Sage Journals: Discover world-class research

Abstract

Background:

The Canadian Network for Mood and Anxiety Treatments (CANMAT) has revised its 2009 guidelines for the management of major depressive disorder (MDD) in adults by updating the evidence and recommendations. The target audiences for these 2016 guidelines are psychiatrists and other mental health professionals.

Methods:

Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. “Psychological Treatments” is the second of six sections of the 2016 guidelines.

Results:

Evidence-informed responses were developed for 25 questions under 5 broad categories: 1) patient characteristics relevant to using psychological interventions; 2) therapist and health system characteristics associated with optimizing outcomes; 3) descriptions of major psychotherapies and their efficacy; 4) additional psychological interventions, such as peer interventions and computer- and technology-delivered interventions; and 5) combining and/or sequencing psychological and pharmacological interventions.

Conclusions:

First-line psychological treatment recommendations for acute MDD include cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and behavioural activation (BA). Second-line recommendations include computer-based and telephone-delivered psychotherapy. Where feasible, combining psychological treatment (CBT or IPT) with antidepressant treatment is recommended because combined treatment is superior to either treatment alone. First-line psychological treatments for maintenance include CBT and mindfulness-based cognitive therapy (MBCT). Patient preference, in combination with evidence-based treatments and clinician/system capacity, will yield the optimal treatment strategies for improving individual outcomes in MDD.

Keywords

major depressive disorder clinical practice guidelines evidence-based medicine meta-analysis systematic reviews psychotherapy biopsychosocial cognitive-behavioural therapy interpersonal therapy mindfulness-based interventions

In 2009, the Canadian Network for Mood and Anxiety Treatments (CANMAT), a not-for-profit scientific and educational organization, published a revision of evidence-based clinical guidelines for the treatment of depressive disorders.¹ CANMAT has updated these guidelines in 2016 to reflect new evidence in the field.

The scope of these guidelines remains the management of adults with unipolar major depressive disorder (MDD). CANMAT, in collaboration with the International Society for Bipolar Disorders, has published separate guidelines for bipolar disorder.² This section on Psychological Treatments is 1 of 6 CANMAT guidelines articles; other sections of the guidelines expand on burden and principles of care, pharmacological treatments, neurostimulation treatments, complementary and alternative medicine treatments, and special populations.

We use the term psychological treatment rather than psychotherapy as a broader term that involves treatment of psychiatric and behavioural disorders through a method of communicating that invokes a psychological model of illness. This method of communication begins with a patient who seeks alleviation of current symptoms or prevention of recurrence of symptoms. With the advent of computer, Internet, self-help, phone, and mobile apps, the relationship is now between the patient and the psychological model, with an implicit link to the “therapist” who designed the therapy. This guideline summarizes depression-specific psychotherapies as well as newer therapies that are promising and seeks to clarify the evidence and usefulness of each major treatment.

Psychological treatments for MDD share many common components: 1) the goal of treatment is alleviation of the core symptoms of depression; 2) there is careful attention to a specific method to deliver the therapy (typically a manual); 3) the psychotherapy focuses on the current problems of the patient; 4) high levels of activity are expected from both the therapist and the patient (who frequently has “homework”); 5) careful symptom monitoring, preferably with rating scales, is expected; 6) psychoeducation about the illness is a frequent component; and 7) the treatment is generally time-limited, often paralleling the time course for pharmacotherapy.

Furthermore, many of these therapies have been modified to be delivered in a group format. While a group approach may allow for integration of new techniques involving peer feedback and may be more cost-effective, the core of the psychotherapy remains unchanged, so group interventions are not evaluated in these guidelines as a separate “group therapy.” Similarly, context-specific therapies (such as marital therapy for MDD coinciding with a severe marital dispute) are not evaluated, since such therapies do not generalize to the average person with depression. Indications for a specific therapy, as well as the choice of either psychological treatment or pharmacotherapy alone or in combination, are reviewed in a number of the following questions, along with discussion of self-help approaches and peer support. The recommendations are presented as guidance for clinicians who should consider them in the context of individual patients and not as standards of care.

Methods

The full methods have been previously described,³ but in summary, relevant studies in English published from January 1, 2009, to December 31, 2015, were identified using computerized searches of electronic databases (PubMed, PsychInfo, Cochrane Register of Clinical Trials), inspection of bibliographies, and review of other guidelines and major reports. Each recommendation includes the level of evidence for each graded line of treatment, using specified criteria (Table 1). The level of evidence criteria now reflect the primacy of meta-analysis because of its increasing use in the evaluation of evidence.

Table 1.

Criteria for Level of Evidence and Line of Treatment.

	Criteria
Level of evidence^a
1	Meta-analysis with narrow confidence intervals and/or 2 or more RCTs with adequate sample size, preferably placebo controlled
2	Meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size
3	Small-sample RCTs or nonrandomized, controlled prospective studies or case series or high-quality retrospective studies
4	Expert opinion/consensus
Line of treatment
First line	Level 1 or Level 2 Evidence, plus clinical support^b
Second line	Level 3 Evidence or higher, plus clinical support^b
Third line	Level 4 Evidence or higher, plus clinical support^b

RCT, randomized controlled trial.

^aNote that Level 1 and 2 Evidence refer specifically to treatment studies in which randomized comparisons are available. Recommendations involving epidemiological or risk factors primarily arise from observational studies, and hence the highest level of evidence is usually Level 3. Higher order recommendations (e.g., principles of care) reflect higher level judgement of the strength of evidence from various data sources and therefore are primarily Level 4 Evidence.

^bClinical support refers to application of expert opinion of the CANMAT committees to ensure that evidence-supported interventions are feasible and relevant to clinical practice. Therefore, treatments with higher levels of evidence may be downgraded to lower lines of treatment due to clinical issues such as side effects or safety profile.

Because of the very large number of randomized-controlled trials (RCTs), this psychological treatments section will primarily focus on systematic reviews and individual and network meta-analyses. Although meta-analyses have advantages in summarizing data, they still have limitations that can lead to erroneous or conflicting results depending on the comprehensiveness of the review, criteria for study selection and quality and generalizability of the included studies, and various types of bias.⁴ One additional limitation of both RCTs and subsequent meta-analyses needs to be highlighted: recruitment of individuals in standard MDD RCTs often excludes people with current suicidality, substance use, and other comorbidities.⁵ This limits the generalizability of these studies. We have included separate sections on depression with various comorbidities to specifically highlight findings in those clinical conditions.

2.1. When Is Psychological Treatment Indicated?

In addition to patients’ attitudes and preferences, a clinician must consider the availability of high-quality evidence-based psychological treatment and the risk from delay in treatment initiation. In more severe and high-risk cases, it is imperative to start a treatment that is immediately available and to consider all treatment modalities, including neurostimulation. In moderately severe and low-risk cases, the choice of initial treatment between psychological treatment and antidepressants may be determined by the balance of patient preferences and availability of each treatment modality. In addition, special circumstances may need to be taken into account. For example, women who are planning to conceive or are pregnant may be preferentially considered for psychological treatment, because of concerns that use of antidepressants in pregnancy may affect the fetus.^6,7 On the other hand, psychological therapies are not indicated for individuals with psychotic depression, who require pharmacotherapy with antidepressants and antipsychotics⁸ or electroconvulsive therapy.

2.2. Which Individuals with Depression Are Most Likely to Benefit from Psychological Treatment?

Demographic factors

Psychological treatments benefit men and women to the same extent; psychological treatments are equally suitable for individuals of all ages, levels of education, and cultural and ethnic backgrounds.⁹ Psychological treatments in general and cognitive-behavioural therapy (CBT) in particular appear to be equally effective for different subtypes of depression, including atypical depression, melancholic depression, and anxious depression.^9,10 In addition, a large individual-level meta-analysis confirmed that men and women derive similar benefits from CBT and from antidepressants.¹¹ In persistent depressive disorder (PDD), medication treatment or combination of medication with psychological treatment provides more benefit than psychological treatment alone.^12,13

Severity

Early findings that CBT as a treatment for severe depression was less effective than medication¹⁴ were followed by evidence of comparable efficacy for CBT and medication.¹⁵ A subsequent meta-analysis confirmed that severity of depression does not differentially predict outcomes of treatment with antidepressants and CBT.¹⁶ As in the case of antidepressant medication, the magnitude of benefit for psychological treatment appears to increase with increasing severity,¹⁷ although there is evidence that psychological treatments are beneficial even for subthreshold depressive symptoms.¹⁸ However, since the time course of improvement is typically faster with pharmacological than psychological treatment,¹⁹ pharmacotherapy may still be preferred as the initial treatment in severe and high-risk cases.

2.3. How Do Co-occurring Psychiatric and Medical Conditions Affect the Efficacy of Psychological Treatments?

Psychiatric comorbidities

This question was addressed by a CANMAT task force in 2012²⁰ with individual studies on anxiety disorders,²¹ attention-deficit/hyperactivity disorder (ADHD),²² substance use disorders,²³ and personality disorders.²⁴ There is insufficient evidence to define formal treatment recommendations, so instead only evidence is summarized.

In summary, Level 2 Evidence supports a negative prognostic impact of comorbid personality disorder on treatment outcomes, including psychological treatments, in depression (Table 2). Insufficient evidence is available to support a positive or negative effect of anxiety symptoms or disorders on depression outcomes, but CBT may be more effective than other treatments. CBT is also effective for depressive symptoms in substance use disorders, and Level 2 Evidence supports integrated psychosocial treatment of alcohol misuse and depression. For ADHD, CBT can improve both depressive and ADHD symptoms.

Table 2.

Impact of Comorbid Psychiatric Disorders on Psychological Treatments in Major Depressive Disorder.

Comorbid Disorder	Summary Findings	Level of Evidence
Anxiety	Anxiety may not complicate or reduce responses to psychological treatments.	Conflicting/insufficient evidence
Anxiety	CBT more beneficial than other psychological treatments.	Level 2
Substance abuse	CBT improves both depression and substance abuse symptoms.	Level 2
Substance abuse	Integrated treatment is effective but with small effect size.	Level 2
Personality	Personality disorders have negative impact on depression outcomes.	Level 2
ADHD	CBT for ADHD helps both disorders, as adjunct to medications.	Level 2

ADHD, attention-deficit/hyperactivity disorder; CBT, cognitive-behavioural therapy.

Medical comorbidities

The CANMAT task force also addressed the management of mood disorders and comorbid medical conditions.^20,25,26 There is insufficient evidence to define formal treatment recommendations, so instead only evidence is summarized.

Several key limitations exist in summarizing this literature: 1) the comorbid medical disorders themselves represent a variety of illnesses grouped according to organ system (e.g., cancer includes a variety of diseases), 2) the medical disorders themselves include patients at varying stages or severity of medical illness, and 3) most studies measure improvement in depressive symptoms as opposed to only improvement of those with a full diagnosis of MDD.

In summary, there is Level 2 Evidence for treatment of depression with co-occurring cardiovascular disease for CBT, interpersonal therapy (IPT), and problem-solving therapy (PST).^25,27
–29 Level 2 Evidence also exists for a variety of psychological treatments in cancer patients, but these are studied by cancer type and stage as noted in Table 3. ^25,30 In the presence of human immunodeficiency virus (HIV), Level 1 Evidence supports a variety of psychological treatments, particularly CBT³¹ and, importantly, improved adherence to medical interventions as well as improvement in depression.³² For a variety of neurological disorders, psychological treatments (almost always CBT) have been tested for comorbid depression or depressive symptoms, with Level 2 Evidence of efficacy for multiple sclerosis and Parkinson’s disease, and Level 3 Evidence for epilepsy and migraines.^25,33,34 Finally, for the strikingly high rates of depression accompanying hepatitis C, only Level 3 Evidence exists for psychological treatments, based primarily on expert recommendations with a single trial using both CBT and IPT approaches.^25,35

Table 3.

Impact of Comorbid Medical Disorders on Psychological Treatments in Major Depressive Disorder.

Comorbid Disorder	Summary Findings	Level of Evidence
Cancer	Evidence varies by type of psychological intervention and phase of cancer treatment, but multiple small positive RCTs²⁴	Level 2
Cardiovascular disease	Effectiveness shown with CBT, IPT, and PST, alone or with antidepressants	Level 2
Multiple sclerosis	Various psychological treatments studied, primarily CBT; all beneficial	Level 2
HIV	CBT effective, most delivered in group format; IPT effective but with limited studies	Level 1 for CBT Level 2 for IPT
Epilepsy	Limited research, using CBT primarily, with moderate benefit for depressive symptoms	Level 3
Migraines	Various psychological treatments have moderate benefit for depressive symptoms	Level 3
Parkinson’s disease	CBT effective for reducing depressive symptoms	Level 2
Hepatitis C	Psychological treatments may be useful	Level 3

CBT, cognitive-behavioural therapy; HIV, human immunodeficiency virus; IPT, interpersonal therapy; PST, problem-solving therapy; RCT, randomized-controlled trial.

2.4. How Do Gender and Age Influence the Decision to Use Psychological Treatment?

More women than men prefer psychological treatment over medication treatment.³⁶ Considerations for women during childbearing years include exposure of the fetus during gestation or neonate during lactation. The scope of evidence for psychological treatment is broader for postpartum rather than during pregnancy, with Level 1 Evidence to support psychological treatment as first-line for perinatal women with mild to moderate depressive illness.^37

–40 Moreover, many pregnant women prefer psychological treatment and report fear of potential adverse effects of antidepressants on the developing fetus or on their newborn via lactation, general worries about a negative outcome, and fears of dependency as well as balancing concerns about their own health or the fetus.^41,42 Treatment for adolescents is addressed elsewhere; for further advice, see the American Academy of Child and Adolescent Psychiatry.⁴³ Similarly, psychological treatments may have increased relevance in the elderly, since older patients with depression are more vulnerable to medication side effects and drug interactions, as many may already be taking multiple medications for comorbid medical disorders. Treatment of depression in youth/adolescents, women, and those in late life is reviewed in Section 6.⁴⁴

2.5. What Are the Key Therapist Factors That Improve Clinical Outcomes?

Recommendations from the American Psychological Association Task Force on psychotherapy relationships⁴⁵ concluded that the best outcomes are likely to come from the concurrent use of evidence-based therapy relationships, not just evidence-based treatments. These conclusions were described as “demonstrably effective,” “probably effective,” and “promising, but insufficiently researched” (Table 4).^46,47 These recommendations are based on literature reviews and process research using secondary analyses, rather than experimental trials of the specific principles; thus, they are supported by Level 3 Evidence and are recommended as a first-line treatment practice. Three evidence-based common factors found to predict positive outcomes are establishing a strong therapeutic alliance, using empathy, and collecting client feedback (Table 4).^46

–49 Therapist characteristics that promote a therapeutic alliance include being genuinely respectful and interested in the well-being and safety of the patient, with empathy for subjective experience.⁵⁰ The collecting of patient feedback helps to track symptoms, experience of treatment, and functioning using validated scales (e.g., the Patient Health Questionnaire–9 [PHQ-9]⁵¹) such that changes can be made if patients are not improving.

Table 4.

Evidence-based Therapy Relationships: Therapist Factors That Improve Clinical Outcomes.^{45,47,48,50,162
-167}

	Elements of a Therapeutic Relationship
Demonstrably effective	Alliance in individual psychotherapy—a collaborative stance predicated on agreement on goals, with consensus on the therapeutic tasks, and an emotional bond Empathy—understanding with communicative attunement Collecting patient feedback—monitoring treatment response with standardized scales
Probably effective	Goal consensus—congruent understanding, agreement, and commitment to goals Collaboration—mutual cooperative involvement of patient and therapist Positive regard—in which patient feels respected and appreciated
Promising but insufficient research to judge	Congruence/genuineness—therapist awareness and authentic use of his or her internal in-session experiences with the patient Repairing alliance ruptures—recognizing and resolving tensions or impasses in the therapeutic alliance to restore collaboration, understanding, or communication Managing countertransference—therapist awareness and self-management of strong feelings precipitated by the patient’s manner of relating and/or the therapist’s unresolved conflicts

Adapted with permission from Norcross (2011).

Additionally, therapist supervision and feedback can improve patient outcomes,^52,53 although the research was not exclusively focused on patients with depression. Therapist experience, adherence, and ability to be responsive to individual patient differences are associated with better outcomes.^54,55 Most importantly, the evidence for psychological therapies for depression is based on studies with highly competent therapists, hence the second-line recommendation (Level 3 Evidence) that psychological therapies for depression should be delivered by trained and proficient therapists, although even less-trained therapists can have efficacy in treating depression and indeed may be the only source of treatment.⁵⁶

2.6. How Do You Choose a Psychological Treatment for MDD?

Choosing a specific type of psychological treatment should consider treatment efficacy, quality, and availability, as well as patient preference. Comparisons of different psychological treatments are fewer in number and quality, as well as complicated by methodological challenges, including lack of blinding and the effects of allegiance to a particular model.

Table 5 lists recommendations for acute and maintenance psychological treatments (respectively) for depression, with the evidence level conveying the efficacy in comparison to control conditions, not to alternative psychological treatments. When choosing psychological treatment for a patient with depression, we recommend preferentially selecting from first-line treatments. Second-line treatments should be used if first-line treatments have failed or are unavailable. Third-line treatments should be reserved for use in specialist centres where first- and second-line treatments are also available. All high-quality evidence in psychotherapy research is based on studies where extensively trained therapists receive regular supervision and adhere to principles of the given therapeutic model with high fidelity. Therefore, the evidence-based recommendations do not extend to psychological treatments that eclectically use elements of different models.

Table 5.

Recommendations for Psychological Treatments for Acute and Maintenance Treatment of Major Depressive Disorder.

	Acute Treatment	Maintenance Treatment (Relapse Prevention)
Cognitive-behavioural therapy (CBT)	First line (Level 1)	First line (Level 1)
Interpersonal therapy (IPT)	First line (Level 1)	Second line (Level 2)
Behavioural activation (BA)	First line (Level 1)	Second line (Level 2)
Mindfulness-based cognitive therapy (MBCT)	Second line (Level 2)	First line (Level 1)
Cognitive-behavioural analysis system of psychotherapy (CBASP)	Second line (Level 2)	Second line (Level 2)
Problem-solving therapy (PST)	Second line (Level 2)	Insufficient evidence
Short-term psychodynamic psychotherapy (STPP)	Second line (Level 2)	Insufficient evidence
Telephone-delivered CBT and IPT	Second line (Level 2)	Insufficient evidence
Internet- and computer-assisted therapy	Second line (Level 2)	Insufficient evidence
Long-term psychodynamic psychotherapy (PDT)	Third line (Level 3)	Third line (Level 3)
Acceptance and commitment therapy (ACT)	Third line (Level 3)	Insufficient evidence
Videoconferenced psychotherapy	Third line (Level 3)	Insufficient evidence
Motivational interviewing (MI)	Third line (Level 4)	Insufficient evidence

2.7. How Do Psychological Treatments for MDD Compare in Efficacy?

Some meta-analytic comparisons between specific models of psychological treatment have shown no significant differences in efficacy,⁵⁷ with others showing modest differences.⁵⁸ When only bona-fide therapies (defined as delivered by trained therapists, based on psychological principles, and designed to be a viable treatment) were considered, there were no differences between CBT and IPT, but CBT was more effective than other psychotherapies considered as a group⁵⁹; using a different definition of bona-fide therapy, supportive therapy was less effective than other types of therapy, with no differences between CBT, IPT, and psychodynamic psychotherapy (PDT).⁶⁰ Short-term psychodynamic psychotherapy (STPP) compared to other types of psychotherapies resulted in slightly worse outcomes on some measures of depression at the end of treatment.⁶¹

Individual psychological treatments are discussed in more detail in the following, but in summary, CBT remains the most established evidence-based, first-line treatment for depression, both acute and maintenance. With more than 40 original reports and meta-analyses published on CBT for MDD or PDD since 2009, there is substantial evidence of efficacy even in severely affected individuals and in those who had not responded to treatment with antidepressants.^62,63 Similarly, there is evidence across populations (adult, adolescents, perinatal women) to support IPT as an alternative strong first-line treatment for acute MDD and second-line as a maintenance treatment.^64
–66 Mindfulness-based cognitive therapy (MBCT) has new evidence to qualify as a second-line acute treatment. With several meta-analyses demonstrating efficacy^67,68 and a large, high-quality RCT (N = 424)⁶⁹ demonstrating equal efficacy of MBCT to medication as maintenance treatment for recurrent MDD, MBCT has emerged as a first-line maintenance treatment adjunctive to medication.

While there are new studies using Internet- or smartphone-delivered treatment, a single additional face-to-face study together with a new meta-analysis including many older, small studies elevate behavioural activation (BA) to first-line treatment.^70,71 The evidence base for STPP has expanded with recent studies, including comparisons with CBT⁷² and antidepressant medication⁷³ and a recently updated meta-analysis.⁶¹ A key limitation of the STPP literature is the conflation of different models of psychodynamic therapy (PDT) into the broad term STPP, whereby no single model has a replicated large RCT with positive findings for MDD, unlike CBT and IPT. Consequently, STPP is recommended as a second-line therapy with Level 2 Evidence. While long-term PDT is not within the scope defined earlier of an acute treatment for depression, there is limited evidence of efficacy for acute MDD treatment.⁷⁴ Thus, the limited evidence base confines general PDT—as separate from specific STPP—as a third-line treatment. While the amount of evidence for the cognitive-behavioural analysis system of psychotherapy (CBASP) has increased, results of the most recent large trial (N = 491 in 3 conditions) are inconsistent with previous results and do not support the efficacy of CBASP.⁷⁵ Therefore, CBASP remains a second-line treatment for chronic depression. An updated meta-analysis of acceptance and commitment therapy (ACT) concluded that there is insufficient evidence of efficacy⁷⁶; therefore, ACT remains a third-line treatment. The evidence status for other types of psychotherapies has not changed significantly since the 2009 guidelines.

2.8. Does Group or Individual Format for Psychological Treatment Influence Outcome?

Meta-analyses that evaluated efficacy of group psychological therapy for depression concluded that it is more effective than treatment as usual.^77,78 However, group therapy was less effective than individual therapy at the end of treatment and had a higher dropout rate, although no differences were found at follow-up.⁷⁷ While efficacy evidence may slightly favour individual therapy, other factors, including availability, cost, and patient preference, are still important factors in choosing between group and individual treatments. Finally, given the gap between needed and available psychological treatments, group psychotherapy could improve access to treatment.

2.9. How Many Sessions of Psychological Treatment Are Required to Be Effective?

Recent research has examined shorter durations for various psychotherapies. Overall, there is Level 1 Evidence that brief interventions can be effective. A number of trials have demonstrated the efficacy of an 8-session CBT intervention.^79,80 A review of 4 small trials of an 8-session brief IPT intervention in depressed women also found efficacy,⁸¹ while 2 other meta-analyses looking at brief (8 or fewer sessions) of CBT, MBCT, and PST noted significant efficacy in symptom reduction.^82,83 Studies comparing 8 versus 16 or more sessions are rare but suggestive of similar effectiveness.^84
–86

In the absence of definitive “dose-finding” trials, insufficient evidence exists to state a minimum dose; it is recommended that after selecting a first- or second-line psychological treatment, the specific treatment manual be followed. In several RCTs,^15,62,86,87 treatment was offered twice weekly for the first 2 to 8 weeks. Furthermore, in a recent analysis of 70 controlled studies (N = 5403), which account for natural recovery, there was no association between clinical improvement and the number of psychological treatment sessions or hours; however, a strong positive association was found for increased frequency of psychological treatment sessions per week and increased size of clinical improvement.¹² Thus, more frequent treatment sessions, particularly at the start of therapy, should be considered (Level 3 Evidence).

2.10. What Is Cognitive-Behavioural Therapy (CBT) and Its Efficacy in the Acute and Maintenance Phases of MDD Treatment?

CBT is an intensive, time-limited, symptom-focused psychological treatment built on the premise that depression is maintained by unhelpful behaviours and by inaccurate thoughts and beliefs about oneself, others, and the future. Behavioural interventions are aimed at increasing the patients’ participation in activities that promote a sense of pleasure and achievement and thus lift their mood. Patients also assess the impact of various behaviours on their mood. The cognitive techniques help patients evaluate the accuracy of their negative thoughts and beliefs. Practising the new skills outside the therapy room (i.e., homework) is crucial for the effectiveness of therapy.

Since 2009, several meta-analyses have been published^57,88,89 using the same database (www.evidencebasedpsychotherapies.com). The authors found that CBT is as effective as antidepressant medication,⁸⁸ and the combination of CBT and an antidepressant is more effective than either alone.^57,88,89 Results of a recent RCT⁶² suggested that when both CBT and pharmacotherapy are of high quality, the addition of CBT to pharmacotherapy increases recovery rates. When participant characteristics were taken into account, this effect was limited to participants with severe nonchronic depression. CBT is also effective for people with treatment-resistant depression (i.e., those who did not respond to at least 2 adequate antidepressant trials). An RCT of 469 primary care patients with depression with poor response to medication found CBT improved response and remission,⁶³ with sustained effects at 3-year follow-up.⁸⁹ In summary, CBT has Level 1 Evidence of efficacy and continues to be recommended as a first-line treatment for acute treatment of MDD.

Regarding maintenance treatment, a meta-analysis of 9 RCTs comparing CBT and pharmacotherapy concluded that after 1 year, those who received CBT in the acute phase of depressive illness had a lower rate of relapse than those who discontinued medication. There was no difference, however, between the CBT group and those who continued pharmacotherapy at 1-year follow-up.⁵⁷ A meta-analysis of 10 trials demonstrated a reduction in the risk of relapse by 21% in the first year and by 28% in the first 2 years.⁹⁰ In a subsequent meta-analysis, which included more heterogeneous studies, CBT delivered during remission decreased the likelihood of relapse by 32%. The comparison with pharmacotherapy did not show a significant difference.⁹¹ To prevent depressive relapse/recurrence, CBT versus pharmacotherapy delivered during the acute phase offers better protection. During maintenance phase treatment, CBT and pharmacotherapy provide comparable prevention of relapse. In summary, CBT has Level 1 Evidence and is recommended as a first-line maintenance therapy, whether the CBT is delivered either in the acute or maintenance phase of MDD.

2.11. What Is Mindfulness-Based Cognitive Therapy (MBCT) and Its Efficacy in the Acute and Maintenance Phases of MDD Treatment?

MBCT for MDD was formally developed as an 8-week group treatment designed to teach patients how to disengage from maladaptive cognitive processes through an integration of mindfulness meditation training and cognitive-behavioural techniques.⁹² MBCT improves clinical outcomes via changes in mindfulness, rumination, worry, compassion, and meta-awareness, consistent with underlying theory.⁹³

MBCT was originally developed to prevent relapse in remitted patients. Clinical trials have supported its therapeutic value as an adjunct to treatment as usual^94,95 and its comparability to maintenance antidepressant medication^69,96 in this context. Of note, evidence has accrued to suggest that MBCT may only be efficacious or advantageous over other forms of aftercare for those patients with greater vulnerability, in the form of recurrent depression,^97,98 unstable remission,^99,100 or a history of childhood trauma⁹⁸ (although see also Geschwind et al.¹⁰¹).

MBCT has been increasingly applied to treatment of residual depressive symptoms following treatment and more recently to depressive symptoms in the context of a full MDD, particularly in patients who have not responded to an earlier treatment. MBCT has exhibited efficacy as an augmentation to treatment as usual in a heterogeneous sample of both currently and remitted depressed outpatients, albeit with modest effect sizes.^102,103 MBCT has also exhibited superior efficacy to a psychoeducation control treatment¹⁰⁴ and comparable efficacy to group CBT,¹⁰⁵ although a brief follow-up period and small sample size, respectively, were notable in these studies.

In summary, MBCT is recommended as a second-line adjunctive treatment (Level 2 Evidence) for acute depression and as a first-line maintenance treatment (Level 1 Evidence).

2.12. What Is Interpersonal Therapy (IPT) and Its Efficacy in the Acute and Maintenance Phases of MDD Treatment?

IPT focuses on patients’ relational stressors involving losses, changes, disagreements, or interpersonal sensitivity, which are associated with the onset or perpetuation of present symptoms. The 4 focal interpersonal problem areas (i.e., bereavement, social role transitions, social deficits with interpersonal sensitivity, and disputes) each have a set of therapeutic guidelines.^106,107 The goals of IPT are to alleviate suffering, remit symptoms, and improve functioning.

A meta-analysis (16 RCTs, N = 1472) compared IPT to a control group for depression or depressive symptoms, with an effect size of 0.63.⁶⁵ A subsequent systematic review of comparative outcomes between IPT and other psychological treatments (8 studies, N = 1233) concluded that differences were small.⁶⁶ Finally, specific examination of IPT versus CBT for adults with MDD (7 trials, N = 741) found no differences between them.⁶⁴ In summary, Level 1 Evidence supports IPT as a first-line treatment for acute depression.

For maintenance treatment, a meta-analysis demonstrates that combined IPT with pharmacotherapy treatment was more effective than pharmacotherapy alone.⁶⁵ However, heterogeneity among the treatment formats (individualized vs. group) and small sample size in the studies reduce evidence to Level 2, and therefore IPT combined with medication is recommended as a second-line maintenance treatment for depression.

2.13. What Are Short-Term Psychodynamic Psychotherapy (STPP) and Long-Term Psychodynamic Therapy (PDT) and Their Efficacy in the Acute and Maintenance Phases of MDD Treatment?

Gunderson and Gabbard¹⁰⁸ have defined PDT as “a therapy that involves careful attention to the therapist/patient interaction with carefully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the therapist’s contribution to the two-person field.” PDT has contributed deeply to understanding the importance of relationship/alliance issues (Table 4). Similarly, in the treatment of the depressed patient with comorbid personality disorder, PDT may have particular utility.²⁴ However, there is only weak evidence, and only after prolonged treatment, for efficacy of long-term PDT for acute treatment of MDD.^74,109 Hence, PDT is considered a third-line treatment for acute MDD.

For STPP, a meta-analysis identified 54 studies (33 RCTs).⁶¹ STPP was significantly more effective than waitlist or treatment-as-usual control conditions, but some analyses indicated STPP was similar to other psychotherapies in outcomes while other findings noted STPP was significantly less effective on depressive symptoms than alternative psychotherapies at posttreatment.⁶¹ Overall, the literature shows increasing evidence of a variety of improvements in outcomes related to STPP, but an absence of replication of specific models leaves evidence of efficacy at Level 2, and STPP models designed for depression should be considered second-line treatment. There is insufficient evidence to recommend STPP or PDT as a maintenance treatment for MDD.

2.14. What Is the Overall Level of Efficacy for Motivational Interviewing (MI) in the Acute and Maintenance Phases of MDD Treatment?

Motivational interviewing (MI) was originally designed for engaging and treating patients with substance use disorders¹¹⁰ and takes the view that people approach change with ambivalence along a continuum of readiness.¹¹¹ There are no trials of MI as a stand-alone treatment for MDD; however, it has been used in conjunction with CBT, IPT, or medications to improve treatment engagement or adherence and for treatment of depression and comorbid substance misuse. For patients less likely to engage in or respond to unmodified treatments, it is worth considering integration of MI.¹¹² In the absence of specific MDD studies, evidence remains at Level 4 (expert opinion), and MI receives a third-line treatment recommendation.

2.15. What Is the Overall Level of Efficacy for Cognitive-Behavioural Analysis System of Psychotherapy (CBASP) in the Acute and Maintenance Phases of MDD Treatment?

CBASP was developed specifically for the treatment of chronic depression.¹¹³ It involves cognitive, behavioural, and interpersonal strategies and is focused on helping patients to recognize how maladaptive cognitions and behaviours influence each other and lead to and perpetuate negative outcomes. Since the first CBASP trial published in 2000,¹¹⁴ 5 CBASP studies have been published that provide only mixed results supporting CBASP.^{75,115

–118} Overall, Level 2 Evidence supports CBASP as a second-line monotherapy, or in combination with antidepressants, for partial-responding or nonresponding patients, in the treatment of PDD.

2.16. What Is Acceptance and Commitment Therapy (ACT) and Its Efficacy?

The aim of ACT is to mindfully increase acceptance of distressing experiences by taking an observer perspective and by clarifying and orienting behaviour towards valued directions, instead of struggling against or trying to control perceived suffering.¹¹⁹ Since 2009, there have been 3 meta-analyses with a comparison of ACT to CBT.^120
–122 In 16 studies of various diagnoses, there was improvement in depressive symptoms and anxiety with ACT, although less than with CBT. ACT may also have particular value in the presence of comorbid medical conditions.¹²² In the absence of specific large trials in MDD, evidence remains at Level 3 and ACT is recommended as a third-line treatment for MDD.

2.17. What Is Behavioural Activation (BA) for Depression and Its Efficacy?

The rationale for BA is that depression is caused and maintained by escape and avoidance of aversive emotions and stimuli that become self-reinforced and also prevents positive reinforcement of nondepressive behaviour, consequently causing longstanding patterns of inertia, avoidance, and social withdrawal.¹²³ Manuals are available to address techniques to be applied in BA.^124
–126

One meta-analysis (34 studies, N > 2000 patients with depressive symptoms, but not necessarily MDD)¹²⁷ found similar large effect sizes for BA and CBT compared to control conditions, as well as a similar effect to CBT. Subsequent clinical trials evaluating BA in MDD have almost exclusively involved Internet- or smartphone-delivered treatments as opposed to in-person therapy.^70,128,129 A subsequent meta-analysis (26 RCTs, N = 1524) that incorporated older studies, the Internet/smartphone studies, and 1 recent face-to-face trial reported a large effect size of BA compared to control conditions.^130,131 Overall, Level 1 Evidence supports BA as a first-line treatment for acute depression, with modest evidence that BA in acute depression provides protection against future relapse (Level 2), suggesting its role as a second-line treatment for maintenance.

2.18. What Are Peer Interventions and Their Efficacy for Depression?

Peer interventions for depression include self-help groups and peer-run organizations and services.¹³² Peer support can be beneficial either alone or as a complement to clinical care. Guidelines from the Mental Health Commission of Canada provide direction to decision makers, program leaders, and the public about peer support training and practice.¹³³

An initial meta-analysis of peer support for depression was positive, but subsequent results are mixed.^134
–136 Given the general benefits of social and peer support, as well as the widespread availability of this resource,¹³⁷ peer interventions are recommended as a second-line adjunctive treatment for MDD (Level 2 Evidence).

2.19. What Is Problem-Solving Therapy (PST) and Its Efficacy?

PST is a structured brief, empirically tested intervention focusing on the adoption of adaptive problem-solving attitudes and skills to treat MDD. It has been shown to be more effective when training includes both positive problem orientation and problem-solving skills.¹³⁸

PST has been tested most extensively in primary care settings in individuals with a variety of depressive symptoms spanning subclinical depression, adjustment disorders, and MDD, with clear efficacy in reducing depressive symptoms. Both telephone-delivered and in-person PST were effective for treating MDD in low-income homebound older adults.¹³⁹ Two separate meta-analyses found that the use of PST as an acute treatment for late life depression resulted in a significant reduction of depressive symptoms as well as disability in comparison to control treatments.^138,140

Overall, since most studies include a focus on depressive symptoms rather than formal MDD, PST is recommended as a second-line acute treatment in primary care and geriatric depression (Level 2 Evidence); there is insufficient evidence to recommend PST as a maintenance treatment.

2.20. What Is Bibliotherapy and What Is Its Efficacy?

Bibliotherapy, the reading and use of self-help materials such as books to treat depression, has been tested in many older trials, particularly as RCTs involving a waitlist control compared to use of the book Feeling Good by David Burns.¹⁴¹ With the expansion of computer/Internet approaches to self-help, very few bibliotherapy trials have been published since 2009. Although 1 RCT¹⁴² highlighted the need for physician guidance to ensure active engagement, an RCT evaluating usual care versus prescription for Feeling Good found no difference in patient outcomes.¹⁴³ Overall, bibliotherapy has practical utility due to ease of use and low cost, may be useful for people waiting to be seen for clinical care, and remains a second-line treatment, either alone or as an adjunct to medication, ideally with clinician encouragement and monitoring.

2.21. How Effective Is Internet- and Computer-Delivered Therapy for Depression?

Meta-analyses and reviews of computer-based psychological treatment for the treatment of MDD, whether delivered over the Internet or as a stand-alone program, confirm efficacy.^{144

–150} Internet- and computer-delivered therapy (I/CT) can also be helpful in relapse prevention.¹⁵¹ I/CT studies usually use adaptations of CBT, but 1 trial compared updated versions of CBT and IPT with the established “MoodGym” online version of CBT with over 600 participants in each of the 3 groups; self-guided IPT was similar to the other treatments in reducing depressive symptoms.¹⁵² When the Internet therapy is guided by a clinician, both adherence and efficacy are much more substantial.⁸⁸ Across psychiatric disorders, 1 meta-analysis¹⁵³ found that guided Internet CBT was no different in outcomes from face-to-face CBT, while a noninferiority study¹⁵⁴ specifically for depression also found no differences between the 2 approaches. I/CT remains a second-line treatment for depression, with improved efficacy if the I/CT is actively guided by a clinician.

2.22. How Effective Is Remote Interactive Psychological Treatment for Depression (Phone, Video, Internet) Compared to Face-to-Face Therapy?

Psychological treatments with a live therapist are being increasingly mediated by technology, whether by phone, videoconferencing, or live interaction over the Internet. In addition to CBT, a significant number of studies have evaluated other methods of telephone-delivered support and disease management.

Telephone-delivered psychological treatment remains the most studied model. In one of the first large trials (600 patients starting antidepressants in primary care offices), both 8-session CBT and disease management by phone improved clinical efficacy and satisfaction, compared to medication alone.⁷⁹ The same 8-session CBT phone intervention added to an antidepressant improved work performance and satisfaction compared to antidepressant alone.⁸⁰ Collectively, telephone-delivered CBT has Level 1 Evidence, while other therapies have Level 2 Evidence, positioning telephone-delivered therapy as a second-line treatment.

Videoconferencing approaches to psychological treatment may include use of traditional videoconference suites with television cameras in 2 different locations or, more recently, Internet technologies on personal computing devices, including Skype, Medeo, FaceTime, and many others. The broader application of such technologies to psychiatry has been extensively reviewed and found to be acceptable and generally equivalent to face-to-face care for many psychiatric conditions.^155,156 Relatively few studies have been done using videoconferencing for MDD, but there is limited evidence of efficacy in several small RCTs,^156
–158 suggesting that videoconferenced psychological treatment for depression may be considered a promising third-line treatment.

2.23. Is Combined Psychological Treatment with Medication Superior to Psychological Treatment Alone?

Accumulated evidence shows that combined psychological and antidepressant treatment is more effective than psychological treatment alone or psychological treatment with placebo.^159,160 The evidence is mostly based on studies where either CBT or IPT was delivered alone and combined with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). There was a trend for SSRIs and IPT to be less effective in combinations than TCAs, CBT, and other psychotherapies. The small to moderate effect size of the differences suggests that combined treatment should be offered to individuals with moderate to severe depression based on a consideration of benefit-burden balance and preferences of a given patient.

2.24. Is Combined Psychological Treatment with Medication Superior to Medication Alone?

A recent meta-analysis shows that psychological treatment combined with antidepressants is more effective than antidepressants alone.¹⁵⁹ The evidence is primarily based on studies where individual CBT or IPT was combined with SSRIs or TCAs. The effect size of the difference was moderate, suggesting that combined treatment should be offered in preference to antidepressants alone to individuals with moderate to severe depression.

2.25. Is Sequential Treatment Superior to Monotherapy?

A meta-analysis of 8 studies found that psychological treatment after antidepressant treatment reduces the likelihood of relapse by 20%, compared to treatment as usual, which included discontinuation of antidepressants.¹⁶¹ Although the meta-analysis aimed to examine the effect of any type of psychological treatment, the evidence was limited to CBT and MBCT.¹⁶¹ In addition, a large pragmatic trial found that a course of up to 18 sessions of face-to-face individual CBT significantly reduced depressive symptoms and increased the likelihood of therapeutic response to antidepressants in treatment-resistant depression.⁶³ Another large primary care trial compared the effects of group MBCT and maintenance antidepressant therapy on time to relapse; while there were no significant differences between the 2 conditions, the risk of relapse was greater in those who had prematurely discontinued antidepressant treatment.⁶⁹ In contrast, PDT (up to 60 sessions over 18 months) did not significantly increase the likelihood of remission.⁷⁴

In summary, CBT or MBCT is recommended as sequential first-line treatment (Level 1 Evidence) after a course of antidepressants, and MBCT is recommended as a second-line alternative to long-term maintenance antidepressant treatment (Level 2 Evidence).

Footnotes

Disclosures

The guidelines process and publication were funded entirely by internal CANMAT funds; no external support was sought or received. No honoraria were paid to authors and no professional editorial assistance was used. All members of the CANMAT Depression Work Group disclosed potential conflicts of interest (available at ). CANMAT is a project-driven organization governed by a volunteer, unpaid advisory board, with no permanent staff or dedicated offices. CANMAT has a conflict of interest policy that includes disclosures by all participants, and all continuing professional development (CPD) projects are accredited by academic institutions. CANMAT has diverse funding, but in the past 5 years (2011-2015), sources of CANMAT revenue (excluding CIHR and research funding) included national/international scientific conferences (28% of revenue), publications (26%), industry-supported CPD projects (26%), and academic projects (18%).

The CANMAT guidelines are not officially endorsed by the Canadian Psychiatric Association.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article:

SVP has been a consultant to Bristol Myers Squibb, Lundbeck, and Takeda; has had a research contract with Assurex; and has equity in Mensante.

LCQ, PR, BP, VV, and RU have nothing to disclose.

MR received honoraria from AstraZeneca, Bristol-Myers Squibb, Canadian Psychiatric Association, Eli Lilly, Lundbeck, Otsuka, Pfizer, and Sunovion.

SG has received honoraria as a consultant, member of an advisory committee, or for lectures from Actavis, Bristol Myers Squibb, Eli Lilly Canada, and Pfizer, as well as research grant support from Canadian Institutes of Health Research, CR Younger Foundation, Ontario Mental Health Foundation, and Ontario Ministry of Health and Long-Term Care.

SHK has received honoraria for ad hoc speaking or advising/consulting or received research funds from Allergan, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Janssen, Lundbeck, Ontario Brain Institute, Pfizer, St. Jude Medical, Servier, and Sunovion.

RWL has received honoraria for ad hoc speaking or advising/consulting or received research funds from Asia-Pacific Economic Cooperation, AstraZeneca, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Depression Research and Intervention Network, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Coast Capital Savings, Johnson & Johnson, Lundbeck, Lundbeck Institute, Medscape, Pfizer, St. Jude Medical, Takeda, University Health Network Foundation, and Vancouver Coastal Health Research Institute.

GMM has been on advisory board or speaker for Janssen, Lilly, Lundbeck, and Pfizer.

RVM has received speaker and consultant honoraria or research funds from Allergan, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Eli Lilly, Johnson & Johnson, Lallemand, Lundbeck, Merck, Ontario Brain Institute, Ontario Mental Health Foundation, Otsuka, Paladin, Pfizer, Queen’s University, Sunovion, Takeda, the University Health Network Foundation, and Valeant.

AVR has received speaker and consultant honoraria or research funds from Bristol-Myers Squibb, Canadian Depression Research and Intervention Network, Canadian Foundation for Innovation and the Ministry of Economic Development and Innovation, Canadian Institutes of Health Research, Grand Challenges Canada, Janssen, Lundbeck, Ontario Mental Health Foundation, Pfizer, and Sunovion.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Kennedy

Lam

Parikh

. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. Introduction. J Affect Disord. 2009;117(Suppl 1):S1–S2.

Yatham

Kennedy

Parikh

. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord. 2013;15:1–44.

Lam

Kennedy

Parikh

. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: introduction and methods. Can J Psychiatry. 2016;61(9):506–509.

Walker

Hernandez

Kattan

. Meta-analysis: its strengths and limitations. Cleve Clin J Med. 2008;75:431–439.

Zimmerman

Mattia

Posternak

. Are subjects in pharmacological treatment trials of depression representative of patients in routine clinical practice? Am J Psychiatry. 2002;159:469–473.

Huang

Coleman

Bridge

. A meta-analysis of the relationship between antidepressant use in pregnancy and the risk of preterm birth and low birth weight. Gen Hosp Psychiatry. 2014;36:13–18.

Ross

Grigoriadis

Mamisashvili

. Selected pregnancy and delivery outcomes after exposure to antidepressant medication: a systematic review and meta-analysis. JAMA Psychiatry. 2013;70:436–443.

Farahani

Correll

. Are antipsychotics or antidepressants needed for psychotic depression? A systematic review and meta-analysis of trials comparing antidepressant or antipsychotic monotherapy with combination treatment. J Clin Psychiatry. 2012;73:486–496.

Simon

Perlis

. Personalized medicine for depression: can we match patients with treatments? Am J Psychiatry. 2010;167:1445–1455.

10.

Driessen

Hollon

. Cognitive behavioral therapy for mood disorders: efficacy, moderators and mediators. Psychiatr Clin North Am. 2010;33:537–555.

11.

Cuijpers

Weitz

Twisk

. Gender as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression: an “individual patient data” meta-analysis. Depress Anxiety. 2014;31:941–951.

12.

Cuijpers

Huibers

Ebert

. How much psychotherapy is needed to treat depression? A metaregression analysis. J Affect Disord. 2013;149:1–13.

13.

Kriston

von Wolff

Westphal

. Efficacy and acceptability of acute treatments for persistent depressive disorder: a network meta-analysis. Depress Anxiety. 2014;31:621–630.

14.

Elkin

Gibbons

Shea

. Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol. 1995;63:841–847.

15.

DeRubeis

Hollon

Amsterdam

. Cognitive therapy vs medications in the treatment of moderate to severe depression. Arch Gen Psychiatry. 2005;62:409–416.

16.

Weitz

Hollon

Twisk

. Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: an individual patient data meta-analysis. JAMA Psychiatry. 2015;72:1102–1109.

17.

Bower

Kontopantelis

Sutton

. Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data. BMJ. 2013;346:f540.

18.

Cuijpers

Koole

van Dijke

. Psychotherapy for subclinical depression: meta-analysis. Br J Psychiatry. 2014;205:268–274.

19.

Thase

Friedman

Biggs

. Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report. Am J Psychiatry. 2007;164:739–752.

20.

McIntyre

Alsuwaidan

Goldstein

. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid metabolic disorders. Ann Clin Psychiatry. 2012;24:69–81.

21.

Schaffer

McIntosh

Goldstein

. The CANMAT task force recommendations for the management of patients with mood disorders and comorbid anxiety disorders. Ann Clin Psychiatry. 2012;24:6–22.

22.

Bond

Hadjipavlou

Lam

. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid attention-deficit/hyperactivity disorder. Ann Clin Psychiatry. 2012;24:23–37.

23.

Beaulieu

Saury

Sareen

. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid substance use disorders. Ann Clin Psychiatry. 2012;24:38–55.

24.

Rosenbluth

MacQueen

McIntyre

. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid personality disorders. Ann Clin Psychiatry. 2012;24:56–68.

25.

Ramasubbu

Taylor

Samaan

. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and select comorbid medical conditions. Ann Clin Psychiatry. 2012;24:91–109.

26.

Ramasubbu

Beaulieu

Taylor

. The CANMAT task force recommendations for the management of patients with mood disorders and comorbid medical conditions: diagnostic, assessment, and treatment principles. Ann Clin Psychiatry. 2012;24:82–90.

27.

Dickens

Cherrington

Adeyemi

. Characteristics of psychological interventions that improve depression in people with coronary heart disease: a systematic review and meta-regression. Psychosom Med. 2013;75:211–221.

28.

Mavrides

Nemeroff

. Treatment of depression in cardiovascular disease. Depress Anxiety. 2013;30:328–341.

29.

Ski

Jelinek

Jackson

. Psychosocial interventions for patients with coronary heart disease and depression: a systematic review and meta-analysis. Eur J Cardiovasc Nurs J. 2015 Oct 16. [Epub ahead of print]

30.

Piet

Würtzen

Zachariae

. The effect of mindfulness-based therapy on symptoms of anxiety and depression in adult cancer patients and survivors: a systematic review and meta-analysis. J Consult Clin Psychol. 2012;80:1007–1020.

31.

Sherr

Clucas

Harding

. HIV and depression—a systematic review of interventions. Psychol Health Med. 2011;16:493–527.

32.

Sin

DiMatteo

. Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis. Ann Behav Med. 2014;47:259–269.

33.

Mehndiratta

Sajatovic

. Treatments for patients with comorbid epilepsy and depression: a systematic literature review. Epilepsy Behav. 2013;28:36–40.

34.

Fernie

Kollmann

Brown

. Cognitive behavioural interventions for depression in chronic neurological conditions: a systematic review. J Psychosom Res. 2015;78:411–419.

35.

Neri

Bertino

Petralia

. A multidisciplinary therapeutic approach for reducing the risk of psychiatric side effects in patients with chronic hepatitis C treated with pegylated interferon α and ribavirin. J Clin Gastroenterol. 2010;44:e210–e217.

36.

McHugh

Whitton

Peckham

. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013;74:595–602.

37.

Yonkers

Wisner

Stewart

. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31:403–413.

38.

Howard

Megnin-Viggars

Symington

. Antenatal and postnatal mental health: summary of updated NICE guidance. BMJ. 2014;349:g7394.

39.

Miniati

Callari

Calugi

. Interpersonal psychotherapy for postpartum depression: a systematic review. Arch Womens Ment Health. 2014;17:257–268.

40.

Sockol

. A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. J Affect Disord. 2015;177:7–21.

41.

Battle

Salisbury

Schofield

. Perinatal antidepressant use: understanding women’s preferences and concerns. J Psychiatr Pract. 2013;19:443–453.

42.

Walton

Ross

Stewart

. Decisional conflict among women considering antidepressant medication use in pregnancy. Arch Womens Ment Health. 2014;17:493–501.

43.

Birmaher

Brent

, AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503–1526.

44.

MacQueen

Frey

Ismail

. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. special populations: youth, women, and the elderly. Can J Psychiatry. 2016;61(9):588–603.

45.

Norcross

JC.

Psychotherapy relationships that work: evidence-based responsiveness. 2nd ed. New York (NY): Oxford University Press; 2011.

46.

Norcross

Lambert

. Psychotherapy relationships that work II. Psychotherapy. 2011;48:4–8.

47.

Norcross

Wampold

. Evidence-based therapy relationships: research conclusions and clinical practices. Psychotherapy. 2011;48:98–102.

48.

Elliott

Bohart

Watson

. Empathy. Psychotherapy (Chic). 2011;48:43–49.

49.

Hill

Knox

. Processing the therapeutic relationship. Psychother Res. 2009;19:13–29.

50.

Leszcz

Pain

Hunter

. Psychotherapy essentials to go: achieving psychotherapy effectiveness. New York (NY): Norton; 2015.

51.

Kroenke

Spitzer

Williams

. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613.

52.

Shimokawa

Lambert

Smart

. Enhancing treatment outcome of patients at risk of treatment failure: meta-analytic and mega-analytic review of a psychotherapy quality assurance system. J Consult Clin Psychol. 2010;78:298–311.

53.

Simon

Lambert

Harris

. Providing patient progress information and clinical support tools to therapists: effects on patients at risk of treatment failure. Psychother Res. 2012;22:638–647.

54.

Fournier

DeRubeis

Amsterdam

. Gains in employment status following antidepressant medication or cognitive therapy for depression. Br J Psychiatry. 2015;206:332–338.

55.

Johnsen

Friborg

. The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: a meta-analysis. Psychol Bull. 2015;141:747–768.

56.

van Ginneken

Tharyan

Lewin

. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev. 2013;11:CD009149.

57.

Cuijpers

Berking

Andersson

. A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Can J Psychiatry. 2013;58:376–385.

58.

Linde

Rücker

Sigterman

. Comparative effectiveness of psychological treatments for depressive disorders in primary care: network meta-analysis. BMC Fam Pract. 2015;16:103.

59.

Tolin

. Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clin Psychol Rev. 2010;30:710–720.

60.

Braun

Gregor

Tran

. Comparing bona fide psychotherapies of depression in adults with two meta-analytical approaches. PLoS One. 2013;8:e68135.

61.

Driessen

Hegelmaier

Abbass

. The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis update. Clin Psychol Rev. 2015;42:1–15.

62.

Hollon

DeRubeis

Fawcett

. Effect of cognitive therapy with antidepressant medications vs antidepressants alone on the rate of recovery in major depressive disorder: a randomized clinical trial. JAMA Psychiatry. 2014;71:1157–1164.

63.

Wiles

Thomas

Abel

. Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial. Lancet. 2013;381:375–384.

64.

Jakobsen

Hansen

Simonsen

. Effects of cognitive therapy versus interpersonal psychotherapy in patients with major depressive disorder: a systematic review of randomized clinical trials with meta-analyses and trial sequential analyses. Psychol Med. 2012;42:1343–1357.

65.

Cuijpers

Geraedts

van Oppen

. Interpersonal psychotherapy for depression: a meta-analysis. Am J Psychiatry. 2011;168:581–592.

66.

van Hees

MLJM

Rotter

Ellermann

. The effectiveness of individual interpersonal psychotherapy as a treatment for major depressive disorder in adult outpatients: a systematic review. BMC Psychiatry. 2013;13:22.

67.

Galante

Iribarren

Pearce

. Effects of mindfulness-based cognitive therapy on mental disorders: a systematic review and meta-analysis of randomised controlled trials. J Res Nurs. 2013;18:133–155.

68.

Piet

Hougaard

. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis. Clin Psychol Rev. 2011;31:1032–1040.

69.

Kuyken

Hayes

Barrett

. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015;386:63–73.

70.

Carlbring

Hägglund

Luthström

. Internet-based behavioral activation and acceptance-based treatment for depression: a randomized controlled trial. J Affect Disord. 2013;148:331–337.

71.

Moradveisi

Huibers

MJH

Renner

. Behavioural activation v. antidepressant medication for treating depression in Iran: randomised trial. Br J Psychiatry. 2013;202:204–211.

72.

Driessen

Van

Don

. The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: a randomized clinical trial. Am J Psychiatry. 2013;170:1041–1050.

73.

Barber

Barrett

Gallop

. Short-term dynamic psychotherapy versus pharmacotherapy for major depressive disorder: a randomized, placebo-controlled trial. J Clin Psychiatry. 2012;73:66–73.

74.

Fonagy

Rost

Carlyle

. Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry. 2015;14:312–321.

75.

Kocsis

Gelenberg

Rothbaum

. Cognitive behavioral analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression: the REVAMP Trial. Arch Gen Psychiatry. 2009;66:1178–1188.

76.

Ost

L-G

. The efficacy of acceptance and commitment therapy: an updated systematic review and meta-analysis. Behav Res Ther. 2014;61:105–121.

77.

Huntley

Araya

Salisbury

. Group psychological therapies for depression in the community: systematic review and meta-analysis. Br J Psychiatry. 2012;200:184–190.

78.

Okumura

Ichikura

. Efficacy and acceptability of group cognitive behavioral therapy for depression: a systematic review and meta-analysis. J Affect Disord. 2014;164:155–164.

79.

Simon

Ludman

Tutty

. Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial. JAMA. 2004;292:935–942.

80.

Lam

Parikh

Ramasubbu

. Effects of combined pharmacotherapy and psychotherapy for improving work functioning in major depressive disorder. Br J Psychiatry. 2013;203:358–365.

81.

Swartz

Grote

Graham

. Brief interpersonal psychotherapy (IPT-B): overview and review of evidence. Am J Psychother. 2014;68:443–462.

82.

Cape

Whittington

Buszewicz

. Psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression. BMC Med. 2010;8:38.

83.

Nieuwsma

Trivedi

McDuffie

. Brief psychotherapy for depression: a systematic review and meta-analysis. Int J Psychiatry Med. 2012;43:129–151.

84.

Dekker

Molenaar

Kool

. Dose-effect relations in time-limited combined psycho-pharmacological treatment for depression. Psychol Med. 2005;35:47–58.

85.

Molenaar

Boom

Peen

. Is there a dose-effect relationship between the number of psychotherapy sessions and improvement of social functioning? Br J Clin Psychol. 2011;50:268–282.

86.

Dimidjian

Hollon

Dobson

. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. J Consult Clin Psychol. 2006;74:658–670.

87.

Luty

Carter

McKenzie

. Randomised controlled trial of interpersonal psychotherapy and cognitive-behavioural therapy for depression. Br J Psychiatry. 2007;190:496–502.

88.

Cuijpers

. Psychotherapies for adult depression: recent developments. Curr Opin Psychiatry. 2015;28:24–29.

89.

Wiles

Thomas

Turner

. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. Lancet Psychiatry. 2016;3:137–144.

90.

Clarke

Mayo-Wilson

Kenny

. Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clin Psychol Rev. 2015;39:58–70.

91.

Biesheuvel-Leliefeld

KEM

Kok

Bockting

CLH

. Effectiveness of psychological interventions in preventing recurrence of depressive disorder: meta-analysis and meta-regression. J Affect Disord. 2015;174:400–410.

92.

Segal

Williams

Teasdale

. Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York (NY): Guilford; 2002.

93.

van der Velden

Kuyken

Wattar

. A systematic review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of recurrent major depressive disorder. Clin Psychol Rev. 2015;37:26–39.

94.

Bondolfi

Jermann

der Linden

. Depression relapse prophylaxis with mindfulness-based cognitive therapy: replication and extension in the Swiss health care system. J Affect Disord. 2010;122:224–231.

95.

Godfrin

van Heeringen

. The effects of mindfulness-based cognitive therapy on recurrence of depressive episodes, mental health and quality of life: a randomized controlled study. Behav Res Ther. 2010;48:738–746.

96.

Kuyken

Byford

Taylor

. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psychol. 2008;76:966–978.

97.

Teasdale

. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol. 2004;72:31–40.

98.

Teasdale

Segal

Williams

. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol. 2000;68:615–623.

99.

Segal

Bieling

Young

. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch Gen Psychiatry. 2010;67:1256–1264.

100.

Williams

Crane

Barnhofer

. Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a randomized dismantling trial. J Consult Clin Psychol. 2014;82:275–286.

101.

Geschwind

Peeters

Huibers

. Efficacy of mindfulness-based cognitive therapy in relation to prior history of depression: randomised controlled trial. Br J Psychiatry. 2012;201:320–325.

102.

van Aalderen

Donders

ART

Giommi

. The efficacy of mindfulness-based cognitive therapy in recurrent depressed patients with and without a current depressive episode: a randomized controlled trial. Psychol Med. 2012;42:989–1001.

103.

van Aalderen

Donders

ART

Peffer

. Long-term outcome of mindfulness-based cognitive therapy in recurrently depressed patients with and without a depressive episode at baseline. Depress Anxiety. 2015;32:563–569.

104.

Chiesa

Castagner

Andrisano

. Mindfulness-based cognitive therapy vs. psycho-education for patients with major depression who did not achieve remission following antidepressant treatment. Psychiatry Res. 2015;226:474–483.

105.

Manicavasgar

Parker

Perich

. Mindfulness-based cognitive therapy vs cognitive behaviour therapy as a treatment for non-melancholic depression. J Affect Disord. 2011;130:138–144.

106.

Weissman

Markowitz

Klerman

. Clinician’s quick guide to interpersonal psychotherapy. New York (NY): Oxford; 2007.

107.

Ravitz

Watson

. Interpersonal psychotherapy: healing with a relational focus. FOCUS. 2014;12:275–284.

108.

Gunderson

Gabbard

. Making the case for psychoanalytic therapies in the current psychiatric environment. J Am Psychoanal Assoc. 1999;47:679–703.

109.

Leichsenring

Ablon

Barber

. Developing a prototype for short-term psychodynamic (supportive-expressive) therapy: an empirical study with the psychotherapy process Q-set. Psychother Res. 2015;26:500–510.

110.

Miller

Rollnick

. Motivational interviewing: helping people change. New York (NY): Guilford; 2012.

111.

Lundahl

Kunz

Brownell

. A meta-analysis of motivational interviewing: twenty-five years of empirical studies. Res Soc Work Pract. 2010;20:137–160.

112.

Flynn

. Setting the stage for the integration of motivational interviewing with cognitive behavioral therapy in the treatment of depression. Cogn Behav Pract. 2011;18:46–54.

113.

McCullough

. Treatment for chronic depression using cognitive behavioral analysis system of psychotherapy (CBASP). J Clin Psychol. 2003;59:833–846.

114.

Keller

McCullough

Klein

. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med. 2000;342:1462–1470.

115.

Schatzberg

Rush

Arnow

. Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not. Arch Gen Psychiatry. 2005;62:513–520.

116.

Schramm

Zobel

Dykierek

. Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: a randomized pilot study. J Affect Disord. 2011;129:109–116.

117.

Wiersma

Van Schaik

DJF

Hoogendorn

. The effectiveness of the cognitive behavioral analysis system of psychotherapy for chronic depression: a randomized controlled trial. Psychother Psychosom. 2014;83:263–269.

118.

Brakemeier

E-L

Radtke

Engel

. Overcoming treatment resistance in chronic depression: a pilot study on outcome and feasibility of the cognitive behavioral analysis system of psychotherapy as an inpatient treatment program. Psychother Psychosom. 2015;84:51–56.

119.

Hayes

Luoma

Bond

. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1–25.

120.

Powers

Zum Vorde Sive Vording

Emmelkamp

PMG

. Acceptance and commitment therapy: a meta-analytic review. Psychother Psychosom. 2009;78:73–80.

121.

Ruiz

. Acceptance and commitment therapy versus traditional cognitive behavioral therapy: a systematic review and meta-analysis of current empirical evidence. Int J Psychol Psychol Ther. 2012;12:333–357.

122.

A-Tjak

JGL

Davis

Morina

. A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychother Psychosom. 2015;84:30–36.

123.

Ferster

. A functional analysis of depression. Am Psychol. 1973;28:857–870.

124.

Jacobson

Martell

Dimidjian

. Behavioral activation treatment for depression: returning to contextual roots. Clin Psychol Sci Pract. 2001;8:255–270.

125.

Martell

Dimidjian

Herman-Dunn

. Behavioral activation for depression: a clinician’s guide. New York (NY): Guilford; 2010.

126.

Lejuez

Hopko

LePage

. A brief behavioral activation treatment for depression. Cogn Behav Pract. 2001;8:164–175.

127.

Mazzucchelli

Kane

Rees

. Behavioral activation treatments for depression in adults: a meta-analysis and review. Clin Psychol Sci Pract. 2009;16:383–411.

128.

Moritz

Kelly

. A spirituality teaching program for depression: qualitative findings on cognitive and emotional change. Complement Ther Med. 2011;19:201–207.

129.

Janni

Wrede

. Experiences of a guided smartphone-based behavioral activation therapy for depression: a qualitative study. Internet Interv. 2015;2:60–68.

130.

Ekers

Webster

Van Straten

. Behavioural activation for depression: an update of meta-analysis of effectiveness and sub group analysis. PLoS One. 2014;96:e100100.

131.

Moradveisi

Huibers

Renner

. Behavioural activation v. antidepressant medication for treating depression in Iran: randomised trial. Br J Psychiatry. 2013;202:204–211.

132.

O’Hagan

Cyr

McKee

. Making the case for peer support: report to the Peer Support Project Committee of the Mental Health Commission of Canada. Ottawa (ON): Mental Health Commission of Canada; 2010.

133.

Sunderland

Mishkin

. Guidelines for the practice and training of peer support [Internet]. Mental Health Commission of Canada 2013 [cited 2016 April 13]. Available from: http://www.mentalhealthcommission.ca/English/node/18291

134.

Pfeiffer

Heisler

Piette

. Efficacy of peer support interventions for depression: a meta-analysis. Gen Hosp Psychiatry. 2011;33:29–36.

135.

Fuhr

Salisbury

De Silva

. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1691–1702.

136.

Valenstein

Pfeiffer

Brandfon

. Augmenting ongoing depression care with a mutual peer support intervention versus self-help materials alone: a randomized trial. Psychiatr Serv. 2016;67:236–239.

137.

Goldstrom

Campbell

Rogers

. National estimates for mental health mutual support groups, self-help organizations, and consumer-operated services. Adm Policy Ment Health. 2006;33:92–103.

138.

Bell

D’Zurilla

. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev. 2009;29:348–353.

139.

Choi

Marti

Bruce

. Six-month postintervention depression and disability outcomes of in-home telehealth problem-solving therapy for depressed, low-income homebound older adults. Depress Anxiety. 2014;31:653–661.

140.

Kirkham

Choi

Seitz

. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults. Int J Geriatr Psychiatry. 2015;31:526–535.

141.

Parikh

Segal

Grigoriadis

. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults: II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord. 2009;117(Suppl 1):S15–S25.

142.

Joling

van Hout

HPJ

van’t Veer-Tazelaar

. How effective is bibliotherapy for very old adults with subthreshold depression? A randomized controlled trial. Am J Geriatr Psychiatry. 2011;19:256–265.

143.

Naylor

Antonuccio

Litt

. Bibliotherapy as a treatment for depression in primary care. J Clin Psychol Med Settings. 2010;17:258–271.

144.

Andrews

Cuijpers

Craske

. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One. 2010;5:e13196.

145.

Arnberg

Linton

Hultcrantz

. Internet-delivered psychological treatments for mood and anxiety disorders: a systematic review of their efficacy, safety, and cost-effectiveness. PLoS One. 2014;9:e98118.

146.

Vallury

Jones

Oosterbroek

. Computerized cognitive behavior therapy for anxiety and depression in rural areas: a systematic review. J Med Internet Res. 2015;17:e139.

147.

Titov

. Internet-delivered psychotherapy for depression in adults. Curr Opin Psychiatry. 2011;24:18–23.

148.

Richards

Richardson

. Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clin Psychol Rev. 2012;32:329–342.

149.

Eells

Barrett

Wright

. Computer-assisted cognitive-behavior therapy for depression. Psychotherapy. 2014;51:191–197.

150.

Renton

Tang

Ennis

. Web-based intervention programs for depression: a scoping review and evaluation. J Med Internet Res. 2014;16:e209.

151.

Holländare

Anthony

Randestad

. Two-year outcome of Internet-based relapse prevention for partially remitted depression. Behav Res Ther. 2013;51:719–722.

152.

Donker

Bennett

. Internet-delivered interpersonal psychotherapy versus internet-delivered cognitive behavioral therapy for adults with depressive symptoms: randomized controlled noninferiority trial. J Med Internet Res. 2013;15:e82.

153.

Andersson

Cuijpers

Carlbring

. Guided internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis. World Psychiatry. 2014;13:288–295.

154.

Wagner

Horn

Maercker

. Internet-based versus face-to-face cognitive-behavioral intervention for depression: a randomized controlled non-inferiority trial. J Affect Disord. 2014;152-154:113–121.

155.

Gajaria

Conn

Madan

. Telepsychiatry: effectiveness and feasibility. Smart Homecare Technol TeleHealth. 2015;2015:59–67.

156.

Chakrabarti

. Usefulness of telepsychiatry: a critical evaluation of videoconferencing-based approaches. World J Psychiatry. 2015;5:286–304.

157.

Khatri

Marziali

Tchernikov

. Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: a pilot study. Clin Interv Aging. 2014;9:765–770.

158.

Stubbings

Rees

Roberts

. Comparing in-person to videoconference-based cognitive behavioral therapy for mood and anxiety disorders: randomized controlled trial. J Med Internet Res. 2013;15:e258.

159.

Cuijpers

De Wit

Weitz

. The combination of psychotherapy and pharmacotherapy in the treatment of adult depression: a comprehensive meta-analysis. J Evid Based Psychother. 2015;15:147.

160.

de Maat

Dekker

Schoevers

. Relative efficacy of psychotherapy and combined therapy in the treatment of depression: a meta-analysis. Eur Psychiatry. 2007;22:1–8.

161.

Guidi

Fava

. Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis. Psychol Med. 2011;41:321–331.

162.

Baldwin

Imel

. Therapist effects: findings and methods. In: Lambert

, editor. Bergin and Garfield’s handbook of psychotherapy and behavior changes. 6th ed. New York (NY): John Wiley; 2013. pp. 258–297.

163.

Barth

Munder

Gerger

. Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis. PLoS Med. 2013;10:e1001454.

164.

Horvath

Del Re

Flückiger

. Alliance in individual psychotherapy. Psychotherapy (Chic). 2011;48:9–16.

165.

Kraus

Castonguay

Boswell

. Therapist effectiveness: implications for accountability and patient care. Psychotherapy Res. 2011;21:267–276.

166.

Luborsky

Rosenthal

Diguer

. The Dodo bird verdict is alive and well—mostly. Clin Psychol Sci Pract. 2002;9:2–12.

167.

Safran

Muran

Eubanks-Carter

. Repairing alliance ruptures. Psychotherapy (Chic). 2011;48:80–87.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder

Abstract

Background:

Methods:

Results:

Conclusions:

Keywords

Methods

2.1. When Is Psychological Treatment Indicated?

2.2. Which Individuals with Depression Are Most Likely to Benefit from Psychological Treatment?

Demographic factors

Severity

2.3. How Do Co-occurring Psychiatric and Medical Conditions Affect the Efficacy of Psychological Treatments?

Psychiatric comorbidities

Medical comorbidities

2.4. How Do Gender and Age Influence the Decision to Use Psychological Treatment?

2.5. What Are the Key Therapist Factors That Improve Clinical Outcomes?

2.6. How Do You Choose a Psychological Treatment for MDD?

2.7. How Do Psychological Treatments for MDD Compare in Efficacy?

2.8. Does Group or Individual Format for Psychological Treatment Influence Outcome?

2.9. How Many Sessions of Psychological Treatment Are Required to Be Effective?

2.10. What Is Cognitive-Behavioural Therapy (CBT) and Its Efficacy in the Acute and Maintenance Phases of MDD Treatment?

2.11. What Is Mindfulness-Based Cognitive Therapy (MBCT) and Its Efficacy in the Acute and Maintenance Phases of MDD Treatment?

2.12. What Is Interpersonal Therapy (IPT) and Its Efficacy in the Acute and Maintenance Phases of MDD Treatment?

2.13. What Are Short-Term Psychodynamic Psychotherapy (STPP) and Long-Term Psychodynamic Therapy (PDT) and Their Efficacy in the Acute and Maintenance Phases of MDD Treatment?

2.14. What Is the Overall Level of Efficacy for Motivational Interviewing (MI) in the Acute and Maintenance Phases of MDD Treatment?

2.15. What Is the Overall Level of Efficacy for Cognitive-Behavioural Analysis System of Psychotherapy (CBASP) in the Acute and Maintenance Phases of MDD Treatment?

2.16. What Is Acceptance and Commitment Therapy (ACT) and Its Efficacy?

2.17. What Is Behavioural Activation (BA) for Depression and Its Efficacy?

2.18. What Are Peer Interventions and Their Efficacy for Depression?

2.19. What Is Problem-Solving Therapy (PST) and Its Efficacy?

2.20. What Is Bibliotherapy and What Is Its Efficacy?

2.21. How Effective Is Internet- and Computer-Delivered Therapy for Depression?

2.22. How Effective Is Remote Interactive Psychological Treatment for Depression (Phone, Video, Internet) Compared to Face-to-Face Therapy?

2.23. Is Combined Psychological Treatment with Medication Superior to Psychological Treatment Alone?

2.24. Is Combined Psychological Treatment with Medication Superior to Medication Alone?

2.25. Is Sequential Treatment Superior to Monotherapy?

Footnotes

Disclosures

Declaration of Conflicting Interests

Funding

References