Plain language summary
'Third wave' cognitive and behavioural therapies versus other psychological therapies for depression
Major depression is a very common condition, in which people experience persistently low mood and loss of interest in pleasurable activities, accompanied by a range of symptoms including weight loss, insomnia, fatigue, loss of energy, inappropriate guilt, poor concentration and morbid thoughts of death. Psychological therapies are an important and popular alternative to antidepressants in the treatment of depression. Many different psychological therapy approaches have been developed over the past century, including behavioural, cognitive-behavioural (CBT), 'third wave' CBT, psychodynamic, humanistic and integrative therapies.
In this review, we focused on third wave CBT approaches, a group of psychological therapies that target the process of thoughts (rather than their content, as in CBT) to help people become aware of their thoughts and accept them in a non-judgemental way. The aim of the review was to find out whether third wave CBT was more effective and acceptable than other psychological therapy approaches for people with acute depression. The review included three studies, involving a total of 144 people. The studies examined two different forms of third wave CBT, consisting of acceptance and commitment therapy (ACT) (two studies) and extended behavioural activation (BA) (one study). All three studies compared these third wave CBT approaches with CBT. The results suggested that third wave CBT and CBT approaches were equally effective in treating depression. However, the quality of evidence was very low because of the small number of studies of poor quality that we included in the review; therefore it is not possible to conclude whether third wave CBT approaches might be more effective and acceptable than other psychological therapies in the short term or over a longer period of time. Given the increasing popularity of third wave CBT approaches in clinical practice, further studies should be prioritised to establish whether third wave CBT approaches are more helpful than other psychological therapies in treating people with acute depression.
Comparaison des thérapies cognitives et comportementales de « troisième vagues » à d’autres thérapies psychologiques pour le traitement de la dépression
La dépression majeure est une pathologie très courante, qui se manifeste par une morosité persistante et une perte d’intérêt pour les activités agréables, accompagnée de divers symptômes tels que la perte de poids, l’insomnie, la fatigue, la perte d’énergie, un sentiment injustifié de culpabilité, un manque de concentration et des pensées morbides. Les thérapies psychologiques constituent une alternative importante et très répandue aux antidépresseurs pour le traitement de la dépression. De nombreuses approches psychothérapeutiques différentes ont été développés au cours du siècle passé, notamment les psychothérapies comportementales, cognitivo-comportementales (TCC), les TCC de la « troisième vague », les psychothérapies humanistes et les psychothérapies intégratives.
Dans cette revue, nous nous sommes concentrés sur les TCC dites de troisième vague, un groupe des psychothérapies qui s’intéressent aux processus de pensée (plutôt qu’à leur contenu comme les TCC classiques) pour aider les sujets à prendre conscience de leurs pensées et à les accepter sans porter de jugement. L’objectif de cette revue était de déterminer si les TCC de la troisième vague étaient plus efficaces et plus acceptables que d’autres approches psychothérapeutiques pour les personnes souffrant de dépression aiguë. La présente revue a inclus trois études, impliquant un total de 144 personnes. Ces études examinaient deux formes différentes de TCC de troisième vague : thérapie d’acceptation et d’engagement (ACT) (deux études) et activation comportementale étendue (une étude). Les trois études comparaient ces TCC de troisième vague avec la TCC classique. Les résultats suggéraient que la TCC de la troisième vague et la TCC classique étaient aussi efficaces l’une que l’autre dans le traitement de la dépression. Cependant, la qualité des preuves était très faible en raison du petit nombre d’études que nous avons incluses dans la revue et de la mauvaise qualité de celles-ci. Par conséquent, il n’est pas possible de conclure si les TCC de la troisième vague pourraient être plus efficaces et plus acceptables que d’autres psychothérapies à court terme ou à plus long terme. Compte tenu la popularité croissante des TCC de la troisième vague dans la pratique clinique, la priorité devrait être donnée à la réalisation de nouvelles études visant à établir si cette approche est plus utile que d’autres psychothérapies dans le traitement des patients atteints de dépression aiguë.
Notes de traduction
Traduit par: French Cochrane Centre 9th January, 2014
Traduction financée par: Financeurs pour le Canada : Instituts de Recherche en Sant� du Canada, Minist�re de la Sant� et des Services Sociaux du Qu�bec, Fonds de recherche du Qu�bec-Sant� et Institut National d'Excellence en Sant� et en Services Sociaux; pour la France : Minist�re en charge de la Sant�
このレビューでは、（CBTのように思考の内容ではなく）思考の過程を標的とし、評価を下される方法ではなく、自己の思考に気づき、受け入れられるように手助けをする心理療法のグループのひとつである、第3世代CBTに注目した。急性うつ病の人に対し、第3世代CBTが他の心理療法よりも効果的かつ受容性であるかを調査するためにレビューを実施した。レビューには合計144例から成る研究2件が含まれた。研究はacceptance and commitment therapy (ACT)（2件）、extended behavioural activation (BA)（1件）から成る異なる2種類の第3世代CBTを解析した。3件の研究すべてが第3世代CBTとCBTを比較した。その結果から、第3世代CBTとCBTのうつ病治療に対する効果は同等であることが示唆された。しかし、レビューに含まれる研究は数が少なく、質も低いことから、非常に質の低いエビデンスしかなかった。したがって、短期あるいは長期に渡って効果と受容性において第3世代CBTの方が他の心理療法よりも良好であると結論付けることはできない。臨床診療の場において第3世代CBTが一般的になりつつあることから、第3世代CBTが他の心理療法よりも急性うつ病患者の治療に役立つかどうか結論付けるには更なる研究を優先的に実施すべきである。
《注意》この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、eJIM事務局までご連絡ください。なお、2013年6月からコクラン・ライブラリーのNew review, Updated reviewとも日単位で更新されています。eJIMでは最新版の日本語訳を掲載するよう努めておりますが、タイム・ラグが生じている場合もあります。ご利用に際しては、最新版（英語版）の内容をご確認ください。
"Treći val" kognitivnih i bihevioralnih terapija u odnosu na druge psihološke terapije za depresiju
Veliki depresivni poremećaj je učestalo stanje, kod kojeg osobe doživljavaju dugotrajno sniženo rapoloženje i gubitak interesa za aktivnosti u kojima su prije uživali, što je udruženo s nizom simptoma kao što su gubitak težine, nesanica, umor, gubitak energije, neprimjerena tuga, loša koncentracija i učestale misli o smrti. Psihološke terapije su važna i popularna druga mogućnost u odnosu na lijekove antidepresive za liječenje depresije. Tijekom prošlog stoljeća razvijeno je mnogo različitih terapijskih pristupa, uključujući bihevioralni, kognitivno-bihevioralni (KBT), "treći val" KBT-a, psihodinamski, humanistički i integrativni pristup.
U ovom Cochrane sustavnom pregledu cilj je bio ispitati dokaze o djelotvornosti i sigurnosti "trećeg vala" KBT pristupa, grupe psiholoških terapija koje su usmjerene na procese misli (umjesto na njihov sadržaj, kao u KBT-u) kako bi se pomoglo osobama da postanu svjesni svojih misli i prihvate ih na bez osuđivanja. Cilj ovog pregleda je bio otkriti je li treći val KBT-a učinkovitiji i prihvatljiviji nego ostali terapijski pristupi za osobe s akutnom depresijom. Ovaj pregled je uključio tri istraživanja, u kojima je sudjelovalo ukupno 144 osobe. Istraživanja su proučavala dva različita oblika trećeg vala KBT-a, koja su se sastojala od terapije prihvaćanjem i predanosti (engl. acceptance and commitment therapy, ACT) (dva istraživanja) i proširene bihevioralne aktivacije (engl. extended behavioural activation, BA) (jedno istraživanje). Sva tri istraživanja su uspoređivala pristup trećeg vala KBT-a s KBT-om. Rezultati pokazuju da su treći val KBT-a i pristupi KBT-a podjednako učinkoviti u liječenju depresije. Međutim, kvaliteta tih dokaza je jako niska zbog malog broja istraživanja koja su i loše kvalitete, a koja su uključena u ovaj pregled literature. Zbog toga nije moguće zaključiti je li pristup trećeg vala KBT-a učinkovitiji i prihvatljiviji za pacijente od ostalih psiholoških terapija u kraćem ili tijekom dužeg vremenskog perioda. Uzevši u obzir rastuću popularnost pristupa trećeg vala KBT u kliničkoj praksi, daljnja istraživanja bi trebala prvenstveno utvrditi je li pristup trećeg vala KBT-a pomaže više nego ostale psihološke terapije u liječenju osoba s akutnom depresijom.
Preveo: Ivan Buljan
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: email@example.com
Description of the condition
Major depression is characterised by persistent low mood and loss of interest in pleasurable activities, accompanied by a range of symptoms, including weight loss, insomnia, fatigue, loss of energy, inappropriate guilt, poor concentration and morbid thoughts of death (APA 2000). Somatic complaints are also a common feature of depression, and people with severe depression might develop psychotic symptoms (APA 2000).
Depression is the third leading cause of disease burden worldwide and is expected to show a rising trend over the next 20 years (WHO 2004; WHO 2008). A recent European study has estimated the point prevalence of major depression and dysthymia (a mild long-term form of depression) at 3.9% and 1.1%, respectively (ESEMeD/MHEDEA 2004). As the largest source of non-fatal disease burden in the world, accounting for 12% of years lived with disability (Ustun 2004), depression is associated with marked personal, social and economic morbidity and loss of functioning and productivity and creates significant demands on service providers in terms of workload (NICE 2009). Depression is also associated with a significantly increased risk of mortality (Cuijpers 2002). The strength of this association, even when confounders such as physical impairment, health-related behaviours and socio-economic factors are taken into account, has been shown to be comparable with, or greater than, the strength of the association between smoking and mortality (Mykletun 2009).
Description of the intervention
Clinical guidelines recommend pharmacological and psychological interventions, alone or in combination, for the treatment of moderate to severe depression (NICE 2009). The prescribing of antidepressants has increased dramatically in many Western countries over the past 20 years, mainly with the advent of selective serotonin reuptake inhibitors and newer agents such as venlafaxine, and antidepressants remain the mainstay of treatment for depression in healthcare settings (Ellis 2004; NICE 2009).
Whilst antidepressants are of proven efficacy in acute depression (Cipriani 2005; Guaiana 2007; Arroll 2009; Cipriani 2009; Cipriani 2009a; Cipriani 2009b), adherence rates remain very low (Hunot 2007; van Geffen 2009), in part because of patients' concerns about side effects and possible dependency (Hunot 2007). Furthermore, surveys consistently demonstrate patients' preference for psychological therapies over antidepressants (Churchill 2000; Riedel-Heller 2005). Therefore, psychological therapies can provide an important alternative or adjunctive intervention for depressive disorders.
A diverse range of psychological therapies is now available for the treatment of common mental disorders (Pilgrim 2002). Psychological therapies may be broadly categorised into four separate philosophical and theoretical schools, comprising psychoanalytic/dynamic (Freud 1949; Klein 1960; Jung 1963), behavioural (Watson 1924; Skinner 1953; Wolpe 1958), humanistic (Maslow 1943; Rogers 1951; May 1961) and cognitive approaches (Lazarus 1971; Beck 1979). Each of these four schools incorporates several differing and overlapping psychotherapeutic approaches. Some psychotherapeutic approaches, such as cognitive analytic therapy (Ryle 1990), explicitly integrate components from several theoretical schools. Other approaches, such as interpersonal therapy for depression (Klerman 1984), have been developed to address characteristics considered to be specific to the disorder of interest.
Increasing interest in the role of cognition gave rise to a ‘cognitive revolution’ in the field of psychology in the 1970s (Mahoney 1978). The most influential approaches were rational emotive behaviour therapy (Ellis 1962), cognitive behaviour modification (Meichenbaum 1977) and cognitive therapy (Beck 1979). The latter developed as an approach to understanding and treating depression. However, both Beck and Ellis acknowledged the value of behaviour therapy (Rachman 1997), and during the 1980s and 1990s, the two approaches were merged to form cognitive-behavioural therapy (CBT).
CBT is generally regarded as a family of allied therapies (Mansell 2008) that draw on a common base of behavioural and cognitive models of psychological disorders and utilise a set of overlapping techniques (Roth 2008). In CBT, cognition is central to the treatment of psychological disorders, with emotions and behaviour thought to be mediated by cognitive processes. The fundamental aim of CBT is to identify unhelpful cognitions or ‘negative automatic thoughts’ derived from long-standing negative beliefs/assumptions about the self, other people or the world. The CBT model proposes that by challenging their meaning and eliciting more realistic thoughts and assumptions, emotions and behaviours can be changed (Clark 1995). An extensive evidence base is available on the effectiveness of CBT, which is recommended as the first-line psychological therapy approach for depression (NICE 2009).
Although the evolution of CBT over the past three decades has tended to overshadow approaches that are more behavioural in nature, evidence supporting purely behavioural approaches has continued to emerge. The findings from Jacobson 1996, a component analysis trial of CBT, suggested that behavioural components alone might work just as well as CBT. These findings revitalised interest in purely behavioural treatments for depression and the development of a more fully realised behavioural intervention based on a contextual approach (Martell 2001).
Prompted by continuing debate in this area, a recent systematic review of 17 randomised controlled trials (RCTs) demonstrated equivalence between CBT and behavioural therapy in terms of depression recovery rates, symptom levels and participant dropout (Ekers 2008). Proponents of a new generation of behavioural therapies, the ‘third wave’ of CBT (Hayes 2004; Hofmann 2010), have suggested that rational challenging of thoughts (a principal feature of CBT interventions) is less important than was believed (Longmore 2007) and have sought new strategies by which change can be achieved (Segal 2002). Whilst differing perspectives on which approaches should be categorised as third wave interventions continue to be put forth (Hofmann 2010), those frequently described by experts in the field as third wave include acceptance and commitment therapy (ACT) (Hayes 2004), compassionate mind training (CMT) (Gilbert 2005), functional analytic psychotherapy (FAP) (Kohlenberg 1991), metacognitive therapy (MCT) (Wells 2008), mindfulness-based cognitive therapy (MBCT) (Teasdale 1995), dialectical behaviour therapy (DBT) (Linehan 1993), and the expanded model of behavioural activation (BA) (Martell 2001) (see Types of interventions section for a detailed description of each type of therapy).
How the intervention might work
Third wave CBT approaches conceptualise cognitions and cognitive thought processes as psychological or 'private' events (Hayes 2006; Hofmann 2008) and target the emotional response to the situation, focusing primarily on the function of cognitions, such as thought suppression (trying to suppress distressing thoughts) or experiential avoidance (trying to avoid any thoughts, feelings and memories that are causing distress) (Hofmann 2008). This contrasts with traditional CBT, which links thoughts, feelings and behaviours and targets the situation or trigger that generates the emotional response, encouraging cognitive appraisal of these triggers and focusing on changing the content of cognitions.
Third wave approaches use strategies such as mindfulness exercises (eg, body scan, mindfulness of senses meditation), acceptance of unwanted thoughts and feelings and/or cognitive defusion (stepping back and seeing thoughts as just thoughts) to elicit change in the thinking process and to reduce symptoms of depression. Whilst third wave CBT methods are more often delivered in an experiential rather than didactic manner (Hayes 2004), features of traditional behavioural and cognitive therapies, such as goal setting, exposure and skills acquisition (Hayes 2006), continue to play an important role in helping to reduce depressive symptoms.
Why it is important to do this review
Corrigan 2001 suggested that proponents of third wave CBT approaches were ‘getting ahead of the data'. However, over the past twelve years, an increasing number of third wave CBT trials have been conducted, and the findings have been summarised in several systematic reviews. For example, Hayes and colleagues conducted a narrative review across all conditions/disorders to provide empirical support for dialectical behaviour therapy (DBT) (a treatment used most commonly for borderline personality disorder), functional analytic psychotherapy (FAP) and acceptance and commitment therapy (ACT), but no meta-analyses were conducted (Hayes 2004). Another systematic review of mindfulness-based cognitive therapy (MBCT) focused on prevention of relapse or recurrence of major depression (Coelho 2007). Ost 2008 undertook a review and meta-analysis of third wave CBT approaches for any disorder compared with treatment as usual or any other intervention, and drew attention to the ‘less stringent’ research methodology used in third wave treatment RCTs. However, for each third wave approach, effect sizes were calculated across disorders, rather than by individual disorder. Other reviews of psychological therapies for depressive disorders have not attempted to differentiate between CBT and third wave CBT approaches (Churchill 2001; Cuijpers 2008).
Amongst CBT practitioners, much interest has been expressed in the application of third wave CBT approaches, and the updated National Institute for Health and Care Excellence treatment guidelines for depression (NICE 2009) have already recommended MBCT specifically for preventing depression in patients who have had three or more episodes of depression. Although these guidelines also recommend the use of behavioural activation (BA) for moderate to major depressive disorder, they acknowledge that the evidence for BA is currently less robust. Furthermore, the reviews upon which the recommendation for BA was based, in keeping with the approach of other recent systematic reviews, combined studies using pure behavioural therapy with those using an ‘extended’ behavioural activation approach (Churchill 2001; Cuijpers 2008; Ekers 2008; NICE 2009), the latter of which is increasingly regarded as a third wave CBT intervention because of its explicit focus on moving attention away from depressive 'ruminative' thoughts (Addis 2004).
Given the popularity of third wave CBT approaches and the growing body of evidence, a comprehensive review of the effectiveness and acceptability of third wave CBT interventions for depression is required to inform clinical practice and future clinical guideline development. This review serves as part of a programme of 12 reviews covering behavioural, cognitive-behavioural, psychodynamic, interpersonal, cognitive analytic and other integrative, humanistic and third wave cognitive and behavioural psychological therapies, all compared with treatment as usual or with one another.
Summary of main results
This review aimed to assess the efficacy and acceptability of third wave CBT on the basis of three planned comparisons: all third wave CBT approaches compared with all other psychological therapies, different third wave CBT approaches compared with all other psychological therapies and all third wave CBT approaches compared with different psychological therapy approaches (CBT, BT, psychodynamic, humanistic and integrative therapies).
A total of three studies (144 participants) were included in the review. Results showed no evidence based on dropout rates of any difference between third wave CBT and other psychological therapies in terms of efficacy (RR of clinical response 1.14, 95% CI 0.79 to 1.64) or acceptability (RR 1.12, 95% CI 0.47 to 2.67) at post-treatment. Results at 2-month follow-up showed no evidence of any difference between third wave CBT and other psychological therapies in terms of clinical response (2 studies, 56 participants, RR 0.22, 95% CI 0.04 to 1.15).
Results showed no evidence of any difference in terms of efficacy and acceptability between the two individual third wave CBT approaches of ACT and extended BA when compared with all other psychological therapies. Similarly, results showed no evidence of any difference in terms of efficacy and acceptability between third wave CBT and the individual psychological therapy approach of CBT.
Overall completeness and applicability of evidence
Although every possible effort was made to identify relevant trials, the number of studies currently included in this review is very small. Given increasing interest and more frequent application of third wave CBT approaches over the past ten years, the possibility that some studies may have been missed, either unpublished or in grey literature, cannot be discounted.
All three studies were conducted in North America, and two were conducted before 1990. Therefore, applicability of the findings to contemporary healthcare settings and non-US settings is uncertain.
When recruiting participants, only one of the studies used diagnostic inclusion criteria in a standardised clinical interview to identify potential participants with depression. Nevertheless, whilst it is unclear to what extent many of the participants included in the review met full DSM criteria for major depressive disorder, it could be argued that recruitment of participants based on depression rating scales would be representative of those presenting with depression symptoms in primary care.
Most mindfulness-based third wave CBT, including FAP, CMT, MBCT, DBT and meta-cognitive therapy, were not represented at all in the current version of the review. The lack of MBCT studies to date is likely to be explained by the use of this approach as a relapse prevention intervention for people in remission, hence it is beyond the scope of this review. Similarly, lack of DBT and metacognitive therapy studies may be due to their predominant use in populations with mental health disorders other than depression. A recent search of clinicaltrials.gov conducted by our review team, using the search term 'mindfulness', retrieved more than 300 registered ongoing trials; however, very few of these trials appear to target populations with acute depression. Comparator psychological therapy approaches were equally under-represented in the review, with CBT used as the comparator intervention in all three studies.
None of the studies included all of the primary and secondary outcomes of interest in this review, and in particular, and none reported on quality of life, adverse events or economic outcomes. Beck 2012 comments that a certain equivalence between psychological therapy models may occur in a well-designed study, but that an essential feature of the efficacy of a psychological therapy approach is its durability over an extended time. However, follow-up data in the current review were limited to two-month follow-up and were collected in only two of the three studies; therefore evidence for the sustained effect of third wave CBT compared with other psychological therapy approaches remains very limited.
Quality of the evidence
The quality of evidence for each of our main outcomes was very low (Summary of findings for the main comparison). The most common reasons for downgrading were imprecision, indirectness of evidence and risk of bias in all outcomes. All analyses included no more than three studies, two of which had very small sample sizes, resulting in wide confidence intervals and lack of statistical power to assess the relative effects between third wave CBT approaches and other psychological therapies. The psychological therapies examined in the three studies were limited to two third wave CBT approaches and just one comparator psychological therapy approach, thus offering a restricted version of the main review question in terms of intervention and comparator. The acceptability outcome was also downgraded on the grounds of inconsistency, which remained unexplained because of the small number of studies included in the review.
Each of the three studies included in this review described its assignment procedure as 'randomised'; however, only one study provided information on sequence generation and allocation concealment methods used. Lack of information in two studies introduces considerable uncertainty as to whether bias may have been introduced during the allocation process, leading to the decision to assess these risk of bias domains as unclear across studies.
Testing of therapists' fidelity to treatment manuals through systematic or random checking of videotapes/audiotapes against standardised checklists by independent clinicians is a key methodological requirement of psychological therapy studies to provide certainty that any observed treatment effect can be attributed to specific components and characteristics of the model. All three studies used audiotapes, a random selection of which were assessed for fidelity by independent assessors. However, only one study used standardised checklists (Dimidjian 2004), and competence was not measured consistently for each psychological therapy approach under evaluation in any of the studies. Therefore the extent to which bias was minimised in the delivery of therapy approaches across studies is unclear.
Another common source of bias in psychological therapy trials is that of researcher allegiance, whereby trialists responsible for developing the manuals/protocols under evaluation might be considered to have a vested interest in their superior efficacy over other approaches. Each of the studies included in this review were exposed to this form of bias, as authors were involved in development of the therapy or were associated with those who had developed the psychological therapy under investigation. It is notable that Dimidjian 2004 did attempt to mitigate the effect of researcher allegiance to extended BA by including on the research team clinicians with an allegiance to CBT, although researcher allegiance is acknowledged by the authors as a possible limitation of the study. The studies by Zettle 1984 and Zettle 1989 were assessed as vulnerable to researcher allegiance, as the first author (who was also a therapist in both studies) was supervised by Dr Steve Hayes, the psychologist who developed ACT. Overall, therefore, the presence of researcher allegiance towards the third wave CBT approaches under evaluation might have resulted in less favourable findings for other psychological therapies.
Therapist qualifications and experience are regarded as one further potential source of bias in psychological therapy studies, as the risk of unqualified or inadequately trained therapists delivering the intervention without skill and accuracy is considered high. Whilst Dimidjian 2004 employed highly trained clinicians, the BA therapists had an average of seven years' experience, in contrast with the CT therapists, who had been in clinical practice for a much longer average time of 14 years. The other two studies employed less-experienced clinicians, including a CT intern (Zettle 1984) and a qualified psychologist assisted by a psychology graduate (Zettle 1989), who provided both therapies. Therefore, the risk of less skilled and accurate delivery of third wave therapy approaches and/or other psychological therapies was high across all three studies.
Potential biases in the review process
Whilst two of the review authors specialise in CBT (TAF is a diplomate of the Academy of Cognitive Therapy, and VH provides CBT in independent practice), no therapists specialising in other psychological therapy approaches have been included on the review team; therefore the possibility of a bias towards CBT cannot be excluded.
While developing the third wave cognitive and behavioural therapies review, we have aimed to be transparent about our management of the third wave therapy classification. We have held regular team meetings to ensure 100% consensus on the categorisation of approaches, and where any uncertainties remained because of lack of information provided in the articles, we have made contact with the study authors to obtain a fuller description. We acknowledge that there is likely to be considerable debate over which CBT approaches should be regarded as 'third wave' in theoretical principle. We acknowledge, too, that the decision to combine a diverse group of third wave approaches for the purposes of conducting comparisons with other psychological therapy approaches is open to debate. In future versions of the review, it may be necessary to reconsider our management of the categories based on further development of psychological therapy models and approaches. It is possible too that as the evidence base grows, scope will be adjusted to allow management of the approaches in separate reviews.
Perhaps the most contentious decision in this review was to categorise the extended version of BA as a third wave CBT approach. We note that this decision contrasts with the approach of previous reviews, in which extended BA has been regarded as a form of BT. Whilst acknowledging the common components, we decided that the addition of behavioural strategies for targeting rumination, including 'an emphasis on the function of ruminative thinking and on moving attention away from the content of ruminative thoughts towards direct, immediate experience' (Dimidjian 2004), in extended BA set it apart from earlier BA approaches and placed it more in line with third wave approaches.
To address the over-arching question of whether third wave CBT is more effective and acceptable than other psychological therapies, the comparison between third wave CBT and all other psychological therapy approaches was selected as the main comparison in the protocol. This meant that the overall comparator of all other psychological therapies included a wide range of approaches (BT, CBT, psychodynamic, humanistic, integrative therapies) with the potential for differing levels of efficacy. It could be argued that results of the comparison between third wave CBT and different psychological therapy approaches would be more meaningful than results of the comparison between third wave CBT and all other psychological approaches combined. However, the findings would be limited by the small number of studies for inclusion in each analysis, thereby reducing the ability of review authors to draw any meaningful conclusions.
Agreements and disagreements with other studies or reviews
Two previous systematic reviews of third wave CBT approaches have limited their remit to participants in remission from depression who have attended an MBCT course (Coelho 2007) or have not conducted meta-analyses (Hayes 2004).
The systematic review and meta-analysis by Ost 2008 included 29 studies that examined five different third wave behavioural therapies (ACT, DBT and FAP, as covered in the current review, together with the cognitive-behavioural analysis sytem of psychotherapy and integrative behavioural couple therapy) against other psychological therapies, medication and other interventions for a wide range of different disorders, including borderline personality disorder, eating disorders, epilepsy and smoking, as well as depression. Effect sizes were calculated for each third wave approach across all disorders (Ost 2008), precluding the ability to make comparisons with the current review.
Two systematic reviews have examined the efficacy of behavioural activation treatments (Cuijpers 2008; Ekers 2008), but neither attempted to differentiate between the extended BA model developed by Martell 2001 and the 'pure' BT approach originally evaluated in the seminal trial by Jacobson 1996; therefore the findings are not comparable with those of the current review.
A recently published systematic review and network analysis examined the efficacy of seven psychological therapies for individuals with depression (Barth 2013); however, third wave CBT interventions were not managed in a separate category. Therefore, no comparable findings are available. It is notable, too, that the authors included Internet-delivered therapies, as well as those delivered face to face, together with studies of participants whose primary disorder was a medical condition, resulting in a more heterogeneous set of populations and interventions than those included in the current review.
We would like to extend our grateful thanks to Dr Robert Zettle for providing us with additional data from his studies.
Our grateful thanks are also extended to Professor Willem Kuyken, University of Exeter, for his guidance on the assessment/categorisation of psychological therapy manuals and protocols.
CRG Funding Acknowledgement
The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Depression, Anxiety and Neurosis Group.
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, the NHS or the Department of Health.
Appendix 1. CCDAN-CTR References Register search (psychotherapies for depression)
|1||Title/Abstract=||therap* or psychotherap*|
|3||Free-Text=||acceptance* or commitment* or “activity scheduling” or adlerian or art or aversion or behvio* or brief or “client cent*” or cognitive* or color or colour or compassion-focused or “compassion* focus*” or compassionate or conjoint or conversion or conversational or couples or dance or dialectic* or diffusion or distraction or eclectic or (emotion and focus*) or emotion-focus* or existential or experiential or exposure or expressive or family or focus-oriented or “focus oriented” or freudian or gestalt or “group” or humanistic or implosive or insight or integrative or interpersonal or jungian or kleinian or logo or marital or metacognitive or meta-cognitive or milieu or morita or multimodal or multi-modal or music or narrative or nondirective or non-directive or “non directive” or nonspecific or non-specific or “non specific” or “object relations” or “personal construct” or “person cent*” or person-cent* or persuasion or play or ((pleasant or pleasing) and event*) or primal or problem-focused or “problem focused” or problem-solving or “problem solving” or process-experiential or “process experiential” or psychodynamic or “rational emotive” or reality or “reciprocal inhibition” or relationship* or reminiscence or restructuring or rogerian or schema* or self-control* or “self control*” or “short term” or short-term or sex or “social effectiveness” or “social skill*” or socio-environment* or “socio environment*” or “solution focused” or solution-focused or “stress management” or supportive or time-limited or “time limited” or “third wave” or transference or transtheoretical or validation|
|4||Free-Text=||(abreaction or “acting out” or “age regression” or ((assertive* or autogenic or mind or sensitivity) and train*) or autosuggestion or “balint group” or ((behavior* or behaviour*) and (activation or therap* or treatment or contracting or modification)) or biofeedback or catharsis or cognitive* or “mind training” or counsel* or “contingency management” or countertransference or “covert sensitization” or “eye movement desensiti*” or “crisis intervention” or “dream analysis” or “emotional freedom” or “free association” or “functional analys*” or griefwork or “guided imagery” or hypno* or imagery or meditation* or “mental healing” or mindfulness* or psychoanaly* or psychodrama or psychoeducat* or “psycho* support*” or psychotherap* or relaxation or “role play*” or “self analysis” or “self esteem” or “sensitivity training” or “support* group*” or therapist or “therapeutic technique*” or “transactional analysis”)|
|5|| ||((1 or 2) and 3) or 4|
|6||Title/Abstract=||(depress* or dysthymi*)|
|7|| ||5 and 6|
|8||Tagged to CCDANCTR-Study=||Empty|
|9|| ||7 and 8|
Appendix 2. CINAHL and PSYNDEX search strategies
Psychotherapies for depression (n1114) 2010-05-19 (310 duplicates—CCDAN Registers)
EBSCO CINAHL (Cumulative Index to Nursing and Allied Health Literature) was searched as follows:
1. (MH "Clinical Trials+")
2. TI (clinic* N1 trial*) or AB (clinic* N1 trial*)
3. TI ((singl* or doubl* or trebl* or tripl*) and (blind* or dummy or mask)) or AB ((singl* or doubl* or trebl* or tripl*) and (blind* or dummy or mask))
4. TI ( randomi?ed or randomly) or AB (randomi?ed or randomly)
5. AB (random* N3 allocat*) or AB (random* N3 assign*)
6. (MH "Random Assignment")
7. PT clinical trial
8. (MH "Placebos")
9. TI placebo* or AB placebo*
10. AB (control N3 trial*) or AB (control N3 study) or AB (control N3 studies)
11. S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10
12. (MM "Depression+")
13. (MM "Psychotherapy+")
14. (MH "Psychotherapy+")
15. (MM "Psychological Processes and Principles+")
16. (MM "Behavior and Behavior Mechanisms+")
17. (acceptance* or commitment* or “activity scheduling” or adlerian or art or aversion or brief or “client cent*” or cognitive or color or colour or “compassion focused” or compassionate or conjoint or conversion or conversational or couples or dance or dialectic* or diffusion or eclectic or (emotion* W1 focus*) or existential or experiential or exposure or expressive or family or (focus W1 oriented) or gestalt or group or humanistic or implosive or insight or integrative or interpersonal or marital or metacognitive or milieu or morita or multimodal or “multi-modal” or music or narrative or nondirective or “non-directive” or “non directive” or nonspecific or “non-specific” or “non specific” or “object relations” or “personal construct” or “person cent*” or persuasion or play or “pleasant event*” or primal or “problem-focused” or “problem focused” or “problem-solving” or “problem solving” or “process-experiential” or “process experiential” or psychodynamic or “rational emotive” or reality or “reciprocal inhibition” or relationship* or reminiscence or restructuring or schema* or “self-control*” or “self contol*” or “short term” or “short-term” or sex or “social effectiveness” or “social skill*” or socioenvironmental or “solution focused” or “stress management” or supportive or “time-limited” or “time limited” or transference or transtheoretical or validation)
18.(S13 or S14 or S15 or S16) and S17
19. behavio#r W3 modification*
20. behavio#r W3 contract*
21. behavio#r W3 treat*
22. behavio#r W3 therap*
23. (sensitivity W3 train*)
24. (mind W3 train*)
25. (autogenic W3 train*)
26. (assertive* W3 train*)
27. (autosuggestion or “balint group” or biofeedback or catharsis or cognitive or “mind training” or counsel* or “contingency management” or countertransference or “covert sensitization” or “eye movement desensiti*” or “crisis intervention” or distraction or “dream analysis” or “emotional freedom” or “free association” or freudian or “functional analys*” or griefwork or “guided imagery” or hypno* or imagery or jungian or kleinian or meditation* or “mental healing” or mindfulness* or psychoanaly* or psychodrama or psychoeducat* or “psycho* support*” or psychotherap* or relaxation or rogerian or “role play*” or “self analysis” or “self esteem” or “sensitivity training” or “support* group*” or therapist or “therapeutic technique*” or third-wave or “third wave” or “transactional analysis”)
28.S13 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27
29. S11 and S12 and S28
OVID PSYNDEX Search Strategy (11 June 2010, 726 records NOT de-duplicated)
1. Clinical Trials.sh.
2. Treatment Effectiveness Evaluation.sh.
3. Mental Health Program Evaluation.sh.
9. ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$ or dummy)).mp.
10. clinical study.ep.
11. experimental study.md.
12. multicenter study.md.
13. (zugewiesen and kontrollgruppe$).ab.
15. ((zufa?ll$ or randomi$) and (experiment$ or evalu$ or effe?t$) and treat$).mp.
16. (doppelblind$ or doppel-blind$).ti,ab.
18. major depression/ or anaclitic depression/ or dysthymic disorder/ or endogenous depression/ or postpartum depression/ or reactive depression/ or recurrent depression/ or treatment resistant depression/
19. atypical depression/
21. exp Psychotherapy/
(psychotherapy/ or adlerian psychotherapy/ or analytical psychotherapy/ or autogenic training/ or behavior therapy/ or brief psychotherapy/ or client centered therapy/ or cognitive behavior therapy/ or conversion therapy/ or eclectic psychotherapy/ or emotion focused therapy/ or existential therapy/ or experiential psychotherapy/ or expressive psychotherapy/ or eye movement desensitization therapy/ or feminist therapy/ or geriatric psychotherapy/ or gestalt therapy/ or group psychotherapy/ or guided imagery/ or humanistic psychotherapy/ or hypnotherapy/ or individual psychotherapy/ or insight therapy/ or integrative psychotherapy/ or interpersonal psychotherapy/ or logotherapy/ or narrative therapy/ or persuasion therapy/ or primal therapy/ or psychoanalysis/ or psychodrama/ or psychodynamic psychotherapy/ or psychotherapeutic counseling/ or rational emotive behavior therapy/ or reality therapy/ or relationship therapy/ or solution focused therapy/ or supportive psychotherapy/ or transactional analysis/)
22. exp Behavior Therapy/
(behavior therapy/ or aversion therapy/ or conversion therapy/ or dialectical behavior therapy/ or exposure therapy/ or implosive therapy/ or reciprocal inhibition therapy/ or response cost/ or systematic desensitization therapy/)
23. exp Cognitive Behavior Therapy/
(cognitive behavior therapy/ or acceptance and commitment therapy/)
24. exp Cognitive Techniques
(cognitive techniques/ or cognitive restructuring/ or cognitive therapy/ or self instructional training/)
26. Group Psychotherapy/
(group psychotherapy/ or encounter group therapy/ or therapeutic community/)
27. Milieu Therapy/
28. Family Therapy/ or Couples Therapy/ or Cotherapy/ or Conjoint Therapy/ or Sex Therapy/
29. Educational Therapy/ or Psychoeducation/
30. exp Psychotherapeutic processes/
(psychotherapeutic processes/ or contertransference/ or insight (psychotherapeutic process) or negative therapeutic reaction/ or psychotherapeutic breakthrough/ or psychotherapeutic resistance// or psychotherapeutic transference/ or therapeutic alliance/)
31. exp Psychotherapeutic techniques/
(psychotherapeutic techniques/ or animal assisted therapy/ or autogenic training/ or cotherapy/ or dream analysis/ or guided imagery/ or mirroring/ morita therapy/ or motivational interviewing/ or mutual storytelling technique/ or paradoxical techniques/ or psychodrama/)
32. exp Psychoanalysis/
(psychoanalysis or alderian psychotherapy/ or dream analysis/ or self analysis/)
33 Covert Sensitization/
34. Behavior Contracting/
35. exp Biofeedback/
(biofeedback/ or biofeedback training/ or neurofeedback/)
36. Assertiveness Training/ or Behavior Modification/ or Sensitivity Training/
37. Social Skills Training/
38. exp Counseling/
39. exp Contingency Management/
(contingency management/ or token economy programs/)
40. Functional Analysis/
41. exp Problem Solving/
(problem solving/ or anagram problem solving/ or cognitive hypothesis testing/ or group problem solving/ or heuristics/)
42. exp Relaxation Therapy/
(relaxation therapy/ or progressive relaxation therapy/)
43. Meditation/ or Mindfulness/
44. Stress Management/
45. Self Control/
46. Existential Therapy/
47. Gestalt Therapy/
48. exp Jungian Psychology/
(Jungian Psychology/ or Collective Unconscious)
49. Free Association/
50. Object Relations/
51. Multimodal Treatment Approach/
52. Acting Out/
53. exp Hypnotherapy/
(hypnotherapy/ or age regression/)
54. exp Hypnosis/
(hypnosis/ or age regression (hypnotic) or autohypnosis)
55. exp Creative Arts Therapy/
(creative arts therapy/ or art therapy/ or dance therapy/ or music therapy/ or poetry therapy/ or recreation therapy/)
57. Crisis Intervention/
58. Play Therapy/
59. (third wave or mind train* or person cent* or person* construct*).mp.
60. (person cent* or person* construct*).mp.
61. (activity scheduling or behavioral activation or pleasant event*).mp.
62. ((therap* or psychotherap*) adj1 (abreaction or analytic* or color or colour or compassion or diffusion or distraction or emotion* or interpersonal or inter-personal* or insight oriented or focus* or functional anal* or metacognitive or nondirective or non directive or problem focus* or process experiential or reciprocal inhibition or reminiscence or socioenvironmental or socio environmental or supportive or transference or transtheoretical)).mp.
63. (freudian or jungian or klenian or rogerian).mp.
65. mental healing.mp.
67. (17 and 20 and 66)
Contributions of authors
Vivien Hunot provided theoretical and clinical expertise for designing this programme of 12 linked reviews of psychotherapies for depression, drawing from her training and clinical practice as a psychotherapeutic counsellor and cognitive-behavioural therapist in NHS settings and in independent practice. She worked on protocol development, developing a search strategy and compiling data extraction forms, and wrote the protocols for each review. Dr Hunot is responsible for writing and preparing this review. Along with Dr Rachel Churchill, she conducted the original review on which this programme is based.
Theresa HM Moore managed the organisation of data for the 12 linked reviews of psychotherapies for depression, including documenting search results, tracking papers, and managing references for the project. She developed the initial version of the data collection forms. She also designed the database and spreadsheets for data collection and contributed to writing sections of the protocols/commented on text of the protocols.
Deborah Caldwell provided methodological and statistical advice for each of 12 linked protocols assessing the effects of different psychotherapies for depression. She contributed to the design of the data extraction form, drafted some sections of the protocols and commented on the protocol manuscripts. She designed the plan for the multiple treatment meta-analysis for the overview of reviews.
Philippa Davies contributed to the design of the review and the development of the protocol.
Glyn Lewis provided a clinical perspective on 12 linked psychotherapies for depression protocols.
Rachel Churchill conceived, designed, secured funding for and is managing this programme of linked reviews. She worked on all aspects of development of this project, including building and managing the review team, developing the protocol, devising a search strategy, compiling data extraction forms and compiling the overall dataset. Along with Dr Vivien Hunot, she conducted the original review on which this programme is based and has directly contributed to all aspects of drafting this manuscript. She is the guarantor of the individual reviews in this programme of work.
Hannah Jones read and commented on the protocols.
Toshi Furukawa provided theoretical and clinical expertise for this programme of linked reviews. He is Diplomate of the Academy of Cognitive Therapy (Philadelphia). He commented on the protocol manuscripts, helped revise the data extraction and summary forms, extracted data and contacted the original authors of relevant studies.
Mina Honyashiki and Peiyao Chen extracted the data, contributed to the development of the revised data extraction and summary form, managed and organised the data extraction and summary process.
Declarations of interest
Two of the review authors (TAF and VH) specialise in cognitive-behavioural therapies.
No conflicts are known for other review authors.