Cochrane Canada- Reviews by Subject

Anorexia Nervosa
Bulimia Nervosa
Depression
Anxiety and Panic Disorders
Self-Help
Prevention

 

Anorexia Nervosa

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa

2015, Issue 7; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003909.pub2/abstract

Plain Language Summary

There was a limited amount of very low-quality evidence to suggest that people might do better when receiving focal psychodynamic therapy compared to no treatment or treatment as usual. With one exception, we found little difference between specific psychological therapies. Most therapies appeared as acceptable as any other approach, except for dietary advice which had a 100% non-completion rate in one small trial. Because of the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents.


Family therapy for those diagnosed with anorexia nervosa

2010, Issue 4; http://dx.doi.org/10.1002/14651858.CD004780.pub2

Plain language summary
Anorexia nervosa (AN) is a disorder characterised by deliberately maintained low body weight and distorted body image. Those with AN have many medical and psychological complications and the risk of dying from the disease is relatively high. One form of intervention commonly utilised to treat patients with AN is family therapy. Although there are a number of different forms of family therapy, the current review of 13 trials indicated that the therapy most often tested in trials is family based therapy. The trials included in the review had limitations in the reporting of trial conduct and meaningful outcomes. Overall there was some evidence to suggest family therapy may be effective compared to treatment as usual. However, there is not enough evidence to determine whether family therapy is effective compared to other psychological interventions for rates of remission. There were no differences in relapse rates, symptom scores, weight measures, or the number of drop outs between those treated with family therapy versus any other comparison group. Mortality was not measured or reported sufficiently to determine whether it is reduced for those treated with family therapy compared to other interventions. There were very little data about general or family functioning.

Authors' conclusions
There is some evidence to suggest that family therapy may be effective compared to treatment as usual in the short term. However, this is based on few trials that included only a small number of participants, all of which had issues regarding potential bias. There appears to be little advantage of family therapy over other psychological interventions. The field would benefit from a large, well-conducted trial. 

 

Antidepressants for anorexia nervosa

 
Plain language summary
The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy and acceptability of antidepressant treatment in acute AN. Seven small studies were identified; four placebo-controlled trials did not find evidence of efficacy of antidepressants in improving weight gain, eating disorder or associated symptoms, as well as differences in completion rates. Meta-analysis of data was not possible for most outcomes. However, major methodological limitations of these studies (e.g. insufficient power to detect differences) prevent from drawing definite conclusions or recommendations for antidepressant use in acute AN. Further studies testing safer antidepressants in larger and well designed trials are needed to guide clinical practice.
 
Authors' conclusions
There is some evidence to suggest that family therapy may be effective compared to treatment as usual in the short term. However, this is based on few trials that included only a small number of participants, all of which had issues regarding potential bias. There is insufficient evidence to be able to determine whether family therapy offers any advantage over other types of psychological interventions, or whether one type of family therapy is more effective than another. The field would benefit from a large, well-conducted trial.

 

Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa

2003, Issue 4 – updated search 2008; http://dx.doi.org/10.1002/14651858.CD003909
 
Plain language summary
This review aimed to assess evidence about the effects of outpatient psychotherapy on older adolescents and adults with anorexia nervosa. Although anorexia nervosa is a severe and disabling disorder, only seven trials were found. The trials used different types of psychotherapy. It was not possible to make firm conclusions about the therapies tested. Participants who did not receive psychotherapy (e.g. were in a waiting-list control group or who got 'treatment as usual') did poorly. In one study, all those in the control group who got only 'dietary advice' dropped out. There is an urgent need for multi-centre, large randomized controlled trials of commonly used psychotherapies in older adolescents and adults with anorexia nervosa.
 
Authors' conclusions
No specific approach can be recommended from this review. It is unclear why 'treatment as usual' performed so poorly, or why dietary advice alone appeared so unacceptable, as the reasons for non-completion were not reported. There is an urgent need for large well-designed trials in this area.
 


Bulimia Nervosa


Psychological treatments for bulimia nervosa and binging

2009, Issue 4; http://dx.doi.org/10.1002/14651858.CD000562.pub3

Plain language summary
Bulimia nervosa (BN) is an eating disorder in which people binge on food and then try to make up for this by extreme measures such as making themselves sick, taking laxatives or starving themselves. A special form of psychotherapy called cognitive behavioural therapy (CBT-BN) has been developed. We reviewed studies that compared CBT-BN or other similar CBT approaches, with other types of psychotherapy or to control groups who got no treatment (e.g. people on CBT waiting lists). We found that CBT was better than other therapies, and better than no treatment, at reducing binge eating. Some studies found that self-help using the CBT manual can be helpful, but more research and larger trials are needed. Cognitive behavioural therapy can help people with bulimia nervosa.

Authors' conclusions
There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials of CBT are needed, particularly for binge eating disorder and other EDNOS syndromes. Trials evaluating other psychotherapies and less intensive psychotherapies should also be conducted. 
 

Antidepressants versus placebo for people with bulimia nervosa

2003, Issue 4 – updated search 2005; http://dx.doi.org/10.1002/14651858.CD003391

Plain language summary
The use of a single antidepressant agent was clinically effective for the treatment of bulimia nervosa when compared to placebo, with an overall greater remission rate but a higher rate of dropouts. No differential effect regarding efficacy and tolerability among the various classes of antidepressants could be demonstrated.

Authors' conclusions
Individual antidepressants are effective for the treatment of bulimia nervosa when compared to placebo treatment, with an overall greater remission rate but a higher rate of dropouts.
 

Antidepressants versus psychological treatments and their combination for bulimia nervosa

2003, Issue 4 – updated search 2005. http://dx.doi.org/10.1002/14651858.CD003391

Plain language summary
Psychotherapeutic approaches, mainly cognitive behavior therapy, and antidepressant medication are the two treatment modalities that have received most support in controlled outcome studies of bulimia nervosa. Using a more conservative statistical approach, combination treatments were superior to single psychotherapy. This was the only statistically significant difference between treatments. The number of trials might be insufficient to show the statistical significance of a 19% absolute risk reduction in efficacy favouring psychotherapy or combination treatments over single antidepressants. Psychotherapy appeared to be more acceptable to subjects. When antidepressants were combined with psychological treatments, acceptability of the latter was significantly reduced.

Authors' conclusions
Using a more conservative statistical approach, combination treatments were superior to single psychotherapy. This was the only statistically significant difference between treatments. The number of trials might be insufficient to show the statistical significance of a 19% absolute risk reduction in efficacy favouring psychotherapy or combination treatments over single antidepressants. Psychotherapy appeared to be more acceptable to subjects. When antidepressants were combined with psychological treatments, acceptability of the latter was significantly reduced.

Back to top
 

Depression

Pharmacological interventions for self-harm in adults

2015, Issue 7; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011777/abstract

Plain Language Summary

What does the evidence from the review tell us?

There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH.

What should happen next?

We recommend further trials of drugs for SH patients, possibly in combination with psychological treatment.

 

Dance movement therapy for depression

2015, Issue 2; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009895.pub2/abstract

Plain Langu​age Summary

Depression affects 350 million people worldwide, impacting on quality of life, work, relationships and physical health. Medication and talking therapies are not always suitable or available. Dance movement therapy (DMT) uses bodily movements to explore and express emotions with groups or individuals. This is the first review of the effectiveness of DMT for depression and will add to the evidence base regarding depression treatments.

Author's Conclusions

Due to the low number of studies and low quality of evidence, it was not possible to draw firm conclusions about the effectiveness of DMT for depression. It was not possible to compare DMT with medication, talking therapies, physical treatments or to compare types of DMT due to lack of available evidence. Key findings were:

Overall, there is no evidence for or against DMT as a treatment for depression. There is some evidence to suggest DMT is more effective than standard care for adults, but this was not clinically significant. DMT is no more effective than standard care for young people.

Evidence from just one study of low methodological quality suggested that drop-out rates from the DMT group were not significant, and there is no reliable effect in either direction for quality of life or self esteem. A large positive effect was observed for social functioning, but since this was from one study of low methodological quality the result is imprecise.


Behavioural therapies versus other psychological therapies for depression (new)

2013, Issue 10; http://dx.doi.org/10.1002/14651858.CD008696.pub2

Plain language summary
Major depression is one of the common mental illnesses characterised by persistent low mood and loss of interest in pleasurable activities, accompanied by a range of symptoms, including weight loss, insomnia, fatigue, loss of energy, inappropriate guilt, poor concentration and morbid thoughts of death. Whilst antidepressants remain the mainstay of treatment for depression in healthcare settings, psychological therapies are still important alternative or additional interventions for depressive disorders. Nowadays, a diverse range of psychological therapies are available (such as cognitive-behavioural therapies, behavioural therapies, psychodynamic therapies, humanistic therapies and integrative therapies). It is very important to know whether one type of psychological therapy is more effective than another, and to know which psychological therapy is the most effective treatment for depression. In this review, we focused on one of these—behavioural therapies (BT)—because they are relatively simple to deliver, and interest in them has recently been renewed. Behavioural therapies are usually based purely on operant and respondent principles, aimed to change the patient's depressive mood by changing his or her behaviour patterns. Whilst a number of BT models have been developed, we categorised the following approaches as behavioural therapies in this review: behavioural therapy (based on Lewinsohn's model, which focused on increasing pleasant activities), behavioural activation (originated from behavioural component of cognitive-behavioural therapy and based on Jacobson's work in 1996), social skills training/assertiveness training and relaxation therapy.

In this review, we assessed the efficacy and acceptability of behavioural therapies compared with all other psychological therapies in the treatment of acute phase depression (neither long-term nor treatment-resistant depression) in adults. Twenty-five randomised controlled trails were included in this review. The quality of evidence in our review is low because of issues with the design of the studies that we found and lack of precision in our results. Although we found that behavioural therapies and all other psychological therapies are equally effective and acceptable, more research is needed to confirm this finding.

Authors conclusions

We found low- to moderate-quality evidence that behavioural therapies and other psychological therapies are equally effective. The current evidence base that evaluates the relative benefits and harms of behavioural therapies is very weak. This limits our confidence in both the size of the effect and its precision for our key outcomes related to response and withdrawal. Studies recruiting larger samples with improved reporting of design and fidelity to treatment would improve the quality of evidence in this review.

 

'Third wave' cognitive and behavioural therapies versus treatment as usual for depression (new)

2013, Issue 10; http://dx.doi.org/10.1002/14651858.CD008705.pub2

Plain language summary

Major depression is a very common condition in which people experience a persistently low mood and loss of interest in pleasurable activities, accompanied by a range of symptoms including weight loss, insomnia, fatigue, loss of energy, inappropriate guilt, poor concentration and morbid thoughts of death. Psychological therapies are an important and popular alternative to antidepressants in the treatment of depression. Many different psychological therapy approaches have been developed over the past century, including cognitive-behavioural (CBT), behavioural, 'third wave' CBT, psychodynamic, humanistic and integrative therapies.

In this review, we focused on third wave CBT approaches, a group of psychological therapies that target the process of thoughts (rather than their content, as in CBT), helping people to become aware of their thoughts and to accept them in a non-judgemental way. The aim of the review was to find out whether third wave CBT was effective and acceptable to people in the acute phase of depression. The review included four studies, involving a total of 224 people. The studies examined three different forms of third wave CBT, consisting of extended behavioural activation (two studies), acceptance and commitment therapy (ACT) (one study) and another form of third wave CBT called competitive mind training (one study). Three of the studies compared third wave CBT approaches with treatment as usual control conditions. The fourth study compared ACT with a psychological placebo condition. The results suggested that third wave CBT approaches were effective on a short-term basis in treating depression. However, the quality of evidence was very low because of the small number of studies/participants included in the review, together with the diverse client groups, interventions and control conditions used and possible allegiance of researchers towards the active treatments, making it difficult to draw conclusions with any confidence. It is notable, too, that none of the studies looked at the long-term effect of third wave CBT approaches. Given the increasing popularity of third wave CBT approaches in clinical practice, further well-designed studies should be prioritised to establish whether third wave CBT approaches are helpful in treating people with acute depression.

Authors conclusions

Very low quality evidence suggests that third wave CBT approaches appear to be more effective than treatment as usual in the treatment of acute depression. The very small number of available studies and the diverse types of interventions and control comparators, together with methodological limitations, limit the ability to draw any conclusions on their effect in the short term or over a longer term. The increasing popularity of third wave CBT approaches in clinical practice underscores the importance of completing further studies of third wave CBT approaches in the treatment of acute depression, on a short- and long-term basis, to provide evidence of their effectiveness to policy-makers, clinicians and users of services.

 

Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adults

2014, Issue 11; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008324.pub3/abstract

Authors' conclusions

There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.

Interventions for primary prevention of suicide in university and other post-secondary settings

2014, Issue 10; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009439.pub2/abstract

Key results

Three studies, including 312 students, evaluated classroom instruction. Classroom instruction increases short-term knowledge of suicide and suicide prevention. It may slightly enhance short-term confidence in ability to prevent suicide. However, long-term effects have not been studied. Effects of classroom instruction on suicidal behavior have also not been studied. One study evaluated an institutional policy. The policy restricted access to laboratory cyanide and required professional assessment for students who threatened or attempted suicide. The policy significantly reduced student suicides. These findings have not been tested in other post-secondary institutions. Four studies, ranging from 53 to 146 participants, evaluated the effect of gatekeeper training programs. Gatekeeper training may lead to small-to-medium improvements in short-term suicide-related knowledge and confidence about being able to prevent suicide. We found no evidence that gatekeeper training improved short-term attitudes toward suicide or long-term knowledge or behaviors about suicide. The effect of gatekeeper training on suicide or suicidal behavior has not been evaluated.

Back to top

 

Anxiety and Panic Disorders

 

Augmentation of cognitive and behavioural therapies (CBT) with d-cycloserine for anxiety and related disorders

2015, Issue 5; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007803.pub2/abstract

Plain Language Summary

Many people suffer from anxiety and related disorders (post-traumatic stress disorder, social anxiety disorder, panic disorder with or without agoraphobia, specific phobia and obsessive compulsive disorder). These disorders are disabling and can affect a person’s ability to function well at work and in social situations. Current treatment options include talking therapies such as cognitive and behavioural therapies. Many patients, however, do not respond as well as hoped to these treatments. Using cognitive and behavioural therapies in combination with certain medicines, for example d-cycloserine (DCS), is one option that may improve treatment response. In this review we examined the evidence for DCS combined with cognitive behavioural therapies as a treatment for anxiety and related disorders in children, adolescents and adults.

Author's Conclusions

There was no evidence of a difference between combined treatment with DCS and cognitive and behavioural therapies, and combined treatment with placebo and cognitive and behavioural therapies for anxiety and related disorders in children, adolescents or adults. This conclusion was based on low quality evidence mainly due to small sample sizes and inconsistency across studies.

There was no evidence of a difference in the number of children, adolescents and adults who withdrew from treatment with DCS in addition to cognitive behavioural therapies, and those who withdrew from treatment with placebo in addition to psychological therapies.

 

Reiki for depression and anxiety

2015, Issue 4; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006833.pub2/abstract

Plain Language Summary

Reiki is a non-drug treatment that is used on people with anxiety, depression or both. Reiki is a 2500 year old treatment, described as a vibrational or subtle energy therapy and is most commonly facilitated by light touch on or above the body. But there is no systematic review of randomised trials evaluating whether it works in this group of people.

Author's Conclusions

Very few people with anxiety or depression or both have been included in randomised studies. This means there is insufficient evidence to make any comment about the usefulness of Reiki for the treatment of anxiety and depression.

 

Morita therapy for anxiety disorders in adults

2015, Issue 2; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008619.pub2/abstract

Plain Language Summary

Anxiety disorders are some of the most prevalent mental disorders. Morita therapy, a systematic psychological therapy based on eastern philosophy, has been used to treat anxiety disorders for decades. It encourages people with anxiety disorders to accept anxiety as a natural feeling, while at the same time it engages them in constructive behaviours via four phases, which sequentially are bed rest in isolation, light work, heavy work and preparation for normal daily living. Acceptance is merely redirecting attention towards purposeful behaviour. People get better when they stop trying to eliminate anxiety and fulfil their desires with study and work in their actual personal and social lives.

The efficacy of Morita therapy for the treatment of anxiety disorders has been a much-contested issue, often dividing opinion. To date, a systematic review (a review addressing a clearly worded question that uses systematic and explicit methods to identify, select and critically appraise relevant research) investigating the strength of evidence for Morita therapy in the treatment of anxiety disorders has not been conducted.

Author's Conclusions

We found seven small Chinese studies with 449 participants to include in the review. Six of the seven studies provided useable data for us to analyse; they assessed Morita therapy for generalised anxiety disorder (a long-term illness that causes people to feel anxious about a wide range of situations and issues; one study), social phobia (a persistent fear about social situations and being around people; two studies) and obsessive-compulsive disorder (where a person has obsessive thoughts and repetitive behaviours; three studies). However, these studies were small, imprecise and contained considerable risks of bias, so we were unable to draw conclusions on the effectiveness of Morita therapy in the treatment of anxiety disorders. The review highlighted the need for high-quality studies to assess the efficacy of Morita therapy on anxiety disorders.

 

Therapist-Supported Internet cognitive-behavioural therapy for anxiety disorders in adults

2015, Issue 3; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011565/abstract 

What does the evidence from the review tell us?

ICBT with therapist support was significantly more effective than no treatment (waiting list) at improving anxiety and reducing symptoms. The quality of the evidence was low to moderate.

There was no significant difference in the effectiveness of ICBT with therapist support and unguided CBT, though the quality of the evidence was low to very low. Patient satisfaction was generally reported to be higher with therapist-supported ICBT, however patient satisfaction was not formally assessed.

ICBT with therapist support may not differ in effectiveness as compared to face-to-face CBT. The quality of the evidence was low to moderate.

There was a low risk of bias in the included studies, except for blinding of participants, personnel, and outcome assessment. Adverse events were rarely reported in the studies.

 

Cognitive behavioural therapy for anxiety disorders in children and adolescents

2015, Issue 2; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004690.pub4/abstract

What does the evidence from the review tell us?

CBT is significantly more effective than no therapy in reducing symptoms of anxiety in children and young people.

No clear evidence indicates that one way of providing CBT is more effective than another (e.g. in a group, individually, with parents).

CBT is no more effective than other 'active therapies' such as self-help books.

The small number of studies meant the review authors could not compare CBT with medication.

Only four studies looked at longer-term outcomes after CBT. No clear evidence showed maintained improvement in symptoms of anxiety among children and young people.

 

Pharmacotherapy for anxiety and comorbid alcohol use disorders

2015, Issue 1; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007505.pub2/abstract 

What does the evidence from the review tell us?

It was not possible to tell whether medication was effective in treating people with anxiety and alcohol use disorders. Although more than twice as many people (57.7%) with social anxiety disorder who were treated with paroxetine in two trials showed signs of clinical improvement compared with people receiving placebo (25.8%), the quality of the evidence was very low. One study reported that buspirone reduced anxiety disorder symptoms after 12 weeks of treatment. None of the other studies found reductions in symptoms. Treatment with medication appeared to be acceptable to participants, but again the quality of the evidence showing this was very low. Certain medication side effects, such as sexual problems, were commonly reported after treatment with paroxetine and sertraline. There was no evidence that treatment had an effect on alcohol use.

It was difficult to interpret the findings reported by the studies included in this review. Many participants (43.1% altogether) dropped out of the studies before treatment ended. In addition, outcomes that were reported were either not precise, or appeared to be based on the selective reporting of measures that showed an effect of medication. Funding of two of the studies by drug companies may also have led to reporting of results that favoured the medication.

 

Repetitive transcranial magnetic stimulation (rTMS) for panic disorder in adults

2014, Issue 9; http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009083.pub2/abstract

What does the evidence from the review tell us?

One study found that all patients improved during the study period, but the treatment effect did not differ between the group who received rTMS and the group who received sham rTMS. The other study administered more sessions and reported higher levels of improvement of panic symptoms in those people who received rTMS compared to those who received sham rTMS.

Although neither trial reported any serious side effects, they provided only very low quality evidence for adverse event outcomes. On the basis of the limited quality of the evidence available we were unable to determine how safe rTMS is.

The limited information available from these two studies is insufficient to conclude whether rTMS is effective in reducing the severity of panic disorder symptoms. The main limitation of this review was that the number of people with panic disorder who were involved was too small.

Back to Top
 

Self-Help

Self-help and guided self-help for eating disorders

2006, Issue 3; http://dx.doi.org/10.1002/14651858.CD004191.pub2

Plain language summary
The eating disorders (anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS)) are disabling conditions and specialist treatment is not always easily accessible. Self-help may bridge the gap. This review aimed to evaluate pure self-help (PSH) and guided self-help (GSH) interventions for eating disorders for all ages and genders, compared to psychological, pharmacological or control treatments and waiting list. Fifteen trials were identified, all focused on BN, BED or EDNOS, using manual-based self-help. There is some evidence that PSH/GSH reduce eating disorder and other symptoms in comparison to waiting list or control treatment and may produce comparable outcomes to formal therapist-delivered psychological therapies. PSH/GSH may have some utility as a first step in treatment. In the future there need to be large well-conducted effectiveness studies of self-help treatments with or without guidance incorporating cost evaluations and investigation of different types of self-help in different populations and settings.

Authors' conclusions
PSH/GSH may have some utility as a first step in treatment and may have potential as an alternative to formal therapist-delivered psychological therapy. Future research should focus on producing large well-conducted studies of self-help treatments in eating disorders including health economic evaluations, different types and modes of delivering self-help (e.g. computerised versus manual-based) and different populations and settings.

Back to top
 

Prevention

Interventions for preventing eating disorders in children and adolescents

2002, Issue 2; http://dx.doi.org/10.1002/14651858.CD002891

Plain language summary
Eating disorders represent an extremely difficult, time-consuming and costly condition to treat. Being young, female, and dieting are some of the few identified risk factors that have been reliably linked to the development of eating disorders. Several eating disorder prevention programs have been developed and trialled with children and adolescents. There is currently limited evidence in the published literature to suggest that any particular type of program is effective in preventing eating disorders and there has been concern that some interventions have the potential to cause harm. The aim of this systematic review is to determine whether these interventions are effective in the prevention of eating disorders in children and adolescents. Only one statistically significant result was found in the present meta-analysis - a slight effect of media literacy and advocacy programs in reducing acceptance of societal body image ideals. There is not sufficient evidence to suggest that harm was caused by any of the 12 randomised controlled trials included in the review at short-term follow-up. The meta-analysis is in the process of being revised to account for the impact of cluster randomised trials.

Authors' conclusions
The one significant pooled effect in the current review does not allow for any firm conclusions to be made about the impact of prevention programs for eating disorders in children and adolescents, although none of the pooled comparisons indicated evidence of harm. The meta-analysis is in the process of being revised to account for the impact of cluster randomised trials.

 

Back to top