LOS ANGELES – Several types of psychotherapy are effective for late-life depression, studies show. However, the type of control used in those studies plays an important role in the magnitude of the effect size, findings from a systematic review and meta-analysis suggest.
The findings underscore the value of the supportive aspects of care and the importance of good clinical management in late-life depression, regardless of whether medication is used as part of treatment, Dr. Alice X. Huang said at the annual meeting of the American Association for Geriatric Psychiatry.
Several prior reviews have examined the efficacy of psychotherapy for late-life depression. In a 2005 review that included prior reviews and 17 trials, the investigators concluded that cognitive-behavioral therapy, reminiscence therapy, brief dynamic therapy, and combined medication and interpersonal therapy all are "acutely efficacious" for the treatment of major depression in ambulatory adults (Psychiatr. Clin. N. Am. 2005;28:805-20).
Authors of a 2006 review and meta-analysis that included 25 studies concluded, based on the comparable effect size of various types of psychological treatments, that all types of treatment are equally effective (Int. J. Geriatr. Psychiatry 2006;21:1139-49). Meanwhile, authors of a 2009 Cochrane Review and meta-analysis concluded that their findings were constrained by the heterogeneity of trials and the diversity of control conditions used in the various studies (Cochrane Database Syst. Rev. 2008 Jan 23;(1):CD004853).
Taken together, these studies support the use of various types of psychotherapy for late-life depression. But interestingly, no review has looked at the impact of the type of control group used in clinical trials of psychotherapy, which vary widely, including waitlist, treatment as usual, attention control, supportive therapy, and placebo, said Dr. Huang, a third-year psychiatry resident at the University of California, San Francisco.
In their own review and meta-analysis of 27 trials, including 37 psychotherapy vs. control contrasts, Dr. Huang and her colleagues found that the type of control group used in trials of psychotherapy was related to the effect size of the psychotherapy being tested. The standard mean differences (SMDs) were statistically significant between psychotherapy and waitlist control, treatment-as-usual control, attention control, and supportive therapy control, but not placebo control; the SMDs were lower for the supportive therapy, placebo control, and treatment-as-usual groups, compared with the waitlist control and attention control groups.
The findings are in line with the hypothesis that effect sizes would be larger when psychotherapy is compared with less active treatments, and smaller when it is compared with a control that includes significant clinical management, she explained.
Supportive therapy as a control, and placebo, which included extensive clinical management in the studies that were reviewed, both captured many of the elements of psychotherapy that are effective, she noted.
Studies included in the current review and meta-analysis were conducted between 1981 and 2011, and involved a total of 2,229 patients (mean age, 66-81 years). The studies included lasted anywhere from 4 to 28 weeks (median, 8 weeks). Psychotherapies included in the studies were cognitive-behavioral therapy, cognitive therapy, behavioral therapy, problem solving therapy, interpersonal therapy, brief dynamic therapy, bibliotherapy, reminiscence therapy, and variants of these treatments, she said.
The findings suggest that many nonspecific elements of psychotherapy, which are estimated to account for a large percentage of the effect of psychotherapy in older adults according to prior psychotherapy research, are captured by supportive psychotherapy, and this provides evidence for improved clinical management and supportive care in this population, regardless of whether a specific psychotherapy is indicated, she concluded.
Dr. Huang reported having no financial disclosures.