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24 January 2023

Values and Preferences of Patients With Depressive Disorders Regarding Pharmacologic and Nonpharmacologic Treatments: A Rapid ReviewFREE

Publication: Annals of Internal Medicine
Volume 176, Number 2

Abstract

Background:

Developers of clinical practice guidelines need to take patient values and preferences into consideration when weighing benefits and harms of treatment options for depressive disorder.

Purpose:

To assess patient values and preferences regarding pharmacologic and nonpharmacologic treatments of depressive disorder.

Data Sources:

MEDLINE (Ovid) and PsycINFO (EBSCO) were searched for eligible studies published from 1 January 2014 to 30 November 2022.

Study Selection:

Pairs of reviewers independently screened 30% of search results. The remaining 70% of the abstracts were screened by single reviewers; excluded abstracts were checked by a second reviewer. Pairs of reviewers independently screened full texts.

Data Extraction:

One reviewer extracted data and assessed the certainty of evidence, and a second reviewer checked for completeness and accuracy. Two reviewers independently assessed risk of bias.

Data Synthesis:

The review included 11 studies: 4 randomized controlled trials, 5 cross-sectional studies, and 2 qualitative studies. In 1 randomized controlled trial, participants reported at the start of therapy that they expected supportive-expressive psychotherapy and antidepressants to yield similar improvements. A cross-sectional study reported that non-Hispanic White participants and men generally preferred antidepressants over talk therapy, whereas Hispanic and non-Hispanic Black participants and women generally did not have a preference. Another cross-sectional study reported that the most important nonserious adverse events for patients treated with antidepressants were insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction. For other comparisons and outcomes, no conclusions could be drawn because of the insufficient certainty of evidence.

Limitations:

The main limitation of this review is the low or insufficient certainty of evidence for most outcomes. No evidence was available on second-step depression treatment or differences in values and preferences based on gender, race/ethnicity, age, and depression severity.

Conclusion:

Low-certainty evidence suggests that there may be some differences in preferences for talk therapy or pharmacologic treatment of depressive disorders based on gender or race/ethnicity. In addition, low-certainty evidence suggests that insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction may be the most important nonserious adverse events for patients treated with antidepressants. Evidence is lacking or insufficient to draw any further conclusions about patients' weighing or valuation of the benefits and harms of depression treatments.

Primary Funding Source:

American College of Physicians. (PROSPERO: CRD42020212442)
Depressive disorders are the most common mental health disease and a leading cause of disability (1). For outpatients with depressive disorders, several evidence-based and non–evidence-based pharmacologic and nonpharmacologic treatment options are available (2). The choice of treatment should be determined jointly by patients and clinicians (2) to align with patient values and preferences, which can improve acceptance and adherence to treatment (3). Thus, clinical practice guideline developers must take the variability in patients' values and preferences for different treatment options into consideration (4). In the context of guideline development and shared decision making, patient values are defined as how a patient “values” potential beneficial or harmful outcomes that can result from a treatment decision (5, 6). Patient preferences are defined as a patient's most favored health care option (6). Because no up-to-date systematic review on patient values and preferences regarding pharmacologic and nonpharmacologic treatment options for depressive disorders was available, we did a rapid review to meet the time-sensitive needs of guideline developers.
The aim of this rapid review was to support the American College of Physicians (ACP) in developing clinical practice guidelines on the use of pharmacologic and nonpharmacologic treatments for major depressive disorder in adult outpatients.

Methods

We followed the guidance of the Cochrane Rapid Reviews Methods Group (7). We used the following methodological shortcuts: We did not search for gray literature, did not dually screen all of the titles and abstracts, and did not dually extract data.
The review protocol is available on PROSPERO (CRD42020212442).
Our rapid review addressed the following 3 key questions (KQs):
KQ 1: What values and preferences do patients have regarding depression management?
KQ 2: How do patients weigh the benefits and harms of depression treatments?
KQ 3: How do patients use the valuation of benefits and harms in their decision making when undergoing depression treatment?

Data Sources and Searches

We searched MEDLINE (Ovid) and PsycINFO (EBSCO) from 1 January 2014 to 30 November 2022 for primary studies and from 1 January 2010 to 30 November 2022 for systematic reviews (Supplement Table 1). We limited the time frame of the searches because professional organizations have broadened treatment recommendations for depressive disorders over the past decade, making nonpharmacologic treatments a more viable option for patients (2, 8). We considered randomized and nonrandomized studies with a quantitative or qualitative assessment of the values and preferences of adult outpatients with any type of depressive disorder. Appendix Table 1 presents the a priori–specified inclusion and exclusion criteria.
Appendix Table 1. Inclusion and Exclusion Criteria

Study Selection

Pairs of reviewers independently screened 30% of the search results. The remaining 70% of the abstracts were screened by single reviewers; excluded abstracts were checked by a second reviewer. Pairs of reviewers independently screened full texts.

Data Extraction and Quality Assessment

Single reviewers used structured spreadsheets (Microsoft Excel, version 2108) to extract study characteristics and findings. A second reviewer checked extracted data for completeness and accuracy.
To assess the studies' risk of bias, we used the Cochrane Risk of Bias Tool, version 2.0, for randomized controlled trials (9); the Critical Appraisal Skills Programme checklist for qualitative studies (10); and the Appraisal Tool for Cross-Sectional Studies for cross-sectional studies (11). Supplement Figures 1 to 3 show the risk-of-bias assessments for each study design.

Data Synthesis and Analysis

For studies using quantitative methods, we synthesized the data narratively. For studies using qualitative methods, we followed the stepwise textual narrative synthesis approach by classifying studies into more homogeneous groups (12).

Grading Certainty of Evidence

We assessed quantitative outcomes according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach (13) and qualitative outcomes according to the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach (14).

Role of the Funding Source

This rapid review was funded by the ACP. The ACP Clinical Guidelines Committee assisted in the development of the KQs, study inclusion criteria, and outcome measures of interest. The ACP was not involved in data collection, analysis, or manuscript preparation.

Results

Study and Patient Characteristics

The searches yielded 2267 references, of which we included 11 studies (15–25): 4 randomized controlled trials (17, 20, 21, 23), 5 cross-sectional studies (15, 16, 22, 24, 25), and 2 qualitative studies (18, 19) (Tables 1 and 2). The Supplement provides a list of the excluded studies with the reasons for exclusion. The Appendix Figure shows the study selection process.
Table 1. Summary of Quantitative Findings: Patients’ Values and Preferences Regarding Depression Management
Table 2. Summary of Qualitative and Quantitative Findings: Patients’ Weighting and Valuation of Depression Treatments’ Benefits and Harms
Appendix Figure. Evidence search and selection.
KQ = key question.
Participants of the included studies were mainly adult outpatients with major depressive disorder (15, 17, 20, 21, 23, 24); 5 studies also enrolled participants with other types of depression (16, 18, 19, 22, 25). All included studies focused on values and preferences regarding first-step depression treatment. Tables 1 and 2 show the ratings for certainty of evidence. Appendix Table 2 presents the characteristics of included studies in detail.
Appendix Table 2. Characteristics of the Included Studies

Pretreatment Outcome Expectations

One randomized controlled trial (n = 150) with moderate certainty of evidence reported that depressed patients' initial expectations of improvement probably did not differ according to planned treatment—that is, supportive-expressive psychotherapy (17) or antidepressants (Table 1).

Pre- and Posttreatment Preferences

For pretreatment preferences, the certainty of evidence was insufficient (17, 20, 21, 23). The low-certainty evidence of 1 cross-sectional study (22) suggests that after treatment, men (n = 230) may have preferred antidepressants over talk therapy; women (n = 481), overall, may have had no specific preference. When the population was stratified by racial/ethnic group, non-Hispanic White patients (n = 250) also may have preferred treatment with antidepressants over talk therapy. Hispanic (n = 252) and non-Hispanic Black (n = 209) participants may have had no posttreatment preferences for antidepressants or talk therapy.

Patients' Weighing and Valuation of Depression Treatments' Benefits and Harms

Five studies, 3 cross-sectional (15, 16, 25) and 2 qualitative (18, 19), reported on patient evaluations of the benefits and harms of depression treatments (Table 2). Low-certainty evidence from 1 cross-sectional study (25) suggests that the most important nonserious adverse events for patients treated with antidepressants (n = 1631) may have been insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction. Due primarily to the high risk of bias of observational study designs and differing study populations, the evidence was insufficient to draw any further conclusions.

Discussion

Our rapid review suggests that when questioned after treatment, men and non-Hispanic White participants prefer antidepressants to talk therapy. The evidence suggests that women, Hispanic participants, and non-Hispanic Black participants report no preference. Patients treated with antidepressants may consider insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction to be the most important nonserious adverse events. The certainty of evidence is low, however, so the findings must be interpreted cautiously. Before treatment, both participant groups—those prescribed supportive-expressive psychotherapy and those prescribed antidepressants—probably had similar improvement expectations. No firm conclusions could be drawn for any other comparisons or outcomes of interest because of the insufficient certainty of evidence.
Our findings are consistent with those of 2 previous systematic reviews that showed differences in preferences by gender (26, 27). However, the authors found that female gender was associated with a preference for psychotherapy over antidepressants. This difference may be because we found sufficient evidence only for talk therapy in comparison with antidepressants, and these 2 systematic reviews did not identify a study comparing talk therapy and antidepressants. We could not identify a systematic review on preferences by race/ethnicity or on outcome expectations.
The main limitations of our rapid review are the insufficient or low certainty of evidence for most outcomes and the general lack of evidence. The reasons for the insufficient certainty of evidence are the methodological limitations of the included studies, small sample sizes, and heterogeneous study populations. In addition, as for any literature review, undetected publication bias is a potential threat to the validity of our findings.
In conclusion, low-certainty evidence suggests some differences in preferences for talk therapy or pharmacologic treatment of depressive disorders based on gender or race/ethnicity. In addition, low-certainty evidence suggests that insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction may be the most important nonserious adverse events for patients treated with antidepressants. Evidence does not exist or is insufficient to draw any further conclusions about patients' weighing or valuation of the benefits and harms of depression treatments.

Supplemental Material

Supplement. Supplementary Material

References

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 176Number 2February 2023
Pages: 217 - 223

History

Published online: 24 January 2023
Published in issue: February 2023

Keywords

Authors

Affiliations

Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria, and Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (L.A.)
Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria (G.W., A.D., A.T., A.C., E.P., I.K.)
Andreea Dobrescu, MD, PhD
Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria (G.W., A.D., A.T., A.C., E.P., I.K.)
Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria (G.W., A.D., A.T., A.C., E.P., I.K.)
Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria (G.W., A.D., A.T., A.C., E.P., I.K.)
Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria (G.W., A.D., A.T., A.C., E.P., I.K.)
Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria (G.W., A.D., A.T., A.C., E.P., I.K.)
Gerald Gartlehner, MD, MPH https://orcid.org/0000-0001-5531-3678
Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Krems, Austria, and RTI International, Research Triangle Park, North Carolina (G.G.).
Acknowledgment: The authors thank Petra Wellemsen for project administration and formatting, Isolde Sommer and Ludwig Grillich for their input on qualitative synthesis methods, Dawn Gartlehner for editing and making the manuscript more readable, and Itziar Etxeandia Ikobaltzeta for her support.
Financial Support: By the American College of Physicians.
Reproducible Research Statement: Study protocol: Available on PROSPERO (CRD42020212442). Statistical code: Not applicable. Data set: Data extraction available from Lisa Affengruber (e-mail, [email protected]) (28).
Corresponding Author: Lisa Affengruber, MSc, Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems, Dr. Karl Dorrek Straße 30, 3500 Krems, Austria; e-mail, [email protected].
Author Contributions: Conception and design: L. Affengruber, A. Dobrescu, G. Gartlehner, I. Klerings.
Analysis and interpretation of the data: L. Affengruber, A. Chapman, G. Gartlehner, E. Persad, A. Toromanova.
Drafting of the article: L. Affengruber, A. Chapman, I. Klerings, E. Persad.
Critical revision for important intellectual content: A. Chapman, G. Gartlehner, G. Wagner.
Final approval of the article: L. Affengruber, A. Chapman, A. Dobrescu, G. Gartlehner, I. Klerings, E. Persad, A. Toromanova, G. Wagner.
Obtaining of funding: G. Gartlehner.
Administrative, technical, or logistic support: L. Affengruber, A. Dobrescu, E. Persad.
Collection and assembly of data: L. Affengruber, A. Chapman, A. Dobrescu, I. Klerings, E. Persad, A. Toromanova, G. Wagner.
This article was published at Annals.org on 24 January 2023.

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Lisa Affengruber, Gernot Wagner, Andreea Dobrescu, et al. Values and Preferences of Patients With Depressive Disorders Regarding Pharmacologic and Nonpharmacologic Treatments: A Rapid Review. Ann Intern Med.2023;176:217-223. [Epub 24 January 2023]. doi:10.7326/M22-1900

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