1985

MethodsDesign: RCT (however, waiting list people re-randomised after 6 weeks and allocated into treatment arms)
Study duration: 12 to 16 weeks
Follow-up: not stated


ParticipantsSample size: 115 individuals eligible and randomly assigned into four groups

Recruitment: referred by GP or GP surgery, or referred from outpatient setting and media advertisements

Inclusion criteria: diagnostic classification criteria: Research Diagnostic Criteria

Inclusion criteria: rating scales: scores of 17 and higher on BDI, and scores of 14 and higher on HAM-D

Included disorders: major depressive disorder

Gender: 31 men and 64 women

Mean age: 67.07 (SD 5.84) years

Country/Ethnicity: USA/European American

Pharmacotherapy during the study: allowed


InterventionsGroup 1: CBT-cognitive therapy

  • n = unclear
  • Participants received 16 to 20 sessions of individual therapy twice a week for the first 4 weeks and once a week thereafter
  • Cognitive therapists employed the treatment protocol developed by Beck, Rush, Shaw and Emery, which focuses on revising a participant's pathogenic cognitions about himself/herself, the world and the future, as well as providing problem-solving strategies


Group 2: BT-Lewinsohn's behavioural activation

  • n = unclear
  • Participants received 16 to 20 sessions of individual therapy twice a week for the first 4 weeks and once a week thereafter
  • Behavior therapy was conducted in accordance with Lewinsohn's (1974) and Gallagher and Thompson's(1981) manuals and was aimed at increasing pleasurable events in patient's life


Group 3: psychodynamic-relational model (Strupp, Luborsky)

  • n = unclear
  • Therapists used the therapy guidelines put forth by Horowitz, Marmar, Krupnick, Wilner, Kaltreider and Wallerstein, which suggested that therapists should develop a therapeutic alliance and then address participants' warded-off problematic feelings, fantasies and concepts of themselves and others


Group 4: waiting list

Participants were re-randomly assigned after 6 weeks and were allocated into other active treatment arms


OutcomesBDI 

HAM-D       

Geriatric Depression Scale

Brief Symptom Inventory–Depression

Brief Symptom Inventory–Global Severity

Brief Symptom Inventory–Anxiety

Global Assessment Scale

Brief Psychiatric Rating Scale

Automatic Thought Questionnaire

Young Loneliness Inventory

Social Ajustment Scale

Behavioral, Cognitive and Avoidance Coping scales in the Health and Daily Living Questionnaire

Older Persons Pleasant Events Schedule


NotesWe extracted data mainly from Thompson 1987 and Gallagher-Thompson 1990. Outcomes of groups 1, 2 and 3 were analysed

Investigators re-randomly assigned participants who were originally allocated to "delayed-treatment condition (DTC)" into therapy groups after 6 weeks and reported only combined outcomes However, the proportion of re-randomly assigned participants was less than 20% of the whole randomly assigned sample (20 of 115), and we concluded this study was eligible


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
High riskParticipants who dropped out from the study excluded from the analysis. Only completer analysis performed on 91 of 115 randomly assigned participants

Selective reporting (reporting bias)Unclear riskProtocol not available

Researcher allegiance and other conflicts of interest (financial or other)High riskManuarl of behavioural therapy written by the authors (Gallagher and Thompson)    

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsUnclear riskTherapists qualified: unclear

Received specialist training: yes  

"All were doctoral level psychologists with at least 1 year of specialised training in the modality they used "—page 385, right column, 3rd paragraph, Thompson 1987

Treatment fidelityLow riskMonitored against a manual: unclear

Monitored with a scale: yes

Sessions audiotaped: yes

"At least one videotaped treatment session per patient (selected from near the midpoint of therapy) was evaluated by raters at the centres of origination of each therapy modality"—page 386, left column, 1st paragraph, Thompson 1987      

Other biasHigh riskNeither number of participants originally allocated to each treatment first, nor number later re-randomly assigned from the waiting list into treatment groups was reported

Comas-Diaz 1981

MethodsDesign: RCT
Study duration: 4 weeks
Follow-up: 5 weeks


ParticipantsSample size: 26 individuals eligible and randomly assigned into three groups    

Recruitment: referred by local community agencies

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: BDI and HAM-D. Threshold unclear

Included disorders: stated as “Depression” only

Gender: 26 women

Mean age: 38 years

Country/Ethnicity: USA/Puerto Rican woman     

Pharmacotherapy during the study: unclear

  


InterventionsGroup 1: CBT-cognitive therapy

  • n = 8
  • Participants received five 90-minute group therapy sessions over a period of 4 weeks
  • This group was treated according to Beck's approach. Treatment consisted of modification and change of cognitions


Group 2: BT-Lewinsohn's behavioural activation

  • n = 8
  • Participants received five 90-minute group therapy sessions over a period of 4 weeks
  • Treatment emphasised changing of behaviour and consisted of use of activity schedules, verbal contracts and behavioural rehearsal techniques for providing training in social skills and self- reinforcement


Group 3: waiting list

n = 10


OutcomesBDI 

HAM-D

Depression Behavior Rating Scale (developed for this study)      


NotesWe analysed outcomes only for groups 1 and 2 of this trial


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial   

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot stated how incomplete outcome data were treated

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsUnclear riskTherapists qualified: unclear

Received specialist training: unclear 

Treatment fidelityLow riskMonitored against a manual: yes

Monitored with a scale: yes
Sessions audiotaped: yes

"Potential experimenter bias was evaluated by rating 30 3 minute randomly selected segments from the audio-taped sessions"—page 629, 2nd paragraph

"Results suggests that the therapists followed the treatment protocol" "The sessions were distinguishable by an observer familiar with the written treatment manual"—page 629, 2nd paragraph                                               

Other biasUnclear riskNot enough information provided

Gallagher 1979

MethodsDesign: RCT
Study duration: 5 weeks
Follow-up: 5 weeks


ParticipantsSample size: 28 individuals eligible and randomly assigned into two groups

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: Minnesota Multiphasic Personality Inventory–Depression (MMPI-D) scale at least two SD above the mean

Included disorders: major depressive disorder

Gender: unclear

Mean age: 67.65 (SD 5.84) years

Country/Ethnicity: USA/unclear     

Pharmacotherapy during the study: allowed


InterventionsGroup 1: BT-Lewinsohn's behavioural activation

  • n = unclear
  • Participants received ten 60- to 90-minute group therapy sessions twice a week over 5 weeks
  • Treatment followed two modules developed by Lewinsohn and associates: social skills training and increasing frequency of pleasure activities


Group 2: humanistic-non-directive/supportive therapies

  • n = unclear
  • Participants received ten 60- to 90-minute group therapy sessions twice a week over 5 weeks
  • Treatment developed from the writing of Rogers and centred on clarification of statements, expression of feelings


OutcomesMMPI-D

BDI  

Zung Self-rating Depression Scale

Depression Scale of the Symptom Checklist (SCL)-90

Dysfunctional Attitude Scale

Cognitive Distortion Vignettes

Interpersonal Events Schedule     


NotesMeasured outcomes not reported by authors


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskObserver-rated outcomes not reported  

Incomplete outcome data (attrition bias)
All outcomes
High riskNumber of dropouts in each group and how incomplete outcome data were treated not stated

Selective reporting (reporting bias)High riskMean and SD in each scale not reported

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsLow riskTherapists qualified: yes

Received specialist training: yes  

"The therapy were conducted by two therapists.....They had been practicing clinical psychologists for over 10 years"—page 37, last paragraph

"In addition, several training sessions were held in advance of the project to clarify their specific questions"—page 38, 1st paragraph

Treatment fidelityUnclear riskMonitored against a manual: yes

Monitored with a scale: yes
Sessions audiotaped: no

"Three undergraduate students at the University of Southern California were recruited and trained to rate various aspects of therapist"—page 39, second paragraph                    

"Observation[s] were obtained from behind one-way mirror"—page 40, 1st paragraph

"In addition, to measure the extent to which therapists were following the specific treatment protocols, observer counted specific therapist behaviours...."—page 53, 1st paragraph

Other biasUnclear riskNot enough information provided

Gardner 1981

MethodsDesign: RCT
Study duration: 6 weeks
Follow-up: 5 weeks


ParticipantsSample size: 17 individuals eligible and randomly assigned into two groups

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: BDI. Threshold not described

Included disorders: stated as "Depression" only

Gender: 7 men and 9 women

Mean age: unclear

Country/Ethnicity: Australia/unclear     

Pharmacotherapy during the study: unclear


InterventionsGroup 1: BT-other behaviour therapies

  • n = 8
  • Participants received 6 sessions of individual therapy once a week for 6 weeks
  • Treatment was based on Seligman model. Participants were supported to participate the activities that they had avoided


Group 2: CBT-rational emotive behaviour therapy

  • n = 9
  • Participants received 6 sessions of individual therapy once a week for 6 weeks
  • Treatment was based on Ellis's ABC model


OutcomesBDI 

Zung Self-rating Depression Scale

Tennessee Self-concept    


NotesUnpublished data: pretreatment mean and SD


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome reported  

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo missing data     

Selective reporting (reporting bias)Unclear riskNo information provided    

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided  

Therapist qualificationsUnclear riskNo information provided  

Treatment fidelityUnclear riskNo information about monitoring provided

Other biasUnclear riskNot enough information provided

Jacobson 1996

MethodsDesign: RCT
Study duration: 16 weeks
Follow-up: 6, 12, 18, 24 weeks


ParticipantsSample size: 152 individuals eligible and 149 individuals randomly assigned into three groups

Recruitment: media advertisement and other (health maintenance organisation)

Inclusion criteria: diagnostic classification criteria: DSM-III-R

Inclusion criteria: rating scales: scores of 20 or higher on BDI, and scores of 14 or higher on 17-item HAM-D

Included disorders: major depressive disorder and dysthymia

Gender: 38 men and 113 women

Mean age: 38.0 years

Country/Ethnicity: USA/Among 151 participants, 128 (84.7%) were Caucasian, 6 (3.9%) were Native American, 4 (3.1%) were African American, 3 (2.3%) were Hispanic and 3 (2.3%) were Asian

Pharmacotherapy allowed during the study: unclear

    


InterventionsGroup 1: BT-Jacobson's behavioural activation

  • n = 56
  • Participants received 20 sessions for 16 weeks
  • Treatment focused exclusively on behavioural activation of cognitive-behavioural therapy      


Group 2: CBT-other cognitive-behavioural therapies

  • n = 43
  • Participants received 20 sessions for 16 weeks
  • Treatment included behavioural activation and teaching of skills to modify automatic thoughts but excluding components related to core schema


Group 3: CBT-cognitive therapy

  • n = 50
  • Participants received 20 sessions for 16 weeks
  • Treatment was the full form of cognitive-behavioural therapy, including behavioural activation, modification of automatic thought and core schema


OutcomesBDI   

HAM-D 


NotesWe extracted data mainly from Jacobson 1996


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Low riskOutcome assessors blind  

"Raters were also not informed of the treatment condition of the participant"—page 296, right column 1st paragraph

Incomplete outcome data (attrition bias)
All outcomes
Low risk149 of 152 participants analysed; low attrition rate

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)High riskApparent allegiance of researcher for behavioural activation therapy because therapy manual was developed by first author, Jacobson                

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

              

Therapist qualificationsLow riskTherapists qualified: yes

Received specialist training: yes

"Three licensed clinical psychologists and one licensed social worker served as therapists" " All therapists participated previously in controlled trials of CBT and each underwent a pilot training period for the current study"—page 317, 3rd paragraph, Addis 2000

                                                 

Treatment fidelityLow riskMonitored against a manual: yes

Monitored with a scale: yes
Sessions audiotaped: yes

"The measure of treatment integrity used in the present study was a modified version of the National Institute of Mental Health Collaborative Study Psychotherapy Rating Scale (CSPRS; Hollon, Evans, Elkin, Lowery, 1984). Items included both techniques designated by the treatment manual and those prohibited or proscribed [by] it"—page 298, right column, 1st paragraph

"Raters listened to a tape of the therapy sessions..."—page 298, right column, 2nd paragraph

Other biasHigh riskNumber of people included in the analysis different from paper to paper

Kelly 1982

MethodsDesign: RCT
Study duration: 6 weeks
Follow-up: not stated


ParticipantsSample size: 24 individuals eligible and randomly assigned into three groups

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: DSM-III

Inclusion criteria: rating scales: scores of 15 or higher on BDI

Included disorders: major depressive disorder

Gender: 4 men and 16 women

Mean age: 33.9 years

Country/Ethnicity: Greece/unclear

Pharmacotherapy during the study: allowed


InterventionsGroup 1: Lewinsohn's behavioural activation

  • n = 8
  • Participants received six 75-minute group therapy sessions once a week for 6 weeks
  • Treatment was based on the Lewinsohn and Grosscup manual and emphasised development and practice of social skills and activity scheduling to increase frequency of pleasant events  


Group 2: CBT-rational emotive behaviour therapy

  • n = 8
  • Participants received six 75-minute group therapy sessions once a week for 6 weeks
  • Participants were told to change irrational self-statements to more rational ones during treatment


Group 3: control-psychological placebo

  • n = 8
  • Participants received six 75-minute group therapy sessions once a week for 6 weeks


OutcomesBDI  

Social Avoidance and Scale 

DSM-III Checklist

Irrational Beliefs Test

Pleasant Event Schedule


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome reported  

Incomplete outcome data (attrition bias)
All outcomes
High riskHigh attrition rate (4 of 24) but only completer analysis performed by authors  

 

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Low riskInvestigators checked therapist expectancy for improvement of symptoms and reported that ratings were similar across groups

"The second category of ratings involved the consistency of therapist across group, empathy, therapist expectancy for improvement and therapist credibility"—page 44, 3rd paragraph

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: no

"Two masters level clinical psychology graduate students served as therapists"—page 36, 2nd paragraph

Treatment fidelityUnclear riskMonitored against a manual: yes

Monitored with a scale: yes
Sessions audiotaped: unclear

"As a check on the manipulation of the investigation, several ratings were obtained..."—page 41, 4th paragraph

Other biasUnclear riskNot enough information provided

Kelly 1983

MethodsDesign: RCT. Cross-over design
Study duration: 10 weeks. Although the total intervention lasted 10 weeks, researchers switched the content of two interventions at the beginning of week 7. Therefore we extracted only data until the end of week 6

Follow-up: not stated


ParticipantsSample size: 16 individuals eligible and randomly assigned into two groups

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: scores of 10 or higher and 40 or lower on BDI

Included disorders: stated as “Depression” only

Gender: 5 men and 11 women

Mean age: not stated

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: not allowed


InterventionsGroup 1: Lewinsohn's behavioural activation

  • n = 8
  • Participants received six 60-minute individual therapy sessions once a week for 6 weeks
  • Treatment included increased activity level, structured work activity tasks, graded task assignment, behavioural rehearsal, assertion training, increased social behaviour and positive communication  


Group 2: CBT-cognitive therapies

  • n = 8
  • Participants received six 60-minute individual therapy sessions once a week for 6 weeks
  • Treatment included examination and testing of automatic thoughts, causal reattribution techniques and cognitive restructuring


OutcomesBDI  


NotesThis is a study of cross-over design; we extracted data only from the first CBT or BT therapy term


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo missing data      

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

"Therapists for this study were six doctoral students in the Counseling and Human Systems Program at Florida State University. They all received academic training in models... in the therapeutic approach being employed in this study"—page 53, 2nd paragraph

Treatment fidelityUnclear riskNo information provided

Other biasUnclear riskNot enough information provided

Lapointe 1980

MethodsDesign: cluster RCT
Study duration: 6 weeks
Follow-up: 2 weeks


ParticipantsSample size: 41 individuals eligible and randomly assigned into three groups

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: scores between 15 and 31 on BDI

Included disorders: stated as “Depression” only

Gender: 33 (100%) women

Mean age: 35.1 years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: BT-social skills training/assertiveness training

  • n = unclear
  • Participants received six 120-minute group therapy sessions once a week for 6 weeks    
  • Treatment focused on examination and practice of more assertive response


Group 2: psychodynamic-other psychodynamic therapies

  • n = unclear
  • Participants received six 120-minute group therapy sessions once a week for 6 weeks
  • Treatment focused on identifying and admitting feelings to themselves, gaining insight into why they felt as they did and experiencing how positive feedback made them feel and why    


Group 3: CBT-cognitive therapy

  • n = unclear
  • Participants received six 120-minute group therapy sessions once a week for 6 weeks
  • Treatment focused on examination of irrational self-statement and practice of substituting non-depressing cognition


OutcomesBDI

Personality Data Form

Rathus Assertiveness Schedule


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskCluster randomisation trial; allocation determined on the basis of available time  

"In both cases, groups are formed on the basis of available times and treatment conditions randomly assigned to groups"—page 314, right column, 3rd paragraph

Allocation concealment (selection bias)High riskAllocation apparently not concealed because allocation was determined on the basis of available time  

"In both cases, groups are formed on the basis of available times and treatment conditions randomly assigned to groups"—page 314, right column, 3rd paragraph

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychotherapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome reported

Incomplete outcome data (attrition bias)
All outcomes
High riskOf 41 participants, 33 participants completed; completer analysis performed for only 33 completers     

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information about therapist allegiance    

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

"At the end of four weeks...groups which were led by a female intern who had had 190 hours of individual and 100 hours of group therapy experience" "After four additional weeks,...the second set of groups led by the author who had had 105 hours of individual and 120 hours of group therapy experience"—page 314, right column, 3rd paragraph

Treatment fidelityUnclear riskNo information provided   

Other biasUnclear riskNot enough information provided

Maldonado 1982

MethodsDesign: RCT
Study duration: unclear
Follow-up: 3 months


ParticipantsSample size: 24 individuals randomly assigned into three groups

Recruitment: self-referral

Inclusion criteria: diagnostic classification criteria: other ("neurotic depression")

Inclusion criteria: rating scales: not stated

Included disorders: stated as “Depression” only

Gender: unclear

Mean age: unclear

Country/Ethnicity: Spain/unclear

Pharmacotherapy during the study: allowed


InterventionsGroup 1: CBT-cognitive therapy

  • n = 8
  • Participants received ten 60-minute individual therapy sessions. Frequency of sessions not reported


Group 2: BT-social skills training/assertiveness training

  • n = 8
  • Participants received ten 60-minute individual therapy sessions. Frequency of sessions not reported


Group 3: others-drug only

n = 8


OutcomesBDI 

HAM-D 

Zung Self-rating Depression Scale


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskUnclear whether ITT or completer analyses were used      

Selective reporting (reporting bias)Unclear riskNo information provided      

Researcher allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsUnclear riskNo information provided

Treatment fidelityUnclear riskNo information provided

Other biasUnclear riskNot enough information provided

Maldonado 1984

MethodsDesign: RCT
Study duration: unclear
Follow-up: 3 months


ParticipantsSample size: 24 individuals randomly assigned into three groups

Recruitment: self-referral

Inclusion criteria: diagnostic classification criteria: other ("neurotic depression")

Inclusion criteria: rating scales: score ≤ 20 on BDI and HAM-D, score ≤ 40 on Zung Self-Rating Depression Scale

Included disorders: stated as “Depression” only

Gender: unclear

Mean age: unclear

Country/Ethnicity: Spain/unclear

Pharmacotherapy during the study: allowed


InterventionsGroup 1: CBT-other cognitive-behavioural therapy

  • n = 8
  • Participants received 60-minute individual therapy sessions. Neither frequency nor number of sessions reported


Group 2: BT-social skills training/assertiveness training

  • n = 8
  • Participants received 60-minute individual therapy sessions. Neither frequency nor number of sessions reported


Group 3: others-drug only

n = 8


OutcomesBDI

HAM-D

Zung Self-rating Depression Scale


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskUnclear whether ITT or completer analyses were used      

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsUnclear riskNo information provided

Treatment fidelityUnclear riskNo information provided

Other biasUnclear riskNot enough information provided

McNamara 1986

MethodsDesign: RCT
Study duration: 8 or 10 weeks
Follow-up: 2 months


ParticipantsSample size: 50 individuals eligible and randomly assigned into four groups     

Recruitment: other (counselling centre of a large southwestern university)

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: BDI score of 18 or higher at intake and 16 or lower at pretest, and HAM-D score of 20 or higher at pretest

Included disorders: stated as “Depression” only

Gender: 11 men and 29 women

Mean age: 23 years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: CBT-cognitive therapy

  • n = unclear
  • Participants received eight 50-minute individual therapy sessions once a week for 8 weeks
  • Treatment was operationally based on the writings of Beck and associates (Beck 1974, 1976; Beck et al 1979); however, to maximise procedural differences from behaviour therapy, no attempts were made to modify clients' behaviours or environments


Group 2: BT-Lewinsohn's behavioural activation

  • n = unclear
  • Participants received eight 50-minute individual therapy sessions once a week for 8 weeks
  • This condition was derived from the work of Lewinsohn and associates (Lewinsohn 1975; Lewinsohn & Graf 1973; Lewinsohn & Grosscup 1978; Lewinsohn et al 1976; Steinmetz et al 1979); however, to avoid overlapping with cognitive therapy, no reference was made to cognition


Group 3: CBT-other cognitive-behavioural therapies

  • n = unclear
  • Participants received ten 50-minute individual therapy sessions once a week for 10 weeks
  • This condition included the rationales and strategies of both cognitive and behavioural therapy


Group 4: humanistic-person-centred therapy (Rogerian)

  • Participants received eight 50-minute individual therapy sessions once a week for 8 weeks
  • Condition provided clients with a rationale and a general goal statement (e.g. "to have a place to openly express feelings and have someone fully listen to you"). To achieve consistency, all counsellors were instructed to adhere carefully to Chapter 2 of Client-Centered Therapy (Rogers 1951)


OutcomesBDI

HAM-D

Automatic Thoughts Questionnaire

Cognitive Scale

Recalled Cognitions

Self-evaluated Social Skills

Pleasant Events Schedule

Behavioral Scale

Observer-evaluated Social Skills


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
High riskNo information provided about the level of attrition in each group or how this was treated

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention because treatments were not developed by the authors

"This condition was derived from the work of Lewinsohn and his associates"—page 26, left column, 6th paragraph

"This condition was derived from the work of Lewinsohn and his associates"—page 26, left column, 1st paragraph

"All counsellors were instructed to adhere carefully to Chapter 2 of Client-Centered Therapy (Rogers 1951)"—page 26, right column, 3rd paragraph

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskTherapists had interest in specific treatment but declared that they would follow treatment procedures

"At the time of recruitment, seven counsellors were self-described as 'cognitive-behavioural' in orientation; the eighth preferred the term "interpersonal" (cf. Strong 1968). All counsellors had expressed complete willingness to follow the exact procedures required by this study, despite any idiosyncratic preferences that might occur"—page 25, left column, 4th paragraph

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

"Seven doctoral interns in clinical and counselling psychology and one master's level social worker (4 men and 4 women) served as counsellors"—page 25, left column, 4th paragraph

Treatment fidelityLow riskMonitored against a manual: yes

Monitored with a scale: unclear
Sessions audiotaped: yes

"They were also provided with treatment manuals and were closely monitored (via audiotapes) for adherence to the appropriate intervention throughout the course of the study"—page 25, 4th paragraph

Other biasUnclear riskNot enough information provided

Pace 1977

MethodsDesign: RCT
Study duration: 3.5 weeks
Follow-up: 4, 8, 13 weeks and 10 months


ParticipantsSample size: 18 individuals randomly assigned into three groups

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: scores higher than 20 on BDI

Included disorders: stated as “unipolar depression” only

Gender: 18 women

Mean age: 38.4 years

Country/Ethnicity: Australia/unclear

Pharmacotherapy during the study: not allowed


InterventionsGroup 1: control-psychological placebo

  • n = 6
  • Participants received seven 1-hour individual therapy sessions twice a week for 3.5 weeks
  • Sensory awareness training (SAT): Primary goal of SAT was to increase participants' capacity to enjoy all aspects of sensory experience. Therapist presented categories of stimuli, such as pieces of music or pictures of landscapes. Then therapists encouraged participants to express preferences, appreciation and enjoyment


Group 2: BT-relaxation therapy

  • n = 6
  • Participants received seven 1-hour individual therapy sessions twice a week for 3.5 weeks
  • Treatment included muscular relaxation, along the lines suggested by Wolpe (1958,1969), which was based on Jacobson's (1938) method


Group 3: integrative-other integrative therapy approaches

  • n = 6
  • Participants received seven 1-hour individual therapy sessions twice a week for 3.5 weeks
  • Treatment was derived in part from the work of Beck (1967) and Ellis (1962). The first 3 sessions were devoted to cognitive awareness, and the next 3 sessions were devoted to emotional awareness


OutcomesZung Self-rating Depression Scale

Depression Adjective Checklist

Abbreviated version of Sentence Completions Method

State-Trait- Anxiety Inventory

Sleep Measure

Block Design section (B-D) of the Wechsler Adult Intelligence Scale

Edwards Personal Preference Schedule (EPPS)


NotesPace 1977 included three trials. We extracted data from one of the trials in the dissertation


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychotherapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome of our interest reported

Incomplete outcome data (attrition bias)
All outcomes
High riskDropping out of 2 of 18 participants by end of treatment; only the data of completers analysed

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)High riskApparent allegiance of author for BT-relaxation therapy

Manual for both treatments written by the author, but integrative therapy stated to be used as a control

"SAT and RT were compared to a control treatment called 'Cognitive-ernotional therapy' (CET)"—page 95, 3rad paragraph

"The aim of CET was to provide a treatment which would have face validity and which would control for the non-specific effects of therapy (e.g. support and understanding)"—page 98, 3rd paragraph 

Therapist allegiance and other conflicts of interest (financial or other)High riskTherapy provided by he author. Reasons for allegiance of therapist to BT-relaxation therapy similar to reasons for researcher allegiance

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: no

"All three treatments were conducted by two therapists, namely the experimenter and the co-researcher who had assisted in the subject selection process"—page 102, 3rd paragraph

Treatment fidelityUnclear riskNo information about monitoring provided

Other biasUnclear riskNot enough information provided

Padfield 1975

MethodsDesign: RCT
Study duration: 12 weeks
Follow-up: not stated


ParticipantsSample size: 24 eligible individuals randomly assigned into two groups 

Recruitment: referred by GP or GP surgery, media advertisement and other

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: Zung Self-Rating Depression Scale (no information about threshold). Scores above cut-off score for mild depression (1.50) on Grinker Interview Checklist

Included disorders: stated as “Depression” only

Gender: 24 (100%) women

Mean age: unclear

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: not allowed


InterventionsGroup 1: humanistic-non-directive/supportive therapies

  • n = 12
  • Participants received twelve 50-minute individual therapy sessions once a week for 12 weeks
  • Treatment approach involved building a relationship between client and counsellor using only the dimension of responsiveness, which consists of empathy, respect and concreteness, as defined by Carkhuff (1971)


Group 2: BT-Lewinsohn's behavioural activation

  • n = 12
  • Participants received twelve 50-minute individual therapy sessions once a week for 12 weeks
  • Treatment used same relationship approach plus a counsellor-initiated action programme developed by Lewinsohn (Lewinsohn 1974). Participants conducted daily mood ratings and daily pleasant events tracking of activity level to find correlations between specific events and mood fluctuation


OutcomesZung Self-rating Depression Scale

Grinker Interview Checklist

Pleasant Events Schedule

Self-reported Daily Mood Tracking


NotesWe extracted data mainly from the dissertation


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskAllocation sequence adequately generated

"After the women had volunteered for participants ....every two clients in order of appearance were randomly assigned to counselling with the relationship model (group A) or the relationship model plus the behavioral model (Group B) by flipping a coin"—page 36, 2nd paragraph

Allocation concealment (selection bias)High riskAllocation of the next woman suspected by investigators

"After the women had volunteered for participants....every two clients in order of appearance were randomly assigned to counselling with the relationship model (group A) or the relationship model plus the behavioral model (Group B) by flipping a coin"—page 36, 2nd paragraph

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial.

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Low riskOutcome assessors blind

"A psychiatric nurse, after listening to the tape without knowing which counselling approach the woman was receiving, made her assessment"—page 46, 1st paragraph

Incomplete outcome data (attrition bias)
All outcomes
Low riskMissing data for only one of 24

"Posttesting was completed in entirety with 23 women"—page 210, Padfield 1976

Selective reporting (reporting bias)High riskDetail of suicide attempts during the study not reported    

"Two of these attempts (suicide attempt) took place during the time of study"—page 35, 1st paragraph

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsUnclear riskNo information about qualification or training provided

Treatment fidelityLow riskMonitored against a manual: unclear

Monitored with a scale: yes
Sessions audiotaped: yes

"There were 203 counselling sessions and all except two were recorded"—page 47, 4th paragraph

"To check on the possibility of experimenter bias 11 rating scale focusing on relevant treatment variables were devised"—page 48, 1st paragraph

Other biasUnclear riskNot enough information provided

Rehm 1979

MethodsDesign: RCT
Study duration: 6 weeks
Follow-up: 6 weeks


ParticipantsSample size: 27 individuals eligible and randomly assigned into two groups    

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: MMPI scale score of F 80 or less, L 60 or less, D 70 or more, D > Hy, D > Pt and D among the highest two elevations on the profile

Included disorders: stated as “Depression” only

Gender: 27 women

Mean age: unclear

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: CBT-self-control therapy

  • n = 14
  • Participants received six 1-hour group therapy sessions once a week for 6 weeks
  • Programme consisted of three phases, during which emphasis was placed on training of self-monitoring, self-evaluation and self-reinforcement skills


Group 2: BT-social skills training/assertiveness training

  • n = 13
  • Participants received six 1-hour group therapy sessions once a week for 6 weeks
  • Therapy sessions focused on role playing of assertion problem situations


OutcomesBDI

MMPI–Depression

Pleasant Events Schedule

Self-evaluation Questionnaire

Common Associates Test

Concepts Test

Wolpe-Lazarus Assertion Scale


NotesUnpublished data: mean and SD on MMPI-D and BDI at pretreatment and post-treatment


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome of our interest reported

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition rates different between groups (none of 14 in CBT group, 3 of 13 in BT group) but only the data of completers analysed

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)High riskApparent allegiance of researcher for self-control therapy because authors developed this intervention     

"Fuchs and Rehm (1977) developed and evaluated a group administered self-control behavior therapy programme designed to remediate deficits in self-control identified with depression"—page 429, 1st paragraph

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: unclear

"All four therapists were graduate students in a Ph.D. programme in Clinical Psychology"—page 431, 2nd paragraph

Treatment fidelityUnclear riskNo information provided about monitoring

Other biasUnclear riskNot enough information provided

Rehm 1984

MethodsDesign: RCT
Study duration: 10 weeks
Follow-up: 6 months


ParticipantsSample size: 149 individuals eligible, and 147 individuals randomly assigned into three groups

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: Research Diagnostic Criteria

Inclusion criteria: rating scales: MMPI-D 70 or higher; BDI scores 20 or higher

Included disorders: major depressive disorder

Gender: 104 women

Mean age: 38.6 years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: BT-other

  • n = 35
  • Participants received ten 90-minute group therapy sessions once a week for 10 weeks
  • Treatment focused on behavioural component of self-control programme but appeared equal to behavioural therapy. Treatment was aimed at increasing specific categories of overt behaviour, and positive activities were monitored


Group 2: CBT-other

  • n = 35
  • Participants received ten 90-minute group therapy sessions once a week for 10 weeks
  • Treatment focused on cognitive component of self-control programme but appeared equal to cognitive therapy. Participants were monitored and evaluated their self-statement, which often was based on unrealistically stringent standard


Group 3: CBT-self-control

  • n = 34
  • Participants received ten 90-minute group therapy sessions once a week for 10 weeks
  • Treatment is a combination of behavioural and cognitive components of self-control therapy. This is a full package of self-control therapy


OutcomesBDI

MMPI-D

21-Item HAM-D

Raskin Three-item Depression Scale (RDS)–Interviewer Rating

Brief Hopkins Psychiatric Rating Scale

Revised Symptom Checklist

Social Adjustment Scale–Self-report

Self-control Questionnaire

Self-control Schedule

Dysfunctional Attitude Scale


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskRandom sequence generation not adequately conducted

"Assignments of groups were made to balance the order with which therapists began groups in different conditions with meeting time"—page 61, right column, 3rd paragraph     

Allocation concealment (selection bias)High riskAllocation apparently not concealed   

"Assignments of groups were made to balance the order with which therapists began groups in different conditions with meeting time"—page 61, right column, 3rd paragraph                   

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Low riskRaters blind to the allocation

"Interviewers were blind to all test results and to subjects' experimental conditions"—page 61, right column, 2nd paragraph

Incomplete outcome data (attrition bias)
All outcomes
High risk 

Completer analysis performed by authors although 43 of 147 dropped out

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

            

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

"Three therapists were doctoral-level psychologists and one was an advanced clinical psychology graduate student"—page 61, right column, 3rd paragraph

Treatment fidelityUnclear riskMonitored against a manual: unclear

Monitored with a scale: no
Sessions audiotaped: yes

"We randomly selected 72 tape segments by therapy tape-numbers and by tape recorder counter-settings"—page 62, right column, 4th paragraph

Other biasUnclear riskNot enough information provided

Rude 1986

MethodsDesign: cluster RCT. Cross-over design
Study duration: 6 weeks
Follow-up: 2 to 3 months


ParticipantsSample size: 51 individuals eligible and 32 individuals assigned to eight groups of four members each; each group assigned to CBT or BT

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: Research Diagnostic Criteria

Inclusion criteria: rating scales: BDI score 14 or higher; MMPI-Depression scale score 70 or higher and one of the two highest scores on the profile; Depression score > Hysteria and Psychasthenia scores; Lie and Validity scores < 70

Included disorders: major depressive disorder, depressive disorder not otherwise specified (including minor depression)

Gender: 48 women

Mean age: 40 years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: CBT-self-control therapy (followed by BT-assertiveness training)

  • n = 16
  • Participants received five 90-minute group therapy sessions twice a week for 3 weeks
  • Treatment was mainly based on that described by Rehm and Kornblith (1978). Participants monitored cognitions using a particular format and practiced increasing attention to positive events, setting specific proximal goals, using self-reward, replacing irrational automatic thoughts with constructive alternatives and solving problems


Group 2: BT-social skills training/assertiveness training (followed by CBT-self-control therapy)

  • n = 16
  • Participants received five 90-minute group therapy sessions twice a week for 3 weeks
  • Treatment included role-play practice, and assignments were given in the following areas: giving and receiving affection, making and refusing requests, handling criticism and so on


OutcomesBDI

Rathus Assertiveness Schedule

Self-control Schedule

Self-control Questionnaire

Cognitive Self-management


NotesThis is a study of cross-over design, and we extracted data only from the first CBT or BT therapy term


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial      

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome of our interest reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskIn both groups, 2 of 16 individual outcomes missing. Proportion apparently equal and relatively low 

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: unclear

"Four doctoral level counselling psychology students were to instruct two groups each"—page 31, 2nd paragraph

        

Treatment fidelityUnclear riskNo information about monitoring provided

Other biasHigh riskCluster-randomised trial, but intracluster correlation between therapists not reported for the outcome  

Sanchez 1980

MethodsDesign: RCT.
Study duration: 5 weeks
Follow-up: 1 month


ParticipantsSample size: 32 individuals randomly assigned into two groups

Recruitment: referred from outpatient setting 

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales:

  • MMPI: D scale ≧ 70 T, D > H, D > Hy   
  • Grinker Interview rating: one or more factor scores > 1.0, mean factor score > 70
  • Assertive Inventory: discomfort ≧ 95, response probability ≧ 105


Included disorders: major depressive disorder (MDD), depressive disorder NOS (including minor depression)

Gender: 11 men and 21 women

Mean age: unclear

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: allowed


InterventionsGroup 1: BT-social skills training/assertiveness training

  • n = 16
  • Participants received ten 90-minute group therapy sessions twice a week for 5 weeks
  • In treatment, modelling, behaviour rehearsal, coaching and social reinforcement were used to teach assertive responses for each individual's personal problematic situations


Group 2: psychodynamic-other psychodynamic therapies

  • n = 16
  • Participants received ten 90-minute group therapy sessions twice a week for 5 weeks
  • Treatment was aimed at facilitating change by helping individuals gain insight about their problems with little or no advice or retraining provided


OutcomesBDI

MMPI-D

Index of General Affect

Domains of Satisfaction

Assertive Inventory: Inventory Discomfort, Response Probability


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcomes reported

Incomplete outcome data (attrition bias)
All outcomes
High riskOnly data of completers analysed, although 5 of 16 dropped out of both groups

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

"Each of the four groups was led by a different therapist, each an advanced graduate student in clinical psychology"—page 527, 5th paragraph

 

Treatment fidelityUnclear riskNo information about monitoring provided

Other biasHigh riskMore than half of participants in the psychodynamic therapy group placed on medication after start of treatment

Schmitt 1988

MethodsDesign: RCT
Study duration: 12 weeks
Follow-up: 3 and 6 months


ParticipantsSample size: 40 individuals eligible and randomly assigned into three groups

Recruitment: media advertisements

Inclusion criteria: diagnostic classification criteria: Research Diagnostic Criteria

Inclusion criteria: rating scales: 14 or greater on HRDS; 14 and above on BDI

Included disorders: major depressive disorder

Gender: 11 men and 29 women

Mean age: 46.24 years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: CBT-problem-solving therapy

  • n = 15
  • Participants received twelve 90- to 120-minute group therapy sessions once a week for 12 weeks
  • Treatment programme was based on the problem-solving approach described by D'Zurilla and Nezu (1982). Treatment focused on five stages: problem orientation, problem definition and formulation, generation of alternatives, decision making and solution implementation and verification


Group 2: BT-social skills training/assertiveness training

  • n = 14
  • Participants received twelve 90- to 120-minute group therapy sessions once a week for 12 weeks
  • Treatment programme was based on modified version of the social skill training approach described by Bellack and Himmelhoch. Participants were instructed to develop effective social interaction using role playing


Group 3: waiting list

n = 11


OutcomesBDI

HAM-D

Automatic Thoughts Questionnaire

Problem Solving Inventory

Pleasant Events Schedule

Rathus Assertiveness Scale

Self-control Schdule

Attributional Style Questionnaire   


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition rates different between groups (1 of 15 in problem solving, 4 of 14 in social skills training); only the data of completers analysed by authors

Selective reporting (reporting bias)Unclear riskNo information provided    

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

"Therapists underwent extensive training procedures"—page 40, 2nd paragraph  

"Therapy was conducted four doctoral students (two advanced doctoral candidates with approximately three years of supervised psychotherapy experience and two first year doctoral students)"—page 40, 2nd paragraph                         

Treatment fidelityUnclear riskNo information provided about monitoring  

Other biasUnclear riskNot enough information provided

Shaw 1977

MethodsDesign: RCT
Study duration: 4 weeks
Follow-up: 1 month


ParticipantsSample size: 32 individuals eligible and randomly assigned into four groups  

Recruitment: self-referral and other (referral from university's student health service)

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales

  • BDI ≥ 18, HRDS ≥ 20, Visual Analogue Scale (VAS) ≥ 40
  • HRDS: three categories (genital symptoms, hypochondriasis and loss of insight) were excluded (total score range 0 to 72)
  • VAS: 0 = depression absent, 200 = extreme depression
  • Included disorders: major depressive disorder


Gender: 10 men and 22 women

Mean age: 20.1 years

Country/Ethnicity: Canada/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: CBT-cognitive therapy

  • n = 8
  • Participants received four 2-hour group therapy sessions once a week for 4 weeks
  • Treatment was based on methods suggested by Beck and included recording cognitions (automatic thoughts and images), identifying distortions and discussing the validity of basic assumptions, beliefs and attitudes related to depression


Group 2: BT-Lewinsohn's behavioural activation

  • n = 8
  • Participants received four 2-hour group therapy sessions once a week for 12 weeks
  • Treatment programme was adapted from the research of Lewinsohn and colleagues and included the use of activity schedules, verbal contracts and behaviour rehearsal techniques designed to teach communication and social reinforcement skills


Group 3: attention placebo

  • n = 8
  • In sessions, the therapist did not attempt to structure the content of the sessions, nor did he provide specific conceptualisations of the central hypothesised factors (i.e. cognitions, low rate of behaviour) involved in the maintenance of depression


Group 4: waiting list

n = 8


OutcomesBDI

HAM-D

Visual Analogue Scale 


NotesWe extracted the data only from trial groups 1 and 2


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Low riskAssessors blinded

"The raters were blinded to the subjects’ treatment group assignment"—page 545, right column, 5th paragraph

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNumber of participants for whom data were analysed not reported

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of the researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)High riskApparent allegiance of therapists for BT-Lewinsohn’s behavioural activation

"The theoretical orientation of his training was strongly behavioral with the result that he was most experienced with behavior therapy"—page 546, left column, 4th paragraph

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: unclear

"The therapist (experimenter) was a doctoral-level clinical psychology graduate student"—page 546, left column, 4th paragraph

Treatment fidelityLow riskMonitored against a manual: yes

Monitored with a scale: yes
Sessions audiotaped: yes

"All session[s] were audio taped for later evaluation"—page 546, left column, 2nd paragraph

"Also, the therapist's behavior and adherence to the treatment protocols were monitored and rated by a third independent rater"—page 546, left column, 3rd paragraph

Other biasUnclear riskNot enough information provided

Skinner 1983

MethodsDesign: RCT
Study duration: 4 weeks
Follow-up: not stated


ParticipantsSample size: 50 individuals eligible and randomly assigned into four groups

Recruitment: media advertisements

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: scores of 13 or higher on BDI

Included disorders: stated as “Depression” only

Gender: 13 men and 27 women

Mean age: 34 (SD 11.22) years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: allowed


InterventionsGroup 1: CBT-cognitive therapy

  • n = 7
  • Participants received five 1-hour individual therapy sessions once a week for 4 weeks
  • In the first 2 weeks, participants were given instruction on self-recording about positive and negative self-statements and pleasant and unpleasant events; they continued recording during the full treatment period. In the second 2 weeks, participants received cognitive therapy that focused on modification of faculty patterns of thinking


Group 2: BT-Lewinsohn's behavioural activation

  • n = 8
  • Participants received five 1-hour individual therapy sessions once a week for 4 weeks
  • In the first 2 weeks, participants were given instruction on self-recording, similar to the cognitive therapy group, and they continued recording during the full treatment period. In the second 2 weeks, participants received behaviour therapy that focused on restoring an adequate schedule of positive reinforcement by altering activities and interpersonal interactions


Group 3: others

  • n = 16
  • Participants chose the preferred intervention between cognitive therapy and behavioural therapy


Group 4: attention placebo

  • n = 9
  • Participants continued self-recording during the full treatment period


OutcomesBDI

Pleasant Event Schedule (PES)


NotesWe extracted data only from trial groups 1 and 2


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated scale used

Incomplete outcome data (attrition bias)
All outcomes
High riskHigh attrition rate (10 of 50 randomly assigned participants withdrew); only the data of completers analysed by authors     

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

All therapy conducted by one experimenter who had been trained; experimenter apparently the author—a doctoral level psychological student

 

Treatment fidelityUnclear riskNo information about monitoring provided

Other biasUnclear riskNot enough information provided

Taylor 1977

MethodsDesign: RCT
Study duration: 4 weeks
Follow-up: 5 weeks


ParticipantsSample size: 28 individuals eligible and randomly assigned into four groups

Recruitment: media advertisements

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: scores of 13 or higher on BDI, T scores not less than 70 on D-30 scale; 30 of original 60 items of MMPI-D scale taken by Dempsey (1964)

Included disorders: stated as “Depression” only

Gender: 8 men and 20 women

Mean age: 22.4 (SD 2.6) years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: not allowed


InterventionsGroup 1: CBT-cognitive therapy

  • n = 7
  • Participants received six 40-minute individual therapy sessions for 4 weeks
  • Treatment was based on proposals of Beck (1963) and Ellis (1970) and of Bandura (1971) and Marston (1964). Participants were instructed to identify characteristic cognitions related to depressive mood and to construct alternative cognitions. In addition, participants made a list of positive self-statements on a separate card and read each of the cards several times a day


Group 2: BT-Lewinsohn's behavioural activation

  • n = 7
  • Participants received six 40-minute individual therapy sessions for 4 weeks
  • Treatment programme was based on the formulations of Ferster (1965), Lazarus (1968) and particularly Lewinsohn (1974)
  • Participants were instructed to identify typical situations that made them depressed and to develop alternative behaviours


Group 3: CBT-other cognitive-behavioural therapies

  • n = 7
  • Participants received six 40-minute individual therapy sessions for 4 weeks
  • Treatment strategy was simply a combination of cognitive and behavioural treatments


Group 4: waiting list

n = 7


OutcomesBDI

Visual Analogue Scale

Self-acceptance and Self-esteem


NotesUnpublished data: dropouts


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Unclear riskNo observer-rated outcome reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskTreatment completed by all participants; no missing data

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: unclear

"All treatments (six 40-min sessions) were administered individually by a single therapist (the senior author)"—page 62, 6th paragraph

Treatment fidelityUnclear riskNo information provided about monitoring

Other biasUnclear riskNot enough information provided

Wetzel 1992

MethodsDesign: RCT
Study duration: 16 weeks
Follow-up: not stated


ParticipantsSample size: 43 individuals eligible and 37 individuals randomly assigned into three groups 

Recruitment: media advertisement

Inclusion criteria: diagnostic classification criteria: Feighner criteria

Inclusion criteria: rating scales: scores of 14 or higher on BDI; scores of 10 or higher on 17-item HAM-D

Included disorders: stated as “unipolar depression” only

Gender: 11 men and 26 women

Mean age: 39.4 (SD 10.9) years

Country/Ethnicity: USA/36 white, 1 black

Pharmacotherapy during the study: unclear


InterventionsGroup 1: CBT-cognitive therapy

  • n = 11
  • Participants received maximum of twenty 50-minute therapy sessions once or twice a week for the first 4 weeks, then once a week for the remaining 12 weeks
  • Treatment was based on Beck's model of cognitive-behavioural therapy (Beck 1979)


Group 2: BT-relaxation therapy

  • n = 14
  • Participants received maximum of twenty 50-minute therapy sessions once or twice a week for the first 4 weeks, then once a week for the remaining 12 weeks
  • Treatment was based on progressive muscle relaxation using the format described by Bernstein and Borkovec (1973)


Group 3: other-drug only

  • n = 12
  • Participants received a dosage of 150 to 300 mg/d desipramine


OutcomesBDI

HAM-D 


NotesWe extracted the data only from trial groups 1 and 2


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskAllocation sequence adequately generated

"Patients were randomly assigned to one of the three treatments according to a table of random numbers generated for that purpose"—page 406, 3rd paragraph

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)High riskOutcome assessors not blind

"The research coordinator... administered the Hamilton Scale. She was not blind to treatment assignment"—page 406, 5th paragraph

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition rates different between interventions (none of 12 in CBT, 3 of 14 in BT); only completer analysis performed by author

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsLow riskTherapists qualified: yes

Received specialist training: yes

"Therapists were six psychologists, one social worker, and one psychiatrist"—page 406, 6th paragraph

"The psychologists had at least three years of supervised clinical experience, were doctoral candidates...or held a Ph.D. degree"—page 407, 1st paragraph

Treatment fidelityUnclear riskMonitored against a manual: unclear

Monitored with a scale: unclear
Sessions audiotaped: yes

"Cognitive behavioral therapy therapists received pretreatment supervision and training in the theory and practice of cognitive therapy to Beck's model of cognitive behavioral therapy"—page 407, 4th paragraph

"Therapists were trained in progressive muscle relaxation using the format described by Bernstein and Borkovec (1973)"—page 407, 5th paragraph 

"All therapeutic sessions were audio taped"—page 408, 1st paragraph

Other biasUnclear riskNot enough information provided

Wilson 1983

MethodsDesign: RCT  
Study duration: 8 weeks
Follow-up: 5 months


ParticipantsSample size: 29 individuals eligible and 25 individuals randomly assigned into 3 groups

Recruitment: media advertisements

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales: scores of 17 or higher on BDI

Included disorders: stated as “Depression” only

Gender: 5 men and 20 women

Mean age: 39.5 years

Country/Ethnicity: Australia/unclear

Pharmacotherapy during the study: allowed


InterventionsGroup 1: BT- Lewinsohn's behavioural activation

  • n = 8
  • Participants received eight 1-hour individual therapy sessions once a week for 8 weeks
  • Treatment was based on Lewinsohn's conceptualisation of depression (Lewinsohn et al 1976). Overall aim of therapy was to increase frequency, quality and range of activities and social interactions


Group 2: CBT-cognitive therapy

  • n = 8
  • Participants received eight 1-hour individual therapy sessions once a week for 8 weeks
  • Treatment was based on Beck's conceptualisation of depression (Beck 1976). Pervasive negative cognitive distortions and irrational beliefs were identified and subjected to critical scrutiny via discussion. Participants were instructed to develop positive counter statements for each subject


Group 3: waiting list

n = 9


OutcomesBDI

Irrational Beliefs Test

Mood Ratings

17-Item Hamilton Depression Rating Scale 

Pleasant Events Schedule

Cognition Schedule


NotesDropouts were replaced. However, less than 20% of participants were replaced, so this study was included in our analysis 


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Low riskAssessor blinded

"Interviews were tape-recorded and independently assessed by one rater who was blind to both treatment condition and assessment occasion"—page 115, 4th paragraph

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDropouts (4 of 25 randomly assigned sample) replaced by new participants 

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of the researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsUnclear riskNo information about qualifications or training provided

Treatment fidelityUnclear riskNo information about monitoring or supervision provided

Other biasHigh riskDuring treatment, dropouts replaced

"Three subjects in the cognitive therapy condition and 1 subject in the behavior therapy condition discontinued treatment. These subjects were replaced in order to maintain equivalent cell frequencies"—page 114, 3rd paragraph

     

Zeiss 1979

MethodsDesign: RCT
Study duration: 16 weeks
Follow-up: not stated


ParticipantsSample size: 66 individuals eligible and randomly assigned to 3 groups, and again randomly assigned to 2 groups (immediate therapy or delayed therapy)

Recruitment: announcement at University of Oregon and in surrounding metropolitan area

Inclusion criteria: diagnostic classification criteria: unclear

Inclusion criteria: rating scales

  • MMPI-D > 70 T and MMPI-D > all clinical scales, or MMP-DI > 80 T
  • Grinker Interview Scale one or more factor score > 1.0, mean factor score > 70


Included disorders: major depressive disorder

Gender: 20 men and 46 women

Mean age: 33.9 years

Country/Ethnicity: USA/unclear

Pharmacotherapy during the study: unclear


InterventionsGroup 1: BT-social skills training/assertiveness training

  • n = unclear
  • Participants received 12 individual therapy sessions 3 times a week for 4 weeks
  • Treatment covered assertion, interpersonal style of expressive behaviour and social activity. Participants rehearsed assertiveness and received feedback


Group 2: waiting list

  • n = unclear
  • Participants received BT-social skills training/assertiveness training after 1-month waiting period


Group 3: CBT-other cognitive-behavioural therapies

  • n = unclear
  • Participants received 12 individual therapy sessions 3 times a week for 4 weeks
  • Treatment was designed to facilitate change in the way participants thought about reality through fixed-role therapy (Kelly 1995). Participants were to behave and react to everyday situations in line with the fixed role given


Group 4: waiting list

  • n = unclear
  • Participants received CBT-other cognitive behavioural therapies after 1-month waiting period


Group 5: BT-Lewinsohn's behavioural activation

  • n = unclear
  • Participants received 12 individual therapy sessions 3 times a week for 4 weeks
  • Treatment was designed to increase participants' frequency of pleasant activities and enjoyment of potentially pleasant activities


Group 6: waiting list

  • n = unclear
  • Participants received BT-Lewinsohn's behavioural activation after 1-month waiting period


OutcomesMMPI-D

Interpersonal Events Schedule

Social Skill Measures Based on Group Interaction

Coder Ratings of Social Skill, Peer Ratings of Social Skill

Pleasant Events Schedule

Cognitive Events Schedule

Personal Beliefs Inventory

Subjective Probability Questionnaire

Corder Ratings of Cognitive Style, Peer Ratings of Cognitive Style


NotesWe extracted the data only from trial groups 1, 3 and 5


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskImpossible to blind participants in a psychological therapy trial

Blinding of outcome assessment for the OBSERVER-RATED scale (detection bias)Low riskAssessors were blinded

"Verval coders were blind to the experimental condition of participants"—page 431, left column, 3rd paragraph

Incomplete outcome data (attrition bias)
All outcomes
High riskHigh attrition rate (22 of 66); number of dropouts in each group not reported; data of completers analysed by author

Selective reporting (reporting bias)Unclear riskNo information provided

Researcher allegiance and other conflicts of interest (financial or other)Low riskNo apparent allegiance of researcher for any intervention

Therapist allegiance and other conflicts of interest (financial or other)Unclear riskNo information provided

Therapist qualificationsHigh riskTherapists qualified: no

Received specialist training: yes

"Therapists for this study were six graduate students in counselling psychology and two counselling psychologists with master's degrees"—page 432, left column, 6th paragraph

Treatment fidelityUnclear riskNo information about monitoring provided

Other biasUnclear riskNot enough information provided

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Barrera 1979This study compared BT with waiting list

Bowers 1990Quasi-randomisation was used

Brand 1992Participants were inpatients

Broota 1990This study compared BT with no treatment

Cullen 2002This study compared BT with waiting list

Gallagher 1982The author added non-randomly assigned members to supplement the dropouts (8 of 30)

Hayman 1980This study compared BT with waiting list

Hopko 2003bParticipants were inpatients

Losada 2011No threshold for baseline depression severity was noted

Mclean 1979The author replaced participants to supplement the dropouts (37 of 154), and it was unclear whether those participants were randomly assigned

Reynolds 2011Mean depression score at baseline assessment was in the normal range

Rokke 1999Not all participants were randomly assigned to treatment

Snarski 2011Participants were elderly inpatients with mild to moderate cognitive impairment

Turner 1979Quasi-randomisation was used

Wilson 1982This study compared BT with psychological placebo

 
Comparison 1. BT vs all other psychological therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response18690Risk Ratio (M-H, Random, 95% CI)0.97 [0.86, 1.09]

    1.1 BT vs CBT
15544Risk Ratio (M-H, Random, 95% CI)0.93 [0.83, 1.05]

    1.2 BT vs Psychodynamic
2110Risk Ratio (M-H, Random, 95% CI)1.24 [0.84, 1.82]

    1.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

    1.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)9.00 [0.59, 137.65]

 2 Remission18694Risk Ratio (M-H, Random, 95% CI)0.91 [0.80, 1.04]

    2.1 BT vs CBT
16560Risk Ratio (M-H, Random, 95% CI)0.87 [0.75, 1.00]

    2.2 BT vs Psychodynamic
2110Risk Ratio (M-H, Random, 95% CI)1.32 [0.85, 2.06]

    2.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.14 [0.61, 2.13]

 3 Depression severity18656Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.20, 0.15]

    3.1 BT vs CBT
15529Std. Mean Difference (IV, Random, 95% CI)0.06 [-0.12, 0.23]

    3.2 BT vs Psychodynamic
293Std. Mean Difference (IV, Random, 95% CI)-0.37 [-0.79, 0.05]

    3.3 BT vs Humanistic
124Std. Mean Difference (IV, Random, 95% CI)-0.35 [-1.16, 0.45]

    3.4 BT vs Integrative
110Std. Mean Difference (IV, Random, 95% CI)-1.36 [-2.82, 0.09]

 4 Dropouts for any reason15495Risk Ratio (M-H, Random, 95% CI)1.02 [0.65, 1.61]

    4.1 BT vs CBT
11363Risk Ratio (M-H, Random, 95% CI)1.46 [0.68, 3.14]

    4.2 BT vs Psychodynamic
296Risk Ratio (M-H, Random, 95% CI)0.90 [0.47, 1.70]

    4.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)0.5 [0.11, 2.23]

    4.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)1.0 [0.08, 12.56]

 5 Anxiety2101Std. Mean Difference (IV, Random, 95% CI)-0.10 [-0.68, 0.48]

    5.1 BT vs CBT
145Std. Mean Difference (IV, Random, 95% CI)0.07 [-0.55, 0.69]

    5.2 BT vs Psychodynamic
146Std. Mean Difference (IV, Random, 95% CI)0.12 [-0.49, 0.72]

    5.3 BT vs Integrative
110Std. Mean Difference (IV, Random, 95% CI)-1.32 [-2.76, 0.13]

 6 Social adjustment2191Mean Difference (IV, Random, 95% CI)-0.04 [-0.16, 0.09]

    6.1 BT vs CBT
2145Mean Difference (IV, Random, 95% CI)-0.01 [-0.16, 0.14]

    6.2 BT vs Psychodynamic
146Mean Difference (IV, Random, 95% CI)-0.11 [-0.35, 0.13]

 
Comparison 2. BT-Lewinsohn vs all other psychological therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response8303Risk Ratio (M-H, Random, 95% CI)1.00 [0.82, 1.23]

    1.1 Lewinsohn vs CBT
7233Risk Ratio (M-H, Random, 95% CI)0.96 [0.77, 1.20]

    1.2 Lewinsohn vs Psychodynamic
146Risk Ratio (M-H, Random, 95% CI)1.19 [0.58, 2.47]

    1.3 Lewinsohn vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

 2 Dropouts for any reason592Risk Ratio (M-H, Random, 95% CI)0.43 [0.13, 1.45]

    2.1 Lewinsohn vs CBT
468Risk Ratio (M-H, Random, 95% CI)0.33 [0.04, 2.56]

    2.2 Lewinsohn vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)0.5 [0.11, 2.23]

 
Comparison 3. BT-Jacobson vs all other psychological therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response1149Risk Ratio (M-H, Random, 95% CI)1.09 [0.89, 1.34]

    1.1 Jacobson vs CBT
1149Risk Ratio (M-H, Random, 95% CI)1.09 [0.89, 1.34]

 2 Dropouts for any reason1149Risk Ratio (M-H, Random, 95% CI)1.62 [0.54, 4.85]

    2.1 Jacobson vs CBT
1149Risk Ratio (M-H, Random, 95% CI)1.62 [0.54, 4.85]

 
Comparison 4. BT-SST/assertiveness vs all other psychological therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response6184Risk Ratio (M-H, Random, 95% CI)0.88 [0.66, 1.19]

    1.1 SST/assertiveness vs CBT
5120Risk Ratio (M-H, Random, 95% CI)0.78 [0.56, 1.09]

    1.2 SST/assertiveness vs Psychodynamic
164Risk Ratio (M-H, Random, 95% CI)1.25 [0.79, 1.98]

 2 Dropouts for any reason6200Risk Ratio (M-H, Random, 95% CI)1.11 [0.58, 2.12]

    2.1 SST/assertiveness vs CBT
4104Risk Ratio (M-H, Random, 95% CI)2.33 [0.47, 11.49]

    2.2 SST/assertiveness vs Psychodynamic
296Risk Ratio (M-H, Random, 95% CI)0.90 [0.47, 1.70]

 
Comparison 5. BT-Relaxation vs all other psychological therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response237Risk Ratio (M-H, Random, 95% CI)2.12 [0.07, 64.37]

    1.1 Relaxation vs CBT
125Risk Ratio (M-H, Random, 95% CI)0.73 [0.51, 1.04]

    1.2 Relaxation vs Integrative
112Risk Ratio (M-H, Random, 95% CI)9.00 [0.59, 137.65]

 2 Dropouts for any reason237Risk Ratio (M-H, Random, 95% CI)2.13 [0.32, 14.17]

    2.1 Relaxation vs CBT
125Risk Ratio (M-H, Random, 95% CI)5.6 [0.32, 98.21]

    2.2 Relaxation vs Integrative
112Risk Ratio (M-H, Random, 95% CI)1.0 [0.08, 12.56]

 
Comparison 6. BT vs all other psychological therapies (Best/worst case scenario)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response (best case scenario)16495Risk Ratio (M-H, Random, 95% CI)1.08 [0.91, 1.29]

    1.1 BT vs CBT
13395Risk Ratio (M-H, Random, 95% CI)1.00 [0.88, 1.12]

    1.2 BT vs Psychodynamic
164Risk Ratio (M-H, Random, 95% CI)1.75 [1.19, 2.59]

    1.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

    1.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)11.00 [0.74, 163.49]

 2 Response (worst case scenario)16495Risk Ratio (M-H, Random, 95% CI)0.91 [0.80, 1.05]

    2.1 BT vs CBT
13395Risk Ratio (M-H, Random, 95% CI)0.92 [0.80, 1.06]

    2.2 BT vs Psychodynamic
164Risk Ratio (M-H, Random, 95% CI)0.78 [0.56, 1.09]

    2.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

    2.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)4.0 [0.61, 26.12]

 
Comparison 7. Sensitivity analysis: BT vs all other psychological therapies (treatment fidelity) 

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response3264Risk Ratio (M-H, Random, 95% CI)1.10 [0.92, 1.33]

    1.1 BT vs CBT
2194Risk Ratio (M-H, Random, 95% CI)1.08 [0.89, 1.32]

    1.2 BT vs Psychodynamic
146Risk Ratio (M-H, Random, 95% CI)1.19 [0.58, 2.47]

    1.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

 2 Depression severity3264Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.42, 0.08]

    2.1 BT vs CBT
2194Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.43, 0.16]

    2.2 BT vs Psychodynamic
146Std. Mean Difference (IV, Random, 95% CI)-0.23 [-0.84, 0.37]

    2.3 BT vs Humanistic
124Std. Mean Difference (IV, Random, 95% CI)-0.35 [-1.16, 0.45]

 3 Dropouts for any reason2173Risk Ratio (M-H, Random, 95% CI)1.08 [0.44, 2.66]

    3.1 BT vs CBT
1149Risk Ratio (M-H, Random, 95% CI)1.62 [0.54, 4.85]

    3.2 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)0.5 [0.11, 2.23]

 
Comparison 8. Sensitivity analysis: BT vs all other psychological therapies (excluding imputed data)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response125Risk Ratio (M-H, Random, 95% CI)0.73 [0.51, 1.04]

    1.1 BT vs CBT
125Risk Ratio (M-H, Random, 95% CI)0.73 [0.51, 1.04]

 2 Remission5281Risk Ratio (M-H, Random, 95% CI)0.81 [0.60, 1.10]

    2.1 BT vs CBT
4217Risk Ratio (M-H, Random, 95% CI)0.74 [0.57, 0.96]

    2.2 BT vs Psychodynamic
164Risk Ratio (M-H, Random, 95% CI)1.50 [0.81, 2.79]

 3 Depression severity15631Std. Mean Difference (IV, Random, 95% CI)-0.09 [-0.26, 0.08]

    3.1 BT vs CBT
12489Std. Mean Difference (IV, Random, 95% CI)0.00 [-0.18, 0.19]

    3.2 BT vs Psychodynamic
2108Std. Mean Difference (IV, Random, 95% CI)-0.35 [-0.73, 0.03]

    3.3 BT vs Humanistic
124Std. Mean Difference (IV, Random, 95% CI)-0.35 [-1.16, 0.45]

    3.4 BT vs Integrative
110Std. Mean Difference (IV, Random, 95% CI)-1.36 [-2.82, 0.09]

 
Comparison 9. Sensitivity analysis: BT vs all other psychological therapies (pharmacotherapy not allowed)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response473Risk Ratio (M-H, Random, 95% CI)1.18 [0.67, 2.07]

    1.1 BT vs CBT
237Risk Ratio (M-H, Random, 95% CI)0.92 [0.48, 1.78]

    1.2 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

    1.3 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)9.00 [0.59, 137.65]

 2 Depression severity471Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.75, 0.48]

    2.1 BT vs CBT
237Std. Mean Difference (IV, Random, 95% CI)0.26 [-0.42, 0.94]

    2.2 BT vs Humanistic
124Std. Mean Difference (IV, Random, 95% CI)-0.35 [-1.16, 0.45]

    2.3 BT vs Integrative
110Std. Mean Difference (IV, Random, 95% CI)-1.36 [-2.82, 0.09]

 3 Dropouts for any reason473Risk Ratio (M-H, Random, 95% CI)0.60 [0.17, 2.17]

    3.1 BT vs CBT
237Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    3.2 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)0.5 [0.11, 2.23]

    3.3 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)1.0 [0.08, 12.56]

 
Comparison 10. Sensitivity analysis: BT vs all other psychological therapies (excluding other subcategories)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response13427Risk Ratio (M-H, Random, 95% CI)0.97 [0.84, 1.12]

    1.1 BT vs CBT
12357Risk Ratio (M-H, Random, 95% CI)0.95 [0.82, 1.10]

    1.2 BT vs Psychodynamic
146Risk Ratio (M-H, Random, 95% CI)1.19 [0.58, 2.47]

    1.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

 2 Depression severity13413Std. Mean Difference (IV, Random, 95% CI)-0.07 [-0.27, 0.13]

    2.1 BT vs CBT
12343Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.24, 0.19]

    2.2 BT vs Psychodynamic
146Std. Mean Difference (IV, Random, 95% CI)-0.23 [-0.84, 0.37]

    2.3 BT vs Humanistic
124Std. Mean Difference (IV, Random, 95% CI)-0.35 [-1.16, 0.45]

 3 Dropouts for any reason11Risk Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 BT vs CBT
10296Risk Ratio (M-H, Random, 95% CI)1.85 [0.68, 5.04]

    3.2 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)0.5 [0.11, 2.23]

 
Comparison 11. Sensitivity analysis: BT vs all other psychological therapies (major depression only)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response5304Risk Ratio (M-H, Random, 95% CI)1.03 [0.83, 1.27]

    1.1 BT vs CBT
4194Risk Ratio (M-H, Random, 95% CI)0.95 [0.74, 1.22]

    1.2 BT vs Psychodynamic
2110Risk Ratio (M-H, Random, 95% CI)1.24 [0.84, 1.82]

 2 Depression severity5281Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.41, 0.08]

    2.1 BT vs CBT
4189Std. Mean Difference (IV, Random, 95% CI)-0.06 [-0.36, 0.24]

    2.2 BT vs Psychodynamic
292Std. Mean Difference (IV, Random, 95% CI)-0.38 [-0.80, 0.05]

 3 Dropouts for any reason293Risk Ratio (M-H, Random, 95% CI)1.43 [0.31, 6.67]

    3.1 BT vs CBT
129Risk Ratio (M-H, Random, 95% CI)4.29 [0.54, 33.85]

    3.2 BT vs Psychodynamic
164Risk Ratio (M-H, Random, 95% CI)0.84 [0.37, 1.89]

 
Comparison 12. Sensitivity analysis: BT vs all other psychological therapies (fewer than 13 sessions)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response14409Risk Ratio (M-H, Random, 95% CI)0.96 [0.81, 1.13]

    1.1 BT vs CBT
11309Risk Ratio (M-H, Random, 95% CI)0.90 [0.75, 1.07]

    1.2 BT vs Psychodynamic
164Risk Ratio (M-H, Random, 95% CI)1.25 [0.79, 1.98]

    1.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

    1.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)9.00 [0.59, 137.65]

 2 Depression severity14376Std. Mean Difference (IV, Random, 95% CI)4.47 [-0.23, 0.23]

    2.1 BT vs CBT
11295Std. Mean Difference (IV, Random, 95% CI)0.14 [-0.09, 0.38]

    2.2 BT vs Psychodynamic
147Std. Mean Difference (IV, Random, 95% CI)-0.50 [-1.08, 0.08]

    2.3 BT vs Humanistic
124Std. Mean Difference (IV, Random, 95% CI)-0.35 [-1.16, 0.45]

    2.4 BT vs Integrative
110Std. Mean Difference (IV, Random, 95% CI)-1.36 [-2.82, 0.09]

 3 Dropouts for any reason13321Risk Ratio (M-H, Random, 95% CI)0.88 [0.53, 1.46]

    3.1 BT vs CBT
9189Risk Ratio (M-H, Random, 95% CI)1.11 [0.31, 4.03]

    3.2 BT vs Psychodynamic
296Risk Ratio (M-H, Random, 95% CI)0.90 [0.47, 1.70]

    3.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)0.5 [0.11, 2.23]

    3.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)1.0 [0.08, 12.56]

 
Comparison 13. Sensitivity analysis: BT vs all other psychological therapies (excluding studies that replaced dropouts)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response16583Risk Ratio (M-H, Random, 95% CI)0.96 [0.83, 1.10]

    1.1 BT vs CBT
13483Risk Ratio (M-H, Random, 95% CI)0.93 [0.82, 1.05]

    1.2 BT vs Psychodynamic
164Risk Ratio (M-H, Random, 95% CI)1.25 [0.79, 1.98]

    1.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)1.4 [0.61, 3.19]

    1.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)9.00 [0.59, 137.65]

 2 Depression severity16549Std. Mean Difference (IV, Random, 95% CI)0.02 [-0.19, 0.22]

    2.1 BT vs CBT
13468Std. Mean Difference (IV, Random, 95% CI)0.10 [-0.10, 0.29]

    2.2 BT vs Psychodynamic
147Std. Mean Difference (IV, Random, 95% CI)-0.50 [-1.08, 0.08]

    2.3 BT vs Humanistic
124Std. Mean Difference (IV, Random, 95% CI)-0.35 [-1.16, 0.45]

    2.4 BT vs Integrative
110Std. Mean Difference (IV, Random, 95% CI)-1.36 [-2.82, 0.09]

 3 Dropouts for any reason14479Risk Ratio (M-H, Random, 95% CI)1.08 [0.68, 1.72]

    3.1 BT vs CBT
10347Risk Ratio (M-H, Random, 95% CI)1.82 [0.83, 4.00]

    3.2 BT vs Psychodynamic
296Risk Ratio (M-H, Random, 95% CI)0.90 [0.47, 1.70]

    3.3 BT vs Humanistic
124Risk Ratio (M-H, Random, 95% CI)0.5 [0.11, 2.23]

    3.4 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)1.0 [0.08, 12.56]

 
Comparison 14. BT vs all other psychological therapies (follow-up within 6 months)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response9356Risk Ratio (M-H, Random, 95% CI)0.77 [0.59, 1.01]

    1.1 BT vs CBT
8344Risk Ratio (M-H, Random, 95% CI)0.76 [0.59, 0.99]

    1.2 BT vs Integrative
112Risk Ratio (M-H, Random, 95% CI)9.00 [0.59, 137.65]

 2 Remission8344Risk Ratio (M-H, Random, 95% CI)0.77 [0.61, 0.98]

    2.1 BT vs CBT
8344Risk Ratio (M-H, Random, 95% CI)0.77 [0.61, 0.98]

 3 Depression severity9330Std. Mean Difference (IV, Random, 95% CI)0.36 [-0.05, 0.78]

    3.1 BT vs CBT
8322Std. Mean Difference (IV, Random, 95% CI)0.42 [0.04, 0.81]

    3.2 BT vs Integrative
18Std. Mean Difference (IV, Random, 95% CI)-2.41 [-4.57, -0.25]

 
Comparison 15. BT-Lewinsohn vs CBT-Cognitive therapy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response5122Risk Ratio (M-H, Random, 95% CI)1.03 [0.73, 1.46]

 2 Depression severity5122Std. Mean Difference (IV, Random, 95% CI)-0.10 [-0.45, 0.26]

 3 Dropouts for any reason4Risk Ratio (M-H, Random, 95% CI)Subtotals only

 
Comparison 16. BT-SST/assertiveness vs CBT-Self-Control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Response259Risk Ratio (M-H, Random, 95% CI)0.69 [0.34, 1.43]

 2 Depression severity252Std. Mean Difference (IV, Random, 95% CI)0.36 [-0.19, 0.92]

 3 Dropouts for any reason259Risk Ratio (M-H, Random, 95% CI)1.69 [0.11, 24.86]

 
Summary of findings for the main comparison. BT compared with all other psychological therapies for depression

BT compared with all other psychological therapies for depression

Participants or population: people with depression
Settings: outpatient
Intervention: BT
Comparison: all other psychological therapies

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

All other psychological therapies BT

Response584 per 1000567 per 1000
(503 to 637)
RR 0.97
(0.86 to 1.09)
690
(18 studies)
⊕⊕⊝⊝
lowa,b,c
The confidence interval crosses no difference

Remission554 per 1000504 per 1000
(443 to 576)
RR 0.91
(0.8 to 1.04)
694
(18 studies)
⊕⊕⊝⊝
lowa,b,d
The confidence interval crosses no difference

Response at follow-up
Follow-up: 5 to 24 weeks
678 per 1000522 per 1000
(400 to 685)
RR 0.77
(0.59 to 1.01)
356
(9 studies)
⊕⊕⊝⊝
lowa,b,e
The confidence interval crosses no difference

Depression severityMean depression severity in the intervention groups was
0.03 standard deviations lower
(0.2 lower to 0.15 higher)
656
(18 studies)
⊕⊕⊕⊝
moderatea,b
SMD -0.03 (-0.2 to 0.15). The confidence interval crosses no difference

Dropouts for any reason119 per 1000122 per 1000
(78 to 192)
RR 1.02
(0.65 to 1.61)
495
(15 studies)
⊕⊕⊕⊝
moderatea,b
The confidence interval crosses no difference

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: 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.
Very low quality: We are very uncertain about the estimate.

 aAll studies were at unclear or high risk of bias in sequence generation and allocation concealment.
bThe comparison groups were heterogeneous.
cOnly one study reported this outcome, and we used imputed data in other studies.
dBecause five studies reported this outcome, we used imputed data in other studies.
eNo study reported this outcome; we used imputed data.
 
Summary of findings 2. BT compared with CBT for depression

BT compared with CBT for depression

Participants or population: people with depression
Settings: outpatient
Intervention: BT
Comparison: CBT

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

CBTBT

Response 632 per 1000588 per 1000
(525 to 664)
RR 0.93
(0.83 to 1.05)
544
(15 studies)
⊕⊕⊝⊝
lowa,b,c
The confidence interval crosses no difference

Remission 586 per 1000510 per 1000
(439 to 586)
RR 0.87
(0.75 to 1)
560
(16 studies)
⊕⊕⊝⊝
lowa,c,d
The confidence interval crosses no difference

Response at follow-up
Follow-up: 5 to 24 weeks
698 per 1000530 per 1000
(412 to 691)
RR 0.76
(0.59 to 0.99)
344
(8 studies)
⊕⊕⊝⊝
lowa,c,e

Remission at follow-up
Follow-up: 5 to 24 weeks
659 per 1000507 per 1000
(402 to 645)
RR 0.77
(0.61 to 0.98)
344
(8 studies)
⊕⊕⊝⊝
lowa,c,e

Depression severity Mean depression severity in the intervention groups was
0.06 standard deviations higher
(0.12 lower to 0.23 higher)
529
(15 studies)
⊕⊕⊕⊝
moderatea,c
SMD 0.06 (-0.12 to 0.23). The confidence interval crosses no difference

Dropouts for any reason 64 per 100093 per 1000
(44 to 201)
RR 1.46
(0.68 to 3.14)
363
(11 studies)
⊕⊕⊕⊝
moderatea,c
The confidence interval crosses no difference

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: 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.
Very low quality: We are very uncertain about the estimate.

 aAll studies were at unclear or high risk of bias in sequence generation and allocation concealment.
bOnly one study reported this outcome, and we used imputed data in other studies.
cThe confidence interval is wide.
dBecause four studies reported this outcome, we used imputed data in other studies.
eNo study reported this outcome; we used imputed data.
 
Summary of findings 3. BT compared with psychodynamic therapies for depression

BT compared with psychodynamic therapies for depression

Participants or population: people with depression
Settings: outpatients
Intervention: BT
Comparison: psychodynamic therapies

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Psychodynamic therapiesBT

Response426 per 1000529 per 1000
(358 to 776)
RR 1.24
(0.84 to 1.82)
110
(2 studies)
⊕⊕⊝⊝
lowa,b,c
The confidence interval crosses no difference

Remission 377 per 1000498 per 1000
(320 to 777)
RR 1.32
(0.85 to 2.06)
110
(2 studies)
⊕⊕⊝⊝
lowa,b,d
The confidence interval crosses no difference

Depression severity Mean depression severity in the intervention groups was
0.37 standard deviations lower
(0.79 lower to 0.05 higher)
93
(2 studies)
⊕⊕⊕⊝
moderatea,b
SMD -0.37 (-0.79 to 0.05). The confidence interval crosses no difference

Dropouts for any reason 298 per 1000268 per 1000
(140 to 506)
RR 0.9
(0.47 to 1.7)
96
(2 studies)
⊕⊕⊕⊝
moderatea,b
The confidence interval crosses no difference

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: 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.
Very low quality: We are very uncertain about the estimate.

 aAll studies were at unclear or high risk of bias in sequence generation and allocation concealment.
bThe confidence interval is wide.
cNo study reported this outcome; we used imputed data.
dOnly one study reported this outcome, and we used imputed data in other studies.