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KSR Number: KSRA69105

Couple therapy for depression

Risk of Bias Assessment

Overall summary: High risk of bias in the review

Bottom Line

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.

Risk of Bias Assessment

Overall summary High risk of bias in the review

High

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

Details of Review

Number of studies 14
Number of participants 651
Last search date 19 February 2018
Review type Intervention
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.

Results

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).

Full Risk of Bias Assessment

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

Abstract

Background: Couple therapy for depression has the twofold aim of modifying negative interaction patterns and increasing mutually supportive aspects of intimate relationships, changing the interpersonal context of depression. Couple therapy is included in several guidelines among the suggested treatments for depression.Objectives: 1. The main objective was to examine the effects of couple therapy compared to individual psychotherapy for depression. 2. Secondary objectives were to examine the effects of couple therapy compared to drug therapy and no/minimal treatment for depression.Search methods: 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) were searched to 19 February 2018. Relevant journals and reference lists were checked.Selection criteria: Randomised and quasi-randomised controlled trials examining the effects of couple therapy versus individual psychotherapy, drug therapy, or no treatment/minimal treatment for depression were included in the review.Data collection and analysis: We considered as primary outcomes the depressive symptom level, the depression persistence, and the dropouts; the relationship distress level was a secondary outcome. We extracted data using a standardised spreadsheet. Where data were not included in published papers, we tried to obtain the data from the authors. We synthesised data using Review Manager software version 5.3. We pooled dichotomous data using the relative risk (RR), and continuous data calculating the standardised mean difference (SMD), together with 95% confidence intervals (CIs). We employed the random-effects model for all comparisons and also calculated a formal test for heterogeneity, the natural approximate Chi2 test.Main results: We included fourteen studies from Europe, North America, and Israel, with 651 participants. Eighty per cent of participants were Caucasian. Therefore, the findings cannot be considered as applicable to non-Western countries or to other ethnic groups in Western countries. On average, participants had moderate depression, preventing the extension of results to severely depressed patients. Almost all participants were aged between 36 and 47 years.There was no evidence of difference in effect at the end of treatment between couple therapy and individual psychotherapy, either for the continuous outcome of depressive symptoms, based on nine studies with 304 participants (SMD ?0.17, 95% CI ?0.44 to 0.10, low-quality evidence), or the proportion of participants remaining depressed, based on six studies with 237 participants (RR 0.94, 95% CI 0.72 to 1.22, low-quality evidence). Findings from studies with 6-month or longer follow-up confirmed the lack of difference between the two conditions.No trial gave information on harmful effects. However, we considered rates of treatment discontinuation for any reason as a proxy indicator of adverse outcomes. There was no evidence of difference for dropout rates between couple therapy and individual psychotherapy, based on eight studies with 316 participants (RR 0.85, 95% CI 0.51 to 1.41, low-quality evidence).Few data were available for the comparison with drug therapy. Data from a small study with 12 participants showed no difference for the continuous outcome of depressive symptoms at end of treatment (SMD ?0.51, 95% CI ?1.69 to 0.66, very low-quality evidence) and at 6-month follow-up (SMD ?1.07, 95% CI -2.45 to 0.31, very low-quality evidence). Data on dropouts from two studies with 95 participants showed a clear advantage for couple therapy (RR 0.31, 95% CI 0.15 to 0.61, very low-quality evidence). However, this finding was heavily influenced by a single study, probably affected by a selection bias favouring couple therapy.The comparison between couple therapy plus drug therapy and drug therapy alone showed no difference in depressive symptom level, based on two studies with 34 participants (SMD ?1.04, 95% CI -3.97 to 1.89, very low-quality evidence) and on d opouts, based on two studies with 45 participants (RR 1.03, 95% CI 0.07 to 15.52, very low-quality evidence).The comparison with no/minimal treatment showed a large significant effect favouring couple therapy both for depressive symptom level, based on three studies with 90 participants: (SMD ?0.95, 95% CI ?1.59 to ?0.32, very low-quality evidence) and persistence of depression, based on two studies with 65 participants (RR 0.48, 95% CI 0.32 to 0.70, very low-quality evidence). No data were available for dropouts for this comparison.Concerning relationship distress, the comparison with individual psychotherapy showed that couple therapy appeared more effective in reducing distress level at the end of treatment, based on six studies with 187 participants (SMD ?0.50, CI ?0.97 to ?0.02, very low-quality evidence) and the persistence of distress, based on two studies with 81 participants (RR 0.71, 95% CI 0.51 to 0.98, very low-quality evidence). The quality of evidence was heavily affected by substantial heterogeneity (I2 = 59%). In the analysis restricted to studies including only distressed couples, no heterogeneity was found and the effect in distress level at the end of treatment was larger (SMD ?1.10, 95% CI ?1.59 to ?0.61). Very few data on this outcome were available for other comparisons.We assessed the certainty of the evidence using the GRADE system. The results were weakened by the low quality of evidence related to the effects on depressive symptoms, in comparison with individual psychotherapy, and by very low quality evidence for all other comparisons and for the effects on relationship distress. Most studies were affected by problems such as the small number of cases, performance bias, assessment bias due to the non-blinding outcome assessment, incomplete outcome reporting and the allegiance bias of investigators. Heterogeneity was, in particular, a problem for data about relationship distress.Authors' conclusions: Although there is suggestion that couple therapy is as effective as individual psychotherapy in improving depressive symptoms and more effective in improving relations in distressed couples, the low or very low quality of the evidence seriously limits the possibility of drawing firm conclusions. Very few data were available for comparisons with no/minimal treatment and drug therapy. Future trials of high quality should test in large samples with a long follow-up of the effects of couple therapy in comparison to other interventions in discordant couples with a depressed partner, considering the role of relationship quality as a potential effect mediator in the improvement of depression.