Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care : A Network Meta-Analysis

PURPOSE:  Most patients with depression are treated by general practitioners, and most of those patients prefer psychotherapy over pharmacotherapy. No network meta-analyses have examined the effects of psychotherapy compared with pharmacotherapy, combined treatment, care as usual, and other control conditions among patients in primary care.

METHODS: We conducted systematic searches of bibliographic databases to identify randomized trials comparing psychotherapy with pharmacotherapy, combined treatment, care as usual, waitlist, and pill placebo. The main outcome was treatment response (50% improvement of depressive symptoms from baseline to end point).

RESULTS:  A total of 58 studies with 9,301 patients were included. Both psychotherapy and pharmacotherapy were significantly more effective than care as usual (relative risk [RR] for response=1.60; 95% CI, 1.40-1.83 and RR=1.65; 95% CI, 1.35-2.03, respectively) and waitlist (RR=2.35; 95% CI, 1.57-3.51 and RR=2.43; 95% CI, 1.57-3.74, respectively) control groups. We found no significant differences between psychotherapy and pharmacotherapy (RR=1.03; 95% CI, 0.88-1.22). The effects were significantly greater for combined treatment compared with psychotherapy alone (RR=1.35; 95% CI, 1.00-1.81). The difference between combined treatment and pharmacotherapy became significant when limited to studies with low risk of bias and studies limited to cognitive behavior therapy.

CONCLUSIONS: Psychotherapy is likely effective for the treatment of depression when compared with care as usual or waitlist, with effects comparable to those
of pharmacotherapy. Combined treatment might be better than either psychotherapy or pharmacotherapy alone.