Most kinds of therapy for depression worked. Almost none outperformed another.

The largest synthesis of the question — 331 randomised trials covering 34,285 patients — found that the main types of psychotherapy for adult depression did not differ significantly from each other in efficacy [s1]. The one exception was non-directive supportive counseling, which was less efficacious than all the others [s1].

That is a genuinely useful answer, and it is not the answer the marketing around any individual therapy tends to give.

What was compared

The network meta-analysis put cognitive behavioural, interpersonal, psychodynamic, problem-solving, behavioural activation, life-review and "third wave" therapies, plus non-directive supportive counseling, against each other and against three control conditions: care-as-usual, waiting list and pill placebo [s1]. The primary outcome was response, defined as a 50% reduction in symptoms; remission, standardized mean difference and acceptability — measured as all-cause dropout — were also assessed [s1].

All the therapies were more efficacious than care-as-usual and waiting-list controls [s1]. All of them except non-directive supportive counseling and psychodynamic therapy were more efficacious than pill placebo [s1]. Standardized mean differences compared with care-as-usual ranged from −0.81 for life-review therapy to −0.32 for non-directive supportive counseling [s1].

Then the comparison that matters: individual psychotherapies did not differ significantly from each other, with the single exception of non-directive supportive counseling [s1]. The results were similar when only studies at low risk of bias were included — an important robustness check, since the most common way an apparent difference between therapies dissolves is by restricting to well-conducted trials [s1].

Durability and dropout

Most therapies still had significant effects at 12-month follow-up compared to care-as-usual, and problem-solving therapy was found to have somewhat higher long-term efficacy than some of the others [s1]. On acceptability — the proportion of participants who dropped out for any reason — no consistent differences were found [s1].

So neither the follow-up data nor the dropout data rescue the idea that one approach is broadly superior. The authors' own conclusion is that the most important types of psychotherapy are efficacious and acceptable in the acute treatment of adult depression, with few significant differences between them, and that patient preference and the availability of each treatment type may play a larger role in the choice [s1].

They add one caveat that deserves more attention than it usually gets: it is possible that a more detailed characterisation of patients carrying a diagnosis of depression would lead to more precise matching between individual patients and individual psychotherapies [s1]. In other words, the absence of a difference on average does not prove the absence of a difference for a particular person. It proves that the trials, as designed, could not find one.

Children and adolescents look different

The equivalent analysis in younger people is smaller and its findings are sharper. Fifty-two studies covering 3,805 participants compared nine psychotherapies against four control conditions [s2].

At post-treatment, only interpersonal therapy and cognitive-behavioral therapy were significantly more effective than most control conditions, with standardized mean differences ranging from −0.47 to −0.96 [s2]. Both were more beneficial than play therapy, and psychodynamic therapy and play therapy were the only two not significantly superior to waitlist [s2]. At follow-up, interpersonal therapy and CBT again beat most control conditions (SMDs from −0.26 to −1.05), though only interpersonal therapy retained that superiority at both short-term and long-term follow-up [s2].

Acceptability diverged in a way the adult data did not. Interpersonal therapy and problem-solving therapy had significantly fewer all-cause discontinuations than cognitive therapy and CBT, with odds ratios ranging from 0.06 to 0.33 [s2].

The authors conclude that interpersonal therapy and CBT should be considered the best available psychotherapies for depression in children and adolescents, while noting that several alternative psychotherapies are understudied in this age group [s2]. That last clause is the honest frame: the narrower result in young people may reflect a narrower evidence base rather than a real difference in what works.

The methodological warning inside the adolescent analysis

The younger-patient paper makes a point about trial design that reframes a large part of this literature: waitlist may inflate the effect of psychotherapies, so that psychological placebo or treatment-as-usual may be preferable as a control condition in psychotherapy trials [s2]. Waitlist was significantly inferior to the other control conditions in that network [s2].

That matters because a great deal of therapy research is scored against waitlist. An effect size measured against a control condition that is itself worse than doing nothing in a clinic will overstate the treatment.

What this does and does not settle

It settles that the main psychotherapies for adult depression work relative to no treatment, and that on the evidence available they work about as well as each other [s1]. It does not settle which therapy suits which patient, which the adult authors explicitly leave open [s1]. It does not transfer cleanly to children and adolescents, where only two approaches have enough good evidence behind them to be called best available [s2].

And it sits alongside a separate finding from the same research group: across 101 trials, psychotherapy and antidepressant medication produced statistically indistinguishable response rates in adults, while combining them beat either alone [s3].

Choosing between therapies, on this evidence, is less a question of which one is strongest and more one of which is accessible, which a person will stay in, and which they would rather do. This article describes evidence and is not medical advice.

Sources

• Psychotherapies for depression: a network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types — World Psychiatry, 2021-05-18
• Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: A systematic review and network meta-analysis — World Psychiatry, 2015-06-04
• A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression — World Psychiatry, 2020-01-10