Treating Depression in Primary Care: A Critical Overview

A review article published in Current Psychiatry Reports suggests that psychotherapies delivered in primary care are effective in reducing depressive symptoms in the majority of adult patients. The researchers sought to address the large population receiving mental healthcare in primary care settings; many studies focus instead on patients in mental health services and psychiatric settings.

The investigators reviewed literature on the most commonly used psychological interventions in primary care: cognitive behavioral therapy (CBT), behavioral activation therapy (BAT), interpersonal psychotherapy, problem-solving therapy, non-directive counseling, and other therapy methodologies.

In randomized clinical trials, psychotherapies administered in primary care displayed moderate to large effect sizes in reducing depressive symptoms compared with placebo (Cohen’s d range, 0.6 to 0.9). Compared with antidepressant medications, psychotherapies displayed similar short-term efficacy and increased increased long-term efficacy. In patients with moderate to severe depression, combined treatment with psychotherapy and antidepressant medications was more effective than either modality alone.

The investigators also assessed differential delivery methods for psychotherapy. Per recent meta-analyses, technologically delivered therapies were comparable with face-to-face therapies. Specifically, therapies administered via the internet, mobile apps, and telephone were significantly associated with reductions in depressive symptoms. In low- and middle-income settings, psychotherapies administered by lay health counselors — including trained lay persons — also had significant positive effects for depression and anxiety management. In studies that compared psychotherapy types, BAT was found to be as effective as CBT, although the latter is much more widely used. Overall, investigators found that primary care psychotherapy can be delivered effectively in many forms.

The review also proposes an opportunity for depression prevention in primary care, the investigators wrote. Treatment administered to patients with subclinical depression may prevent clinical depression at 1-year follow-up. The majority of the literature focused on primary care patients in general, although some studies examined specific patient subgroups. Patient subgroups that reliably benefitted from primary care psychotherapy included older adults, patients with general medical disorders, and patients with perinatal depression. Results for patients with comorbid substance use disorders and chronic depression were less certain, and little data were available for depression in children and adolescents.

These data suggest that psychotherapy administered in primary care is effective across many delivery methods and target groups. Compared with pharmacotherapy, psychotherapy had longer-lasting effects and was preferable for most patients.

The investigators noted, however, that many patients still do not remit following psychotherapies; in fact, 30% of patients do not respond to any depression treatment. Additionally, many studies had methodologies of suboptimal quality. The researchers noted that further research is necessary to explore the impact of psychotherapy in primary care, particularly in certain vulnerable patient groups, including youths and patients with substance use disorders.

Reference

Cuijpers P, Quero S, Dowrick C, Arroll B. Psychological treatment of depression in primary care: recent developments [published online November 23, 2019]. Curr Psychiatry Rep. doi:10.1007/s11920-019-1117-x