Do psychotherapies for depression have comparable outcomes in age groups across the life span?
In a meta-analysis of 366 randomized clinical trials including 36 072 patients comparing psychotherapy with control conditions, psychotherapies had lower effect sizes in children and adolescents compared with adults, and no significant differences were found between middle-aged and older adults. However, conclusions are not definitive, given the low quality of many studies, the risk of publication bias, and the high heterogeneity among the studies.
There is a need to improve psychotherapies in children and adolescents.
It is not clear whether psychotherapies for depression have comparable effects across the life span. Finding out is important from a clinical and scientific perspective.
To compare the effects of psychotherapies for depression between different age groups.
Four major bibliographic databases (PubMed, PsychINFO, Embase, and Cochrane) were searched for trials comparing psychotherapy with control conditions up to January 2019.
Randomized trials comparing psychotherapies for depression with control conditions in all age groups were included.
Data Extraction and Synthesis
Effect sizes (Hedges g) were calculated for all comparisons and pooled with random-effects models. Differences in effects between age groups were examined with mixed-effects subgroup analyses and in meta-regression analyses.
Main Outcomes and Measures
Depressive symptoms were the primary outcome.
After removing duplicates, 16 756 records were screened and 2608 full-text articles were screened. Of these, 366 trials (36 702 patients) with 453 comparisons between a therapy and a control condition were included in the qualitative analysis, including 13 (3.6%) in children (13 years and younger), 24 (6.6%) in adolescents (≥13 to 18 years), 19 (5.2%) in young adults (≥18 to 24 years), 242 (66.1%) in middle-aged adults (≥24 to 55 years), 58 (15.8%) in older adults (≥55 to 75 years), and 10 (2.7%) in older old adults (75 years and older). The overall effect size of all comparisons across all age groups was g = 0.75 (95% CI, 0.67-0.82), with very high heterogeneity (I2 = 80%; 95% CI: 78-82). Mean effect sizes for depressive symptoms in children (g = 0.35; 95% CI, 0.15-0.55) and adolescents (g = 0.55; 95% CI, 0.34-0.75) were significantly lower than those in middle-aged adults (g = 0.77; 95% CI, 0.67-0.87). The effect sizes in young adults (g = 0.98; 95% CI, 0.79-1.16) were significantly larger than those in middle-aged adults. No significant difference was found between older adults (g = 0.66; 95% CI, 0.51-0.82) and those in older old adults (g = 0.97; 95% CI, 0.42-1.52). The outcomes should be considered with caution because of the suboptimal quality of most of the studies and the high levels of heterogeneity. However, most primary findings proved robust across sensitivity analyses, addressing risk of bias, target populations included, type of therapy, diagnosis of mood disorder, and method of data analysis.
Conclusions and Relevance
Trials included in this meta-analysis reported effect sizes of psychotherapies that were smaller in children than in adults, probably also smaller in adolescents, that the effects may be somewhat larger in young adults, and without meaningful differences between middle-aged adults, older adults, and older old adults.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Pim Cuijpers, PhD, Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Van der Boechorststraat 7-9, Amsterdam, Noord-Holland 1081 BT, the Netherlands (email@example.com).
Accepted for Publication: January 16, 2020.
Published Online: March 18, 2020. doi:10.1001/jamapsychiatry.2020.0164
Author Contributions: Dr Cuijpers had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Cuijpers, Eckshtain, Quero Castellano, Weisz.
Acquisition, analysis, or interpretation of data: Cuijpers, Karyotaki, Eckshtain, Ng, Corteselli, Noma, Weisz.
Drafting of the manuscript: Cuijpers, Eckshtain, Weisz.
Critical revision of the manuscript for important intellectual content: Karyotaki, Eckshtain, Ng, Corteselli, Noma, Quero Castellano, Weisz.
Statistical analysis: Cuijpers, Karyotaki, Noma.
Administrative, technical, or material support: Eckshtain, Corteselli, Weisz.
Conflict of Interest Disclosures: Dr Noma reported personal fees from Boehringer Ingelheim, Kyowa Hakko Kirin, and ASKA Pharmaceutical outside of the submitted work. Dr Cuijpers received expense allowances for his membership of the Board of Directions of “Mind.nl,” for being Chair of the Research committee of the Dutch Council for military care and research, and for being Chair of the Mental Health Priority Area of the Wellcome Trust in London, England, in 2018. In addition, he received royalties for books he has authored or coauthored and for occasional workshops and invited addresses. Dr Weisz received payments for consulting with the Child Health and Development Institute and the National Institute of Mental Health, royalties for books he has authored and coauthored, and honoraria for workshops and invited presentations at professional meetings and conferences. No other disclosures were reported.
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