Current evidence suggests that couple therapy may be as effective as individual psychotherapy in improving depressive symptoms and more effective in improving relationship distress. However, these conclusions should be interpreted with caution, since reviewer error and bias cannot be ruled out. Future well-designed, high-quality trials are needed to support these findings, with a focus on long-term impact.
Overall summary High risk of bias in the review
Only a single reviewer was involved in the initial stage of title and abstract screening, meaning error and bias cannot be ruled out.
|A. Did the interpretation of findings address all of the concerns identified in Domains 1 to 4?||Probably no|
|B. Was the relevance of identified studies to the review's research question appropriately considered?||Probably yes|
|C. Did the reviewers avoid emphasizing results on the basis of their statistical significance?||Probably yes|
|Risk of bias in the review||High|
|Number of studies||14|
|Number of participants||651|
|Last search date||19 February 2018|
|Objective||To determine the effects of couple therapy compared to individual psychotherapy for depression.|
|Population||Heterosexual adult couples aged 18 years or more with a partner having a clinical diagnosis of depressive disorder.
Studies involving patients with comorbidities were included.
|Interventions||Couple therapy (defined as a structured psychological intervention in which a trained therapist meets both partners of a committed relationship in regular face-to-face sessions with the explicit aim of modifying dysfunctional patterns of interaction and enhancing positive relationships).
Studies combining couple therapy and anti-depressant drug therapy were included.
Studies that focused on family therapy, where the treatment was delivered to the whole family unit, including children, and studies that were targeted to postnatal depression were excluded.
|Comparator||Individual psychotherapy, anti-depressant drug therapy or no treatment/minimal treatment.|
|Outcome||Primary outcomes: efficacy based on depressive symptom level; adverse events.
Secondary outcomes: relationship distress; study dropout rate.
|Study design||Randomised controlled trials (including cluster trials) and quasi-randomised controlled trials.|
In terms of the level of depressive symptoms at the end of treatment, pooled analysis reported no significant difference in the depressive symptoms at end of treatment for couple therapy compared to individual psychotherapy (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.44 to 0.10, 9 studies, 304 participants) or for couple therapy compared to drug therapy (SMD -0.51, 95% CI -1.69 to 0.66, 1 study, 12 participants) or for couple therapy plus drug therapy compared to drug therapy alone (SMD -1.04, 95% CI -3.97 to 1.89, 2 studies, 34 participants). However, pooled analysis reported an improvement in depressive symptoms at the end of treatment (SMD -0.95, 95% CI -1.59 to -0.33, 3 studies, 90 participants) and the risk of depressive symptoms at the end of treatment (RR 0.48, 95% CI 0.32 to 0.70, 2 studies, 65 participants) for couple therapy compared to no/minimal treatment.
In terms of the persistence of depression at the end of treatment, pooled analysis reported no significant difference in the persistence of depression at the end of treatment for couple therapy compared to individual psychotherapy (risk ratio (RR) 0.94, 95% CI 0.72 to 1.22, 6 studies, 237 participants). Pooled analysis reported a reduction in the persistence of depression at the end of treatment for couple therapy compared to no/mimimal therapy (RR 0.48, 95% CI 0.32 to 0.70, 2 studies, 65 participants)
In terms of relationship distress at the end of treatment, pooled analysis reported that couple therapy was more effective at reducing the level of distress at the end of treatment compared to individual psychotherapy (SMD -0.50, 95% CI −0.97 to −0.02, 6 studies, 187 participants) and at reducing the risk of relationship distress at the end of treatment (RR 0.71, 95% CI 0.51 to 0.98, 2 studies, 81 participants). Pooled analysis reported no significant difference in relationship distress at the end of treatment for couple therapy compared to drug therapy (SMD -0.47, 95% CI -1.64 to 0.70, 1 study, 12 participants) or for couple therapy compared to no/minimal therapy (SMD -0.80, 95% CI -1.64 to 0.04, 2 studies, 60 participants) or for couple therapy plus drug therapy compared to drug therapy alone (SMD -0.60, 95% CI -1.35 to 0.14, 2 studies, 34 participants).
In terms of treatment dropouts, pooled analysis reported no difference in dropout rates at the end of treatment for couple therapy compared to individual psychotherapy (RR 0.85, 95% CI 0.51 to 1.51, 9 studies, 364 participants) or for couple therapy plus drug therapy compared to drug therapy alone (RR 1.03, 95% CI 0.07 to 15.52, 2 studies, 45 participants). Pooled analysis reported lower dropout rates for couple therapy compared to drug therapy (RR 0.31, 95% CI 0.15 to 0.61, 2 studies, 95 participants).
The research objective was clearly stated and appropriate inclusion criteria were defined. No restrictions were reported based on the study characteristics and sources of information.
|1.1 Did the review adhere to pre-defined objectives and eligibility criteria?||Probably yes|
|1.2 Were the eligibility criteria appropriate for the review question?||Probably yes|
|1.3 Were eligibility criteria unambiguous?||Probably yes|
|1.4 Were all restrictions in eligibility criteria based on study characteristics appropriate (e.g. date, sample size, study quality, outcomes measured)?||Probably yes|
|1.5 Were any restrictions in eligibility criteria based on sources of information appropriate (e.g. publication status or format, language, availability of data)?||Probably yes|
|Concerns regarding specification of study eligibility criteria||Low|
Studies were identified by searching the Cochrane Common Mental Disorders Group Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), EMBASE (Ovid) and PsycINFO (Ovid). In addition, relevant journals, reference lists, ClinicalTrials.gov and the WHO’s trials portal (ICTRP) were checked for additional studies. The search strategy was reported in full and appeared to be adequate. No restrictions on date, language, or publication status were applied to the searches. Only a single reviewer was involved in the initial stage of title and abstract screening, although additional reviewers cross-checked the final list of potentially eligible studies.
|2.1 Did the search include an appropriate range of databases/electronic sources for published and unpublished reports?||Probably yes|
|2.2 Were methods additional to database searching used to identify relevant reports?||Probably yes|
|2.3 Were the terms and structure of the search strategy likely to retrieve as many eligible studies as possible?||Probably yes|
|2.4 Were restrictions based on date, publication format, or language appropriate?||Probably yes|
|2.5 Were efforts made to minimise error in selection of studies?||Probably no|
|Concerns regarding methods used to identify and/or select studies||High|
Two reviewers were independently involved in the data extraction process and disagreements were resolved by discussion with a third reviewer. Sufficient individual study characteristics appear to have been extracted to enable the interpretation of the results. Relevant study results appear to have been extracted. Methodological quality was assessed using the Cochrane Collaboration’s tool for assessing risk of bias. Three review authors independently assessed the risk of bias for each study, and disagreements were resolved by discussion.
|3.1 Were efforts made to minimise error in data collection?||Yes|
|3.2 Were sufficient study characteristics considered for both review authors and readers to be able to interpret the results?||Probably yes|
|3.3 Were all relevant study results collected for use in the synthesis?||Probably yes|
|3.4 Was risk of bias (or methodological quality) formally assessed using appropriate criteria?||Yes|
|3.5 Were efforts made to minimise error in risk of bias assessment?||Yes|
|Concerns regarding methods used to collect data and appraise studies||Low|
The synthesis appeared to have included all relevant studies. The method of analysis was explained and appeared to be appropriate.Heterogeneity was assessed and found to be high for some outcomes; this was narratively highlighted in the text, but no formal assessment of the source of heterogeneity was performed. Sensitivity analyses were performed to check the robustness of the study results. Publication bias could not be assessed due to the low number of included studies; this was considered appropriate. The quality of the individual studies was considered in the synthesis.
|4.1 Did the synthesis include all studies that it should?||Probably yes|
|4.2 Were all pre-defined analyses reported or departures explained?||Probably yes|
|4.3 Was the synthesis appropriate given the degree of similarity in the research questions, study designs and outcomes across included studies?||Probably yes|
|4.4 Was between-study variation minimal or addressed in the synthesis?||Probably yes|
|4.5 Were the findings robust, e.g. as demonstrated through funnel plot or sensitivity analyses?||Probably yes|
|4.6 Were biases in primary studies minimal or addressed in the synthesis?||Probably yes|
|Concerns regarding synthesis and findings||Low|