Age-related effect size differences of psychotherapies show depression not a ‘monolithic entity’
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Effect sizes of psychotherapies differed by patient age, according to results of a systematic review and meta-analysis published in JAMA Psychiatry.
“Psychotherapies for depression do not work as well in children and adolescents compared with adults,” Pim Cuijpers, PhD, head of the department of clinical, neuro and developmental psychology at Vrije University Amsterdam, told Healio Psychiatry. “Psychotherapies are still very important and effective in children and adolescents, but they are more effective among adults.”
Many randomized clinical trials have examined the effects of psychological treatments for depression, but most did so among separate age groups — children and adolescents, younger and middle-aged adults, and older adults. Thus, it remains unknown whether therapies have comparable effects across age groups.
Because no meta-analysis to the researchers’ knowledge has focused on psychotherapies across age groups, they sought to address this research gap. The investigators searched four major bibliographic databases and included randomized trials conducted up to January 2019 that compared psychotherapies for depression with control conditions in all age groups. They calculated effect sizes for all comparisons, pooled them with random-effects models and examined differences in effects between age groups with meta-regression analyses and mixed-effects subgroup analyses. Depressive symptoms served as the primary outcome.
Cuijpers and colleagues removed duplicates and then screened 16,756 records and 2,608 full-text articles. In a qualitative analysis, they included 366 trials with 36,702 patients and 453 comparisons between a therapy and a control condition. Of these, 13 (3.6%) were in conducted in children aged 13 years and younger, 24 (6.6%) in adolescents aged 13 years to 18 years, 19 (5.2%) in young adults aged 18 years to 24 years, 242 (66.1%) in middle-aged adults aged 24 years to 55 years, 58 (15.8%) in older adults aged 55 years to 75 years and 10 (2.7%) in elderly adults aged 75 years and older.
The researchers reported an overall effect size of all comparisons across all age groups of Hedges g = 0.75 (95% CI, 0.67-0.82), with very high heterogeneity (I2 = 80%; 95% CI, 78-82). Children (g = 0.35; 95% CI, 0.15-0.55) and adolescents (g = 0.55; 95% CI, 0.34-0.75) demonstrated significantly lower mean effect sizes for depressive symptoms than middle-aged adults (g = 0.77; 95% CI, 0.67-0.87). Moreover, young adults (g = 0.98; 95% CI, 0.79-1.16) experienced significantly large effect sizes than middle-aged adults. The researchers found no significant difference in effect sizes between older adults (g = 0.66; 95% CI, 0.51-0.82) and elderly adults (g = 0.97; 95% CI, 0.42-1.52).
Although Cuijpers and colleagues said the outcomes should be considered with caution because of the high levels of heterogeneity and suboptimal quality of most of the studies, they noted that most primary findings were robust across sensitivity analyses and addressed type of therapy, diagnosis of mood disorder, risk of bias, target populations included and method of data analysis.
“Therapies can be applied effectively in all age groups, including among older adults, children and adolescents, but the effects are smaller in the two latter groups and will thus require more persistence for clinicians to treat them,” Cuijpers told Healio Psychiatry.
In a related editorial, Stefan G. Hofmann, PhD, director of the Psychotherapy and Emotion Research Laboratory at Boston University, emphasized the importance of age in treating depression.
“Whatever the reason, age (and sex) is a critical factor that needs to be considered for the diagnosis and treatment of depression,” Hoffman wrote. “It is quite possible that we are dealing with different disorders, depending on the age and sex of the patient. Therefore, the same treatment might not be equally effective for all individuals at all ages. This questions the idea that depression is a monolithic entity and supports the call for a paradigm shift toward precision medicine in psychiatry.” – by Joe Gramigna
Disclosures: Cuijpers reports receiving expense allowances for board membership with Mind.nl, for being chair of the research committee of the Dutch Council for military care and research, and for being chair of the Mental Health Priority Area of the Wellcome Trust in London, in 2018, as well as royalties for books he has authored or co-authored and for occasional workshops and invited addresses. Please see the study for all other authors’ relevant financial disclosures. Hofmann reports no relevant financial disclosures.