Brief Psychotherapy for Depression in Primary Care: A Systematic Review of the Evidence
Synopsis "Brief Psychotherapy for Depression in Primary Care: A Systematic Review of the Evidence"
Depressive disorders present a major public health concern. The prevalence of current depression among U.S. adults is 6.6%, affecting up to 16 to 18% of the population over their lifetime. High prevalence rates have also been noted in the Veteran population, and particularly high rates have been found in primary care settings. Although primary care physicians treat a high proportion of patients with depressive disorders, the treatment of depression in primary care tends to be variable and suboptimal. Because of this, it is a public health priority to identify treatments for depression that are effective, evidence-based, and suitable for dissemination in primary care. Despite persuasive evidence of effectiveness for both pharmacotherapy and psychotherapy in the treatment of depression, medication remains by far the most commonly utilized intervention in primary care settings. However, there has been a growing interest in and commitment to the integration of psychotherapy and other mental health services into primary care settings, perhaps most notably within the Veterans Health Administration. Providing primary care patients with the option of receiving psychotherapy for their depression is an important objective for multiple reasons: there are many patients who, given the option, prefer psychotherapy to medication; there is a need to provide alternative treatments for patients who do not improve on or cannot tolerate antidepressant medication; and there may be unique benefits from psychotherapy in terms of costs and relapse prevention. Recognizing that time and resource constraints present important barriers to effectively implementing standard-duration psychotherapies (i.e., 12 to 20 sessions) for depression in primary care settings, this report evaluates whether psychotherapy for depression can be efficacious after a period of 8 or fewer sessions-what we define as brief psychotherapy. In examining the evidence on brief psychotherapies for depression, this report also aims to address issues of the amount of training necessary to deliver psychotherapeutic treatment effectively and the availability of data on key clinical outcomes like social functioning and satisfaction with treatment. Effectively treating depression in primary care patients is an important public health priority. With that in mind, this report endeavors to examine whether brief psychotherapies are often tailored specifically for primary care settings and are efficacious for the treatment of depression. The individual and societal burden of depressive disorders is widely acknowledged, but treating these disorders remains challenging. Clinical guidelines recommend that both pharmacotherapy and psychotherapy should be considered as first-line treatments. Yet, because primary care settings are often the frontline of treatment, pharmacological treatments take precedence. Recent evidence seems to suggest that psychotherapies that are briefer in both duration and intensity may be efficacious in acute-phase treatment. This review of the peer-reviewed literature addresses the following key questions: Key Question 1: For primary care patients with depressive disorders, are brief, evidence-based psychotherapies with durations of up to eight sessions more efficacious than control for depressive symptoms and quality of life? Key Question 2: For primary care patients with depressive disorders treated with a brief, evidence-based psychotherapy, is there evidence that treatment effect may vary by the number of sessions delivered? Key Question 3: For psychotherapies demonstrating clinically significant treatment effects, what are the characteristics of treatment providers, and what are the modalities of therapy? Key Question 4: How commonly reported are the key clinical outcomes of quality of life, social functioning, occupational status, patient satisfaction, and adverse treatment effects in randomized trials of psychotherapy?
