The efficacy of non-directive supportive therapy for adult depression: A meta-analysis
Highlights
► Non-directive supportive therapy is effective in depressed patients. ► Other psychotherapies are somewhat more effective. ► After adjustment for researcher allegiance there is no difference. ► The effects of non-directive supportive therapy are moderate (effect size g = 0.58).
Introduction
Several types of psychotherapy have been found to be effective in the treatment of adult depression, including cognitive behavior therapy (Churchill et al., 2001, Gloaguen et al., 1998), interpersonal psychotherapy (Cuijpers et al., 2010a, de Mello et al., 2001), behavioral activation therapy (Cuijpers et al., 2007a, Ekers et al., 2008), problem-solving therapy (Cuijpers et al., 2007b, Malouff et al., 2007), and possibly psychodynamic therapies (Gerber et al., 2011, Shedler, 2010), and other psychotherapies, such as process-experiential (Greenberg, Elliot, & Lietaer, 1994) and life-review therapies (Bohlmeijer et al., 2003, Hsieh and Wang, 2003). It is not yet clear, however, whether these therapies are equally effective. In a meta-analysis of comparative outcome studies of different psychotherapies, we found that the effects of interpersonal psychotherapy were somewhat larger and the effects of non-directive supportive therapies somewhat smaller than other psychotherapies (Cuijpers, van Straten, Andersson, & van Oppen, 2008). Although these differences were significant, they should be considered with caution because of the small number of comparisons, and the relatively low quality of several included studies. In a recent meta-analysis of interpersonal psychotherapy we could not find support for its superior effects over other therapies (Cuijpers et al., 2011). Furthermore, although we found no significant difference between psychodynamic therapy and other therapies (Cuijpers et al., 2008a, Cuijpers et al., 2008b), a more recent meta-analysis showed that psychodynamic therapy was significantly less effective than other therapies (Driessen, Cuijpers, de Maat, et al., 2010). So, although meta-analyses seem to be an excellent method for examining differential effects of different therapies, there are yet no definite answers to the question whether all psychotherapies for adult depression are equally effective or not.
Although there may be small differences between the effect sizes of different psychotherapies for adult depression, the effects of most therapies do not differ from each other. Furthermore, when differences are found, they tend to be small and unstable. After more than three decades, most quantitative reviews suggest that the different therapies for depression are equally or almost equally effective (Luborsky, 1995, Luborsky et al., 1975, Shadish and Sweeney, 1991, Stiles et al., 1986). This could indicate that most effects of psychological treatments are caused by common, non-specific factors and not by particular techniques (Cuijpers, 1998). These common factors include the therapeutic alliance between therapist and client, belief in the treatment, and a clear rationale explaining why the client has developed the problems (Lambert, 2004, Spielmans et al., 2007). Another possible explanation is that the effects of psychotherapy are realized by a variety of specific therapeutic mechanisms (Butler & Strupp, 1986), but that the number of possible mediators is so large, that small differences between treatments in specific groups of patients (moderation) remain unnoticed due to insufficient statistical power or because our research methods are not sensitive enough (Kazdin, 1986). In this context, it is important to note, that not all patients who receive psychotherapy for depression improve and more still fail to sustain the improvement reached immediately after treatment (Cuijpers, van Straten, Bohlmeijer, Hollon, & Andersson, 2010). The problem then is to discover what works for whom, a venture that would require very large samples and considerable resources.
From this perspective, non-directive supportive therapy (NDST) is an interesting treatment. A considerable number of studies have examined NDST as a treatment for adult depression. Some researchers have included NDST in randomized trials of psychotherapies to control for the nonspecific elements that are common to all therapies, in contrast to the specific techniques of the therapy being tested (Markowitz et al., 1998, McNamara and Horan, 1986, Propst et al., 2002). In other studies, NDST is examined as a treatment that is itself expected to have a full effect on depression (Bower & Rowland, 2006). However, in all of these studies the methods and techniques used in NDSTs are very much the same: an unstructured therapy without specific psychological techniques other than those belonging to the basic interpersonal skills of the therapist, such as reflection, empathic listening, encouragement, and helping people to explore and express their experiences and emotions. In NDSTs the therapist refrains from giving advice or making interpretations, and the therapy typically is not aimed at providing solutions or acquiring new skills. NDSTs are commonly described in the literature as counseling, supportive therapy, or as a non-specific therapy, and include support groups for people with the same comorbid conditions such as cancer (Evans & Connis, 1995) or HIV (Kelly et al., 1993, Markowitz et al., 1998). In the current study, we use the following definition of NDST: a psychological treatment in which therapists do not engage in any therapeutic strategies other than active listening and offering support, focusing on participants' problems and concerns (Arean et al., 2010).
Research on NDST also is of interest because it may give an indication of the relative contribution of specific and non-specific effects to the improvement of depressed people during therapy. Lambert (1992) estimated that 40% of the improvement in clients was caused by extra-therapeutic change, 30% by the therapeutic relationship, 15% by client expectations, and the remaining 15% by specific techniques. Although these estimates have been cited by many, they were not based on empirical data, but rather on the author's impression from reviewing a large number of psychotherapy trials. Research on NDSTs, however, may provide empirical data showing how much improvement is realized by specific versus non-specific factors. Studies directly comparing NDST with other psychotherapies can give an indication what the contribution of the specific techniques of these other psychotherapies is, compared with the nonspecific elements of NDST, which are common to all therapies. Furthermore, studies comparing NDST with no-treatment control conditions can provide an indication regarding the contribution of non-specific treatment elements over and above extra-therapeutic factors.
We decided, therefore, to conduct a meta-analysis of randomized trials examining the efficacy of NDST when compared to control conditions and to other psychotherapies in the treatment of depression. We also aimed to make an estimate of the extent to which extra-therapeutic, non-specific, and specific factors accounted for improvement.
Section snippets
Identification and selection of studies
A database of 1237 papers on the psychological treatment of depression was used. This database has been described in detail elsewhere (Cuijpers, van Straten, Warmerdam, et al., 2008) and has been used in a series of earlier published meta-analyses (www.evidencebasedpsychotherapies.org). The database is continuously updated and was developed through a comprehensive literature search (from 1966 to January 2011) in which 12,368 abstracts in Pubmed (3077 abstracts), PsycInfo (2860), Embase (3811)
Selection and inclusion of studies
Having examined a total of 12,368 abstracts (9634 after removal of duplicates), we retrieved 1237 full-text papers for further consideration. We excluded 956 of the retrieved papers (studies with adolescents: 68; multiple publications from the same trial: 279; no random assignment: 53; included patients who were not depressed: 143; did not meet definition of psychotherapy: 142; no comparison group: 116; maintenance trial: 49; other reason: 107). This resulted in a total of 280 randomized
Discussion
We found that NDST is effective in the treatment of depression in adults, but that it is somewhat less effective than other psychological treatments. The superiority of these other treatments is open to question, however, and could have been an artifact of investigator allegiance, since those differences were no longer significant after controlling for investigator allegiance. The majority of studies compared NDST with CBT and these studies did not result in a significant difference even before
References1 (92)
- et al.
Problem-solving therapy versus supportive therapy in geriatric major depression with executive dysfunction
The American Journal of Geriatric Psychiatry
(2003) - et al.
Effects of support group intervention in postnatally distressed women. A controlled study in Taiwan
Journal of Psychosomatic Research
(2000) - et al.
Behavioral treatment of depression: A meta-analysis of activity scheduling
Clinical Psychology Review
(2007) - et al.
Problem solving therapies for depression: A meta-analysis
European Psychiatry
(2007) - et al.
The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis
Clinical Psychology Review
(2010) - et al.
A meta-analysis of the effects of cognitive therapy in depressed patients
Journal of Affective Disorders
(1998) - et al.
Effect of reminiscence therapy on depression in older adults: A systematic review
International Journal of Nursing Studies
(2003) - et al.
Home-delivered problem adaptation therapy (PATH) for depressed, cognitively impaired, disabled elders: A preliminary study
The American Journal of Geriatric Psychiatry
(2010) - et al.
Size of treatment effects and their importance to clinical research and practice
Biological Psychiatry
(2006) - et al.
The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis
Clinical Psychology Review
(2007)
A comparative trial of psychotherapy and pharmacotherapy for “pure” dysthymic patients
Journal of Affective Disorders
What are the active ingredients in cognitive and behavioral psychotherapy for anxious and depressed children? A meta-analytic review
Clinical Psychology Review
Counselling of postnatal depression: A controlled study on a population based Swedish sample
Journal of Affective Disorders
Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction
The American Journal of Psychiatry
Kognitive Verhaltenstherapie Bei Depressionen Im Klimakterium: Eine Kontrollierte, Randomisierte Interventionsstudie
Zeitschrift für Klinische Psychologie und Psychotherapie
Establishing specificity in psychotherapy: A meta-analysis of structural equivalence of placebo controls
Journal of Consulting and Clinical Psychology
An inventory for measuring depression
Archives of General Psychiatry
Predictors of differential response to cognitive, experiential, and self-directed psychotherapeutic procedures
Journal of Consulting and Clinical Psychology
Effects of reminiscence and life-review on late-life depression: A meta-analysis
International Journal of Geriatric Psychiatry
Introduction to meta-analysis
Effectiveness and cost effectiveness of counseling in primary care
Cochrane Database of Systematic Reviews (Online)
Professional and paraprofessional group treatments for depression: A comparison of cognitive–behavioral and mutual support interventions
Journal of Consulting and Clinical Psychology
Specific and nonspecific factors in psychotherapy: A problematic paradigm for psychotherapy research
Psychotherapy: Theory, Research and Practice
A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression
Health Technology Assessment
Statistical power analysis for the behavioral sciences
Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. I. Impact on maternal mood
British Journal of Psychiatry
Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies
Journal of Consulting and Clinical Psychology
Interpersonal psychotherapy of depression: A meta-analysis
American Journal of Psychiatry
Minimising interventions in the treatment and prevention of depression: Taking the consequences of the ‘Dodo bird verdict’
Journal of Mental Health
The effects of psychotherapy for adult depression are overestimated: A meta-analysis of study quality and effect size
Psychological Medicine
Psychological treatment of depression: A meta-analytic database of randomized studies
BMC Psychiatry
A randomized controlled trial comparing moclobemide and moclobemide plus interpersonal psychotherapy in the treatment of dysthymic disorder
The Journal of Psychotherapy Practice and Research
Cognitive therapy vs medications in the treatment of moderate to severe depression
Archives of General Psychiatry
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression
Journal of Consulting and Clinical Psychology
Does pretreatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis
Journal of Consulting and Clinical Psychology
Meta-analysis of experiments with matched groups or repeated measures designs
Psychological Methods
Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis
Biometrics
A meta-analysis of randomized trials of behavioural treatment of depression
Psychological Medicine
Treatment of depression collaborative research program
Archives of General Psychiatry
Research on the effectiveness of humanistic therapies: A meta-analysis
Research on experiential psychotherapies
Comparison of brief group therapies for depressed cancer patients receiving radiation treatment
Public Health Reports
Coping skills training as a component in the short-term treatment of depression
Journal of Consulting and Clinical Psychology
Antidepressant drug effects and depression severity: A patient-level meta-analysis
Journal of the American Medical Association
Treatment of depression after coronary artery bypass surgery; A randomized controlled trial
Archives of General Psychiatry
A self-control behavior therapy program for depression
Journal of Consulting and Clinical Psychology
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References marked with an asterisk are included in the meta-analysis.