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Brief interventions for depression in primary care

A systematic review

Correspondence: Dr Jennifer McNaughton, c/o Royal Victoria Hospital, 201 Georgian Dr, Barrie, ON L4M 6M2; e-mailmcnaughtonjl{at}gmail.com

Depression is a multifactorial mood disorder, which affects both males and females across all age groups. The prevalence of major depression in the primary care setting in North America has been reported at rates of 4.8% to 11.1%.¹ These rates could easily be doubled when considering the population prevalence of minor depressive symptoms.² Both major and minor depression have been found to be persistently disabling conditions requiring close monitoring,³ and patients with depression are at increased risk of unfavourable outcomes, such as decreased productivity, increased physical illness, and suicide.⁴ Furthermore, depression places a considerable financial burden on health care systems. A recent Health Canada study suggested that depression and distress cost Canadians at least $14.4 billion annually in treatment, medication, lost productivity, and premature death.⁵

Primary care physicians are the providers most likely to see patients when they first become depressed,⁶ thus they often take on the large responsibility of ensuring provision of treatment and adequate follow-up once a diagnosis of depression is made. It has been established that pharmacotherapy and psychotherapy are of comparable efficacy in the treatment of depression in primary care,⁷ and that the combination of these modalities might be more efficacious than either individually, particularly in preventing relapse.⁸ It has also been shown that many patients prefer psychotherapy to pharmacotherapy.⁹

Most primary care physicians are capable of initiating and monitoring treatment of depression with various pharmacologic agents, but owing to time limitations and lack of knowledge or inexperience with other various modalities, they are often unable to provide effective psychotherapeutic treatment for their patients.¹⁰ Patients are often referred for psychotherapy; however, in many Canadian provinces, these services are difficult to obtain. Therapy provided by licensed physicians specializing in mental health is covered by most provincial health insurance plans, but wait times can be extremely long. Services provided by other health care professionals have shorter waiting lists, but can cost patients anywhere from $40 to $180 per hour.¹¹

Owing to a combination of cost, wait times, and reluctance to be referred to specialists, patients often rely solely on their primary caregivers for psychological support as they struggle with depression. Physicians with minimal training in psychotherapy usually provide some form of informal supportive care to patients and often recommend self-help books or other resources. There is some evidence to show that bibliotherapy (book therapy) using a cognitive-behavioural therapy (CBT) approach can be helpful for some depressed patients.¹² Additional research has shown the potential for CBT to be administered via computer or telephone with minimal therapist contact.^13,14 Current Canadian guidelines for depression management include recommendations for CBT but do not describe types of supportive assistance requiring little psychotherapeutic experience.¹⁵

This review explores what types of effective, brief nonpharmacologic interventions are available for primary care physicians with minimal training in psychotherapy to use in managing depression in adult patients. The review process involved systematic selection of articles, extraction of data with critical appraisal of validity, and qualitative analysis of results.

DATA SOURCES

In January of 2007, 3 computer databases were searched for potentially relevant articles (MEDLINE from 1996 to 2007, EMBASE from 1980 to 2007, and EBM Reviews from 1999 to 2007), using the key words depression, psychotherapy, short term, brief, intervention, primary care, and general practice. Retrieved articles were limited to clinical trial and English language. The search strategy yielded a total of 449 potentially relevant studies (62 articles from MEDLINE, 255 articles from EMBASE, 132 Cochrane Review articles); 63 articles were eliminated because they were duplicates.

Study selection
The titles and abstracts of the remaining 386 articles were reviewed and 45 articles were retrieved for more detailed evaluation. Articles were included in the review if the following criteria were met: (1) the study was a randomized controlled trial; (2) an acceptable definition of depression was used (either recognized diagnostic criteria or a depression rating scale); (3) the intervention was performed by or could be used by a primary care physician with little (< 3 days of training) or no training in psychotherapy; (4) the intervention could be used in a primary care setting without the support of additional health care professionals; (5) outcome measures were clinically relevant (ie, improvement of symptoms on a validated depression scale).

Studies were excluded if they were published before 1980 or if the study patients were suffering from depression during the postpartum period, as the result of a medical condition, or within a geriatric setting, or if study patients were adolescents.

Applying these criteria yielded 5 relevant articles.^16–20 Reference lists of these articles were examined for additional relevant articles, and 4 more studies^21–24 that also met the criteria were included.

SYNTHESIS

Table 1^16–24 summarizes the studies included in this review. Study populations consisted largely of middle-aged women. Average age ranged from 37 to 50 years, and the proportion of female participants in the groups ranged from 66% to 93%. Subjects were recruited using various methods, including media announcements, mailed brochures, and recruitment in waiting rooms or on-line. A wide assortment of validated depression and mood disorder scales were used to develop inclusion criteria for the studies, with the exception of 3 studies that included any person who accessed particular study websites and consented to participate.^19,20,23 Study interventions also varied. One study used CBT-based bibliotherapy,²¹ 5 studies used CBT-based websites,^17–20,23 2 studies used computerized programs based on CBT psychodynamic therapy,^22,24 and 1 used an educational package on CBT, which was given to general practitioners.¹⁶ One study used a Web-based discussion group in conjunction with a CBT website, but determined that the discussion group had little effect on outcomes.¹⁸ With the exception of 3 studies,^19,20,23 all subjects were monitored or overseen by study personnel, such as a therapist or a general practitioner, on at least a weekly basis. This weekly monitoring was brief and usually limited to questions on use of the intervention or screening for suicidal thoughts; no therapy was provided.

Overall, statistically significant (P < .05) differences in depression scores were seen in treatment groups within 6^{17–19,21,22,24} of the 8 studies using formal control groups. Successful interventions included bibliotherapy, CBT-based websites, and CBT-based computer programs; and most of the positive changes were maintained within a specified follow-up period, when one existed in the study. Three of the studies^17,19,21 stated that significant differences in baseline characteristics existed among study groups, but analysis in all of these studies deemed these differences inconsequential with regards to outcome. No significant changes in depressive symptoms were seen with the use of a CBT-based website with no contact from study personnel²³; however, use of the same website with the addition of regular postcard or telephone reminders did produce significant reductions in depressive symptoms.¹⁹ Use of an educational package on CBT given to general physicians¹⁶ showed no change in patient outcomes, and although physicians in the treatment group stated that they had increased confidence in providing CBT, they were more likely to refer patients for additional support. A CBT-based website comparing 6 versions of different modules found that extended CBT resulted in a significant (P = .01) reduction of depressive symptoms when compared with brief CBT, problem-solving techniques, and behavioural strategies, but did not elaborate on the specific length of the extended CBT module.²⁰

Validity was assessed using criteria from the Evidence-Based Medicine Working Group.²⁵ These criteria were as follows: (1) randomized study; (2) no clinically significant difference between groups reported at baseline; (3) equal treatment of groups except for the intervention; (4) blind rating of outcomes; (5) all subjects enrolled in the trial are accounted for at follow-up and analyzed in the groups to which they were randomized. A summary of the validity assessment is presented in Table 2.^16–24

Most studies included in this review found significant positive outcomes in depression resulting from a variety of brief interventions, which required minimal therapist or physician contact. Several factors, however, must be considered before final conclusions can be drawn. Despite an extensive literature search, only 9 trials were found to meet the study inclusion criteria. Only 6 of these trials used validated scales to diagnose subjects with depression before entrance into the study. It is nearly impossible to obtain blind-rated outcomes when studying various therapeutic interventions; none of the 9 studies was entirely blinded. However, rated scales were used consistently throughout all of the studies, thus outcomes might have been less biased than more subjective measures of clinical diagnoses or improvement.

Many of the studies had small samples, thus other unknown factors might have confounded results. Several of the studies stated that the prevalence of depression in their samples was either higher or lower than would be found in the general population. Also, subjects were recruited using media advertisements and mailed brochures, thus the generalizability of study results to primary care clinic populations is uncertain. Furthermore, limitations of the review process exist. It is unknown what effect unpublished and irretrievable literature, or studies published in languages other than English, might have had on the results of this review.

Despite these limitations, this review does demonstrate that a variety of brief interventions might be effective and feasible for use in primary care settings with physicians who have limited experience in psychotherapy. Bibliotherapy, CBT-based websites, and CBT-based computer programs were all shown to be effective in reducing depressive symptoms and improving clinical functioning. Regardless of the type of intervention, those with greater structure, shorter intervention periods, and frequent contact or reminders from study personnel resulted in higher completion rates. This finding demonstrates the importance of some amount of contact with support staff when patients are using bibliotherapy, computerized therapies, or on-line therapies. The brief weekly contact described in the studies could potentially be analogous to a primary care physician who sets up weekly appointments with patients undergoing one of the study interventions. Weekly contact would provide time for the physician and patient to discuss how the intervention was going and for the physician to screen for worsening symptoms or suicidal thoughts.

To date, there is little published literature on the effectiveness and feasibility of computerized and on-line interventions for depression. One study found some evidence for equal effectiveness of CBT-based computer programs when compared with therapist-led CBT.²⁶ Researchers concluded that some CBT-based computer programs might be cost-effective, but the quality of this data was uncertain. Another study found that CBT-based web-sites and computer programs might improve depression while reducing per-patient therapist time and cost of CBT.²⁷ One critical review of Internet information about depression found that the quality of information on-line was quite poor²⁸; therefore, caution must be used when referring patients to Internet resources for depression.

More information is available on the efficacy of bibliotherapy in the context of self-administered treatments. Although bibliotherapy has proven to be effective in the treatment of depression^12,13,29 and might be cost-effective in primary care,³⁰ many resources have not yet been properly evaluated. Caution should be used and progress closely monitored when implementing bibliotherapy.²⁹

Potential benefits of interventions such as bibliotherapy and CBT-based websites and computer programs include the fact that most of these services are free and accessible to many patients, that there are no waiting lists, that there is less stigma attached to patients receiving these services compared with seeing a therapist, and that patients can develop a sense of empowerment that comes with choosing to actively help themselves. Additional benefits of computer-based therapies are that some programs can tailor responses to patients and provide prompt feedback based on patient input.

Physician involvement in the use of these services might be necessary to ensure that a proper diagnosis is made and that appropriate adjunctive treatments are initiated. Health care providers must also use their discretion in order to exclude patients who would not benefit from these services, such as those in crisis, those with severe depression, or those unwilling or unable to think through their feelings and problems.

No studies regarding person-to-person psychotherapy mediated on-line or counseling via e-mail exchanges with patients were found, although these types of therapy also exist. Areas for future research on this topic include developing studies on more types of interventions, repeating previous studies with larger sample numbers to ensure that findings are reproducible, developing studies to compare various interventions with one another, and evaluating interventions when they are recommended and mediated by physicians.

Conclusion
Several brief interventions might assist primary care physicians with minimal training in psychotherapy in treating depressed adult patients. These interventions include bibliotherapy, CBT-based websites, and CBT-based computer programs, and they might be most effective when health care personnel have regular contact with patients throughout the intervention period.

According to the results of this study, the following options are currently available, valid, and effective interventions that could be considered for treating patients with mild to moderate depression. After a patient is properly diagnosed and deemed an appropriate candidate for psychotherapeutic intervention, the health care provider might consider using 1 or more of the following options in treatment:

• For motivated patients without Internet access, bibliotherapy with Feeling Good by Dr David Burns could be recommended.²¹ Assigning chapters or pages to a patient to read with scheduled weekly follow-up sessions to discuss patient progress might increase both compliance and effectiveness of the therapy.
  
• Patients who have Internet access and who are motivated to complete 5 weekly or bimonthly modules with ongoing follow-up with their care provider might benefit from using MoodGYM, a CBT-based website (http://moodgym.anu.edu.au).^17,20 Access to the 5 modules on this site is free. It might be most effective to decide on a timeline for the patient to complete each module and to schedule follow-up appointments after each module is completed. Learning to Overcome Depression (www.feelbetter.org)^19,23 is another CBT-based website. It has 7 chapters that can be used by patients and their care providers in a similar fashion; however, at the time of publication this site was undergoing reprogramming and was not available for use.
  
• For patients who would benefit from a longer course of therapy, 2 CBT-based computer programs are also available for consideration: Beating the Blues (www.beatingtheblues.co.uk)²⁴ and the Therapeutic Learning Program (www.masteringstress.com; this site was under construction at the time of publication).²² Full access to these programs must be purchased (although parts of these programs have recently become available for access on-line), and both interventions consist of approximately 10 modules that are intended to be completed on a weekly basis. Again, established timelines for completion and regular follow-up with a care provider would likely increase compliance and effectiveness of these interventions.
  

Although future research is warranted in this area, several brief interventions have shown promise in the psychotherapeutic treatment of patients with depression. Despite the limitations of the studies reviewed and of this systematic review, it is hoped that these findings might help guide efforts in the treatment of depression as well as the development and evaluation of further research.

Interventions used

• Burns DD. Feeling Good. The New Mood Therapy. New York, NY: William Morrow and Company Inc; 1980. (Cognitive-behavioural therapy [CBT] bibliotherapy)
  
• Gould RL. Therapeutic Learning Program. Palm Springs, CA: IHS-Online Inc; 1989. (Computer program using CBT and psychodynamic-based therapy; some of the program is available on-line) www.masteringstress.com
  
• Clarke G. Learning to Overcome Depression. Portland, OR: Center for Health Research; 1999. (Interactive website using CBT-based therapy; available on-line) www.feelbetter.org
  
• Proudfoot J. Beating the Blues. London, UK: Ultrasis; 2000. (Computer multimedia program using CBT-based therapy; software must be purchased by physicians) www.beatingtheblues.co.uk
  
• Christensen H, Griffiths K. MoodGYM. Canberra, ACT: Centre for Mental Health Research, Australian National University; 2004. (Interactive website using CBT-based therapy; available on-line) http://moodgym.anu.edu.au
  
• Griffiths K, Christensen H, Bennett K, Bennett A, Tam A. BluePages. Canberra, ACT: Centre for Mental Health Research, Australian National University; 2001. (Educational website with information on symptoms, treatment, and resources for depression; available on-line) http://bluepages.anu.edu.au
  

EDITOR’S KEY POINTS Depression is a disabling disorder that is extremely common in primary care. Patients with depression often rely solely on their primary care physicians to provide treatment and support, but many primary care physicians have minimal training in psychotherapy. This study aimed to identify existing effective non-drug therapies that physicians could easily implement in the management of their adult patients with depression. For motivated patients without Internet access, bibliotherapy with Feeling Good by Dr David Burns could be recommended. Patients who have Internet access might benefit from using CBT-based websites like MoodGYM or Learning to Overcome Depression. For patients who would benefit from longer courses of therapy, CBT-based computer programs are also available for a fee: Beating the Blues and the Therapeutic Learning Program. Assigning chapters, pages, or modules to patients and scheduling regular follow-up sessions to discuss patient progress would likely increase both compliance and effectiveness of the therapy.

 

POINTS DE REPÈRE DU RÉDACTEUR La dépression est une affection invalidante extrêmement fréquente en médecine primaire. Souvent, les patients déprimés dépendent de leur seul médecin de première ligne pour obtenir traitement et support, mais plusieurs de ces médecins ont peu de formation en psychothérapie. Cette étude voulait identifier les thérapies efficaces non pharmacologiques actuellement disponibles que le médecin pourrait facilement utiliser pour traiter la dépression chez l’adulte. Pour les patients n’ayant pas accès à Internet, on pourrait recommander une bibliothérapie avec Feeling Good du Dr David Burns. Ceux qui ont accès à Internet auraient avantage à utiliser des sites Web de TCC comme MoodGYM ou Learning to Overcome Depression. Pour ceux pouvant nécessiter un traitement de plus longue durée, il existe aussi des programmes informatiques de type TCC non gratuits: Beating the Blues et le Therapeutic Learning Program. Le fait de suggérer aux patients certains chapitres, pages ou modules en plus d’un suivi régulier pour évaluer les progrès pourrait améliorer le respect et l’efficacité du traitement.

 

Acknowledgments

I thank the following people: Dr Ari Zaretsky from the Centre for Addiction and Mental Health in Toronto, Ont, Dr Nicholas Pimlott and Ms Susan Hum from Women’s College Hospital in Toronto, and Ms Rita Shaughnessy from the Department of Family and Community Medicine at the University of Toronto.

Footnotes

Competing interests

None declared

Cet article a fait l’objet d’une révision par des pairs.

This article has been peer reviewed.

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This Article Abstract Résumé Full Text (PDF) Rapid Responses: Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by McNaughton, J. L. Search for Related Content PubMed Articles by McNaughton, J. L.