Highlights
- •All control conditions (PillPlacebo, NoTreatment, and PsycholPlacebo) had higher odds ratios for response against Waiting List.
- •The effect sizes obtained in RCTs must be interpreted differently depending on the control condition used.
- •Weaker controls could be used only in the earlier phases of therapy evaluations, but stronger controls should be used in confirmatory studies.
- •Different control conditions produce different effect sizes in psychotherapy randomized controlled trials for depression when they are all considered simultaneously in network meta-analysis : control conditions should no longer be lumped into one comparison group.
Abstract
Objectives
Control conditions’ influence on effect estimates of active psychotherapeutic interventions
for depression has not been fully elucidated. We used network meta-analysis to estimate
the differences between control conditions.
Study Design and Setting
We have conducted a comprehensive literature search of randomized trials of psychotherapies
for adults with depression up to January 1, 2019 in four major databases (PubMed,
PsycINFO, Embase, and Cochrane). The network meta-analysis included broadly conceived
cognitive behavior therapies in comparison with the following control conditions:
Waiting List (WL), No Treatment (NT), Pill Placebo (PillPlacebo), Psychological Placebo
(PsycholPlacebo).
Results
123 studies with 12,596 participants were included. The I-squared was 55.9% (95% CI:
45.9%; to 64.0%) (moderate heterogeneity). The design-by-treatment global test of
inconsistency was not significant (P = 0.44). Different control conditions led to different estimates of efficacy for
the same intervention. WL appears to be the weakest control (odds ratio of response
against NT = 1.93 (1.30 to 2.86), PsycholPlacebo = 2.03 (1.21 to 3.39), and PillPlacebo = 2.66
(1.45 to 4.89), respectively).
Conclusions
Different control conditions produce different effect estimates in psychotherapy randomized
controlled trials for depression. WL was the weakest, followed by NT, PsycholPlacebo,
and PillPlacebo in this order. When conducting meta-analyses of psychotherapy trials,
different control conditions should not be lumped into a single group.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Clinical EpidemiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Depression and other common mental disorders: Global Health Estimates 2017. World Health Organization, Geneva2017 (CC BY-NC-SA 3.0 IGO)
- Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1603-1658
- Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010.PLoS Med. 2013; 10: e1001547
- Prevalence of depression in the Community from 30 countries between 1994 and 2014.Sci Rep. 2018; 8: 2861
- Gender differences in unipolar depression: a general population survey of adults between age 18 to 64 of German nationality.J Affect Disord. 2003; 77: 203-211
- Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223
- A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression.World Psychiatry. 2020; 19: 92-107
- Defining empirically supported therapies.J Consult Clin Psychol. 1998; 66: 7-18
- Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience.Int Rev Psychiatry. 2011; 23: 318-327
- The effects of fifteen evidence-supported therapies for adult depression: a meta-analytic review.Psychother Res. 2020; 30: 279-293
- Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium.Health Psychol. 2004; 23: 443-451
- Control condition design and implementation features in controlled trials: a meta-analysis of trials evaluating psychotherapy for depression.Transl Behav Med. 2014; 4: 407-423
- The selection and design of control conditions for randomized controlled trials of psychological interventions.Psychother Psychosom. 2009; 78: 275-284
- Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis.Plos Med. 2013; 10: e1001454
- Control conditions for randomised trials of behavioural interventions in psychiatry: a decision framework.Lancet Psychiatry. 2017; 4: 725-732
- Magnitude of placebo response and drug-placebo differences across psychiatric disorders.Psychol Med. 2005; 35: 743-749
- Placebo response rates in antidepressant trials: a systematic review of published and unpublished double-blind randomised controlled studies.Lancet Psychiatry. 2016; 3: 1059-1066
- Can effects of antidepressants in patients with mild depression be considered as clinically significant?.J Affect Disord. 2012; 138: 183-191
- Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis.Acta Psychiatr Scand. 2014; 130: 181-192
- A meta-analysis of outcome studies comparing bona fide psychotherapies: Empiricially, “all must have prizes.Psychol Bull. 1997; 122: 203-215
- Is psychotherapy effective? A re-analysis of treatments for depression.Epidemiol Psychiatr Sci. 2019; 28: 268-274
- The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size.Psychol Med. 2010; 40: 211-223
- Conceptual and technical challenges in network meta-analysis.Ann Intern Med. 2013; 159: 130-137
- Comparison of psychotherapies for adult depression to pill placebo control groups: a meta-analysis.Psychol Med. 2014; 44: 685-695
- Cognitive-Behavioural Analysis System of Psychotherapy (CBASP), a drug, or their combination: differential therapeutics for persistent depressive disorder: a study protocol of an individual participant data network meta-analysis.BMJ Open. 2016; 6: e011769
- The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.Ann Intern Med. 2015; 162: 777-784
- Treatment-as-usual (TAU) is anything but usual: a meta-analysis of CBT versus TAU for anxiety and depression.J Affect Disord. 2015; 175: 152-167
- Treatment as usual (TAU) as a control condition in trials of cognitive behavioural-based psychotherapy for self-harm: impact of content and quality on outcomes in a systematic review.J Affect Disord. 2018; 235: 434-447
- Care-as-usual control groups across different settings in randomized trials on psychotherapy for adult depression: a meta-analysis.Psychol Med. 2019; : 1-11
- Evidence-based treatments for depression and anxiety versus treatment-as-usual: a meta-analysis of direct comparisons.Clin Psychol Rev. 2011; 31: 1304-1312
- Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies.J Consult Clin Psychol. 2008; 76: 909-922
- Combining follow-up and change data is valid in meta-analyses of continuous outcomes: a meta-epidemiological study.J Clin Epidemiol. 2013; 66: 847-855
- Pitfalls of using the risk ratio in meta-analysis.Res Synth Methods. 2019; 10: 398-419
- Statistical methods in meta-analysis.Stat Med. 1985; 20https://doi.org/10.2307/1164953
- A meta-analytic database of randomised trials on psychotherapies for depression.2019https://doi.org/10.17605/OSF.IO/825C6
- Cochrane Handbook for Systematic Reviews of Interventions. vol. 5.1.0.(Available at)www.cochrane-handbook.orgDate: 2011
- Imputing response rates from means and standard deviations in meta-analyses.Int Clin Psychopharmacol. 2005; 20: 49-52
- Using network meta-analysis to evaluate the existence of small-study effects in a network of interventions.Res Synth Methods. 2012; 3: 161-176
- Predictive distributions were developed for the extent of heterogeneity in meta-analyses of continuous outcome data.J Clin Epidemiol. 2015; 68: 52-60
- Predicting the extent of heterogeneity in meta-analysis, using empirical data from the Cochrane Database of Systematic Reviews.Int J Epidemiol. 2012; 41: 818-827
- Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies.Res Synth Methods. 2012; 3: 98-110
- Checking consistency in mixed treatment comparison meta-analysis.Stat Med. 2010; 29: 932-944
- A case study of multiple-treatments meta-analysis demonstrates that covariates should be considered.J Clin Epidemiol. 2009; 62: 857-864
- Comparative efficacy and acceptability of first-generation and second-generation antidepressants in the acute treatment of major depression: protocol for a network meta-analysis.BMJ Open. 2016; 6: e010919
- Predicting the extent of heterogeneity in meta-analysis, using empirical data from the Cochrane Database of Systematic Reviews.Int J Epidemiol. 2012; 41: 818-827
- Usual and unusual care: existing practice control groups in randomized controlled trials of behavioral interventions.Psychosom Med. 2011; 73: 323-335
- Was Eysenck right after all? A reassessment of the effects of psychotherapy for adult depression.Epidemiol Psychiatr Sci. 2019; 28: 21-30
- Initial severity of depression and efficacy of cognitive-behavioural therapy: individual-participant data meta-analysis of pill-placebo-controlled trials.Br J Psychiatry. 2017; 210: 190-196
- Selective publication of antidepressant trials and its influence on apparent efficacy.N Engl J Med. 2008; 358: 252-260
Article info
Publication history
Published online: December 14, 2020
Accepted:
December 8,
2020
Footnotes
Author’s contribution: I.M. took part in the conceptualization and in writing the original draft and the review; T.A.F. took part in the conceptualization, methodology, supervision, and writing the original draft and the review; H.N. took part in the formal analysis; S.K., A.O., E.O., M.C., C.M., and E.K. took part in the acquisition of data and analysis and interpretation of data; P.C. took part in the conceptualization, methodology, supervision, and writing the original draft. All authors have approved the version to be submitted.
Toshiaki Furukawa reports personal fees from Mitsubishi-Tanabe, MSD and Shionogi, and a grant from Mitsubishi-Tanabe, outside the submitted work; TAF has a patent 2018-177688 pending. Ioannis Michopoulos has received consultancy fees from Lundbeck. Pim Cuijpers reports support for unrelated grants from the European Commission, and ZonMw, expense allowances for his membership of the Board of Directors of the “Mind.nl,” “Fonds Psychische Gezondheid,” and “Korrelatie,” for being Chair of the PACO Committee of the “Raad voor Civiel-militaire Zorg en Onderzoek” of the Dutch Ministry of Defense, and for being Chair of the Mental Health Priority Area of the Welcome Trust in London, UK, and he receives royalties for books and for occasional workshops and invited addresses. Edoardo Ostinelli has received research and consultancy fees from Angelini Pharma. All other authors report no financial or other conflicts of interest.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
