Nonpharmacological interventions for relapse prevention in unipolar depression: A network meta-analysis.

BACKGROUND:The development of prophylactic interventions for major depressive disorder (MDD) is an important issue in clinical practice. We aimed to compare the relative efficacy of nonpharmacological interventions for relapse prevention in adult patients with MDD. METHODS:Randomized controlled trials investigating nonpharmachological interventions for relapse prevention were included. A Bayesian network meta-analysis was performed. Hazard ratios are reported as effect sizes with 95% credible intervals. Global inconsistency, local inconsistency, heterogeneity, and transitivity were evaluated. Confidence for the results comparing the active treatment with control conditions or antidepressant medicine (ADM) was assessed. RESULTS:Thirty-six trials were included. Most nonpharmacological interventions were various forms of psychotherapy; others were noninvasive neurostimulation techniques (3 studies with electroconvulsive therapy and 1 study with transcranial magnetic stimulation). Psychotherapy as a monotherapy following ADM or psychotherapy produced significantly better outcomes than control conditions, and there was no significant difference between psychotherapy and ADM. The combination of psychotherapy and ADM was superior to either treatment alone. The results were similar for patients with at least 3 previous episodes. Neurostimulation techniques were also superior to controls, either as a monotherapy or combined with ADM. CONCLUSIONS:Our study provided evidence that psychotherapy as a monotherapy following ADM or psychotherapy was effective and performed as well as ADM for relapse prevention. Neurostimulation techniques also showed promising results but more studies are needed to confirm their efficacy. These findings may be informative for clinical practice and inspire future research.