What Are the Best, Most Effective Psychological Interventions?

A review and meta-analysis in BMC Psychiatry attempted to compare the effectiveness of different psychological interventions—including cognitive behavioral therapy, psychoeducation, and guided self-help—delivered through different vehicles and by different healthcare professionals. What they found is that it is very difficult to definitively assess the effectiveness of each of these different approaches in relation to one another.

The researchers conducted a meta-analysis of 30 randomized trials comparing psychological treatments with usual care or placebo controls in depressed primary care patients. They included randomized controlled trials that compared psychological or combined psychological and pharmacological interventions with one another, a pharmacological intervention, usual care or placebo in the treatment of adult primary care patients suffering from prevalent or incident unipolar depressive disorders. Trials had to report results on at least one of the following outcomes: response to treatment, remission of symptoms, mean score on a depression scale (post-treatment or change from baseline), or study discontinuation.

One key challenge of the review is grouping the psychological interventions in a meaningful way, given that psychological treatments are complex and often multi-faceted. The study authors described their methods: “We grouped interventions according to the following dimensions: (1) theoretical background: cognitive behavioral therapy (CBT) vs. problem solving therapy (PST) vs. interpersonal therapy vs. psychodynamic therapies vs. other interventions; (2) intensity of contact with health care professional: intensively therapist-lead (with a minimum of six sessions) vs. guided self-help (with less than six sessions with the therapist) vs. no or minimal contact (with less than 90 minutes contact) interventions; and (3) face-to-face vs. remote contact interventions.”

A total of 37 studies with 7,024 patients met the inclusion criteria. Among the psychological treatments investigated in at least 150 patients, face-to-face CBT, face-to-face counselling and psychoeducation, CBT led by remote therapist, guided self-help CBT, and even minimal contact CBT were superior to usual care or placebo, but not superior to face-to-face problem-solving therapy and face-to-face interpersonal therapy. “Findings suggest that psychological interventions with a cognitive behavioral approach are promising, and primarily indirect evidence indicates that it applies also when they are delivered with a reduced number of therapist contacts or remotely,” the study authors conclude.

Among the more notable findings in the review is that the effectiveness of CBT is only minimally impaired by reducing the number of contacts with health care professionals and by using remote administration in primary care. But, the study authors note, confidence in this finding should remain limited until confirmed in direct head-to-head trials.

Also of interest, note the researchers, “The results on face-to-face interpersonal psychotherapy are somewhat discouraging showing little to no benefit over usual care unless it is combined with pharmacotherapy… Further large trials comparing psychological treatments with each other, with pharmacotherapy, and combinations of psychological and drug treatments under conditions of routine primary care are highly desirable.”