As usual we have selected three systematic reviews for providing you an evidence based insight.

1. The review on marital therapy is significant for two reasons. It provides some evidence about an intervention which does not figure prominently in the interventions for depression in literature and texts these days. Secondly, it demonstrates that evidence can be produced (and summarised as well!) even for an intervention like marital therapy which is rather difficult to measure even amongst psychotherapies. In our sociocultural context, marital factors play both the negative i-e in the onset and maintenance of this behavioral problem as well as positive role in the form of buffering effect in interpersonal relations. This review should help us in making informed decisions about non pharmacological interventions, alone or in combination with drug therapy in a commonly occurring psychiatric disorder. The authors concluded that there is no evidence of effectiveness. But in view of small number of studies comparing marital therapy with number of interventions (psychotherapy, drugs and minimal or no treatment) in just eight studies, one wonders whether this is the case of lack of evidence rather than no evidence.

2. The Obsessive Compulsive Disorders in children pose a significant therapeutic challenge. The pharmacological treatment with SSRIs, which may be needed in significantly high doses in view of stubborn nature of the disorder, can be particularly problematic in children. The total number of participants in these trials is small but it generally supports the view we had in adult OCD i.e that these psychological interventions augment the Pharmacotherapy and I n some resistant cases provide most effective treatments. We know that in case of poor response to treatment this disorder not only causes high level of psychological distress but also impairs and disrupts the psychosocial development in the adolescent age group. According to this systematic review psychological interventions like behavior or cognitive behavior therapy (BT/CBT) play promising role in treating OCD in children and adolescent. The effectiveness of BT/ CBT can be further potentiated, when combined with pharcotherapy.

3. Final rewieve assesses the role of antidepressants in prevention of postnatal depression This psychiatric disorder has always remained a challenge in developing countries, carrying long term implications for mothers and infant’s mental as well as physical health. The postnatal psychiatric disorders offer a huge potential for prevention in developing countries in view of the high fertility rates and somewhat predictable nature of the disorder in a specific time frame i.e few weeks after the childbirth. It is disappointing to note that there were only two trials with total of 73 participants. This perhaps reflects overall lack of attention in psychiatry towards prevention. According to this rewieve, there is insufficient evidence for the preventive role of antidepressants in postnatal depression during pregnancy or immediately postpartum. So the decision about the use of these drugs in pregnant women, with past or family history of depression should be made with care.

Edited by: Dr. Javed Akhtar,

MBBS, FCPS, Senior Registrar, Department of Psychiatry, Lady Reading Hospital, Peshawar.

1. MARITAL THERAPY FOR DEPRESSION

A Barbato, B D’Avanzo

ABSTRACT

Background: Marital therapy for depression has the twofold aim of modifying negative interaction patterns and increasing mutually supportive aspects of couple relationships, thus changing the interpersonal context linked to depression.

Objectives:

1. To conduct a meta-analysis of all intervention studies comparing marital therapy to other psychosocial and pharmacological treatments, or to non-active treatments.

2. To conduct an assessment of the internal validity and external validity.

3. To assess the overall effectiveness of marital therapy as a treatment for depression.

4. To identify mediating variables through which marital therapy is effective in depression treatment.

Search strategy: CCDANCTR-Studies was searched on 5-9-2005, Relevant journals and reference lists were checked.

Selection criteria

Randomised controlled trials examining the effectiveness of marital therapy versus individual psychotherapy, drug therapy or waiting list/no treatment/minimal treatment for depression were included in the review. Quasi-randomised controlled trials were also included.

Data collection and analysis

Data were extracted using a standardised spreadsheet. Where data were not included in published papers, two attempts were made to obtain the data from the authors. Data were synthesised using Review Manager software. Dichotomous data were pooled using the relative risk (RR), and continuous data were pooled using the standardised mean difference (SMD), and 95% confidence intervals (CIs) were calculated. The random effects model was employed for all comparisons. A formal test for heterogeneity, the natural approximate chisquared test, was also calculated.

Main results

Eight studies were included in the review. No significant difference in effect was found between marital therapy and individual psychotherapy, either for the continuous outcome of depressive symptoms, based on six studies: SMD -0.12 (95% CI -0.56 to 0.32), or the dichotomous outcome of proportion of subjects remaining at caseness level, based on three studies: RR 0.84 (95% CI 0.32 to 2.22). In comparison with drug therapy, a lower drop-out rate was found for marital therapy: RR 0.31 (95% CI 0.15 to 0.61), but this result was greatly influenced by a single study. The comparison with no/minimal treatment, showed a large significant effect in favour of marital therapy for depressive symptoms, based on two studies: SMD -1.28 (95% CI -1.85 to -0.72) and a smaller significant effect for persistence of depression, based on one study only. The findings were weakened by methodological problems affecting most studies, such as the small number of cases available for analysis in almost all comparisons, and the significant heterogeneity among studies.

Authors’ conclusions

There is no evidence to suggest that marital therapy is more or less effective than individual psychotherapy or drug therapy in the treatment of depression. Improvement of relations in distressed couples might be expected from marital therapy. Future trials should test whether marital therapy is superior to other interventions for distressed couples with a depressed partner, especially considering the role of potential effect moderators in the improvement of depression.

Cochrane Database of Systematic Reviews 2007 Issue 4.

Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

2. BEHAVIOURAL AND COGNITIVE BEHAVIOURAL THERAPY FOR OBSESSIVE COMPULSIVE DISORDER IN CHILDREN & ADOLESCENTS

O’Kearney RT, Anstey KJ, von Sanden C

ABSTRACT

Background: While behavioural or cognitivebehavioural therapy (BT/CBT) is recommended as the psychotherapeutic treatment of choice for children and adolescents with obsessive-compulsive disorder (OCD), the application of BT/CBT to paediatric OCD may not be straightforward.

Objectives: This review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against psychopharmacology and whether there are benefits in using BT/CBT combined with medication.

Search strategy: We searched CCDANCTR-Studies and CCDANCTR-References (searched on 5/8/2005), MEDLINE, EMBASE, PsycINFO, the reference lists of all selected studies and handsearched journals specifically related to behavioural treatment of OCD.

Selection criteria

Included studies were randomised controlled trials or quasi-randomised trials with participants who were 18 years of age or younger and had a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included the standard behavioural or cognitive-behavioural techniques, either alone or in combination, compared with wait-list or pill placebo.

Data collection and analysis

The quality of selected studies was assessed by two independent reviewers. The primary outcomes comprised of endpoint scores on the gold standard clinical outcome measure of OCD symptoms, distress and interference (CY-BOCS) and endpoint OCD status.

Main results

Four studies with 222 participants were considered eligible for inclusion and for data extraction. Two studies showed significantly better post-treatment functioning and reduced risk of continuing with OCD at posttreatment for the BT/CBT group compared to placebo or wait-list comparisons. We suggested that the POTS 2004 result, equal to a difference of about eight points on the CY-BOCS, represented the best available estimate for the efficacy of BT/CBT relative to no treatment. (WMD - 7.50; 95% CI -11.55, -3.45). Pooled evidence from two trials indicated that the efficacy of BT/CBT and medication did not differ significantly (WMD -3.87; 95% CI - 8.15, 0.41). There was evidence of the benefit of combined BT/CBT and medication compared to medication alone (WMD -4.55; 95% CI -7.40, -1.70), but not relative to BT/CBT alone (WMD -2.80; 95% CI -7.55, 1.95). The rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families.

Authors’ conclusions

Although only based on a small number of studies, behavioural or cognitive-behaviour therapy appears to be a promising treatment for OCD in children and adolescents. It can lead to better outcomes when combined with medication compared to medication alone. Additional trials are needed to confirm these findings. In the interim, consideration should be given to the ways in which BT/CBT might be made more widely available as a treatment for OCD in children and adolescents.

Cochrane Database of Systematic Reviews 2007 Issue 4 Copyright © 2007

The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

3. ANTIDEPRESSANT PREVENTION OF POSTNATAL DEPRESSION

LM Howard, S Hoffbrand, C Henshaw, L Boath, E Bradley

ABSTRACT

Background: Postnatal depression is a common and important complication of childbearing. Untreated depression can lead to potentially negative effects on the foetus and infant, in addition to serious morbidity for the mother. The use of antidepressants during pregnancy for prevention of postnatal depression is unclear, due to the possibility of adverse effects on the mother and developing foetus, and the difficulty of reliably identifying the women who would go on to develop postnatal depression.

Objectives:

1. To evaluate the effectiveness of different antidepressant drugs in addition to standard clinical care in the prevention of postnatal depression.

2. To compare the effectiveness of different antidepressant drugs and with any other form of intervention for postnatal depression i.e. hormonal, psychological or social support.

3. To assess any adverse effects of antidepressant drugs in either the mother or the foetus/infant.

Search strategy: CCDANCTR-Studies and CCDANCTR-References were searched on 11-6-2007.

Selection criteria

Randomised studies of antidepressants alone or in combination with another treatment, compared with placebo or a psychosocial intervention in non-depressed pregnant women or women who had given birth in the previous six weeks (i.e. women at risk of postnatal depression).

Data collection and analysis

Data were extracted independently from the trial reports by the authors. Missing information was requested from investigators wherever possible. Data were sought to allow an “intention to treat” analysis.

Main results

Two trials involving a total of 73 participants fulfilled the inclusion criteria for this review. Both looked at women with a past history of postpartum depression. Nortriptyline (n=26) did not show any benefit over placebo (n=25). Sertraline (n=14) reduced the recurrence of postnatal depression and the time to recurrence when compared with placebo (n=8). Intention-to-treat analyses were not carried out in either trial.

Authors’ conclusions

It is not possible to draw any clear conclusions about the effectiveness of antidepressants given immediately postpartum in preventing postnatal depression and, therefore, cannot be recommended for prophylaxis of postnatal depression, due to the lack of clear evidence. Larger trials are needed which also include comparisons of antidepressant drugs with other prophylactic treatments to reflect clinical practice, and examine adverse effects for the foetus and infant, as well as assess women’s attitudes to the use of antidepressants at this time.

Cochrane Database of Systematic Reviews 2007 Issue 4.

Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.