The authors concluded that group psychotherapy may reduce depressive symptoms in patients infected with the human immunodeficiency virus, but the results may not be applicable to women. There were limitations to this review but, overall, the authors’ conclusions are likely to be reliable.

To evaluate the efficacy of group psychotherapy for human immunodeficiency virus (HIV)-infected patients with depressive symptoms.

MEDLINE, PsycINFO and the Cochrane CENTRAL Register were searched from 1981 to 2006 using the reported keywords. The reference lists of key reviews were screened for additional published and unpublished studies.

Study designs of evaluations included in the review

Double-blind randomised controlled trials (RCTs) were eligible for inclusion in the review.

Specific interventions included in the review

Studies that evaluated psychotherapy interventions were eligible for inclusion. The included studies compared different types of group psychotherapy with usual care, HIV information/waiting list, wait list alone and medication adherence. The types of group psychotherapy studied were cognitive-behavioural therapy (CBT), supportive psychotherapy, coping effectiveness training (CET), and a combination of emotional expressive and CBT therapy. Some interventions focused on treating grief plus depressive symptoms, while others focused on depressive symptoms alone. The number of treatment sessions ranged from 7 to 15 and the duration of the interventions ranged from 90 to 150 minutes.

Participants included in the review

Inclusion criteria were not specified in terms of the participants, but it was clear that the review focused on HIV-infected patients with depressive symptoms. Only one study required patients to have depression at study entry, while two excluded patients with major depression. All but one study included only men.

Outcomes assessed in the review

Studies that reported depressive symptoms were eligible for inclusion. The included studies assessed depressive symptoms using the Hamilton Depression Rating Scale, the Beck Depression Inventory and the Centre for Epidemiogic Studies-Depression scale.

How were decisions on the relevance of primary studies made?

Three reviewers independently selected the studies.

Three reviewers independently assessed validity using the 15-item scale described by Detsky et al. Any disagreements were resolved by consensus.

Three reviewers independently extracted the data. Any disagreements were resolved by consensus.
For each study, the standardised mean difference between treatment groups (Cohen’s effect size, d) was calculated from mean and standard deviations. Where required, authors were contacted for missing data.

How were the studies combined?

Standardised mean differences were combined and pooled effect sizes (d) calculated using a random-effects model. Funnel plots and Egger’s and Begg’s tests were used to assess the potential for publication bias.

How were differences between studies investigated?

Statistical heterogeneity was assessed using the Q statistic. Where significant heterogeneity (p<0.10) was found, the I-squared statistic was calculated. Separate analyses were conducted according to intervention type and focus of the intervention, and for studies that included and excluded patients with major depression.

Eight RCTs (n=665) were included.

he authors stated that all studies were rated as being good quality, but no further details of study validity were reported.

Group psychotherapy was associated with a small-to-moderate effect size (ES) for depressive symptoms compared with control (ES 0.38, 95% confidence interval, CI: 0.23, 0.53; based on 8 studies, 9 comparisons). No significant heterogeneity was found.

Group CBT was associated with a statistically significant moderate ES for depressive symptoms compared with control (ES 0.37, 95% CI: 0.18, 0.56; 5 studies). CBT with emotion expression therapy was associated with a larger ES but borderline statistical significance in one study (ES 0.79, 95% CI: 0.00, 1.58). There was no significant difference in depressive symptoms between group supportive psychotherapy and control (ES 0.58 (95% CI: -0.05, 1.22; 2 studies), or between CET and control (ES 0.16, 95% CI: -0.27, 0.59; 1 study).

There was a significant small-to-moderate ES associated with interventions focusing on grief and depressive symptoms (ES 0.34, 95% CI: 0.12, 0.56), and a significant moderate ES associated with studies focusing on depressive symptoms alone (ES 0.42, 95% CI: 0.21, 0.63).

For studies that excluded patients with major depression, there was no significant difference in depressive symptoms between group psychotherapy and control (ES 0.26, 95% CI: -0.10, 0.61; 2 studies). For studies that included patients with major depression, psychotherapy was associated with a statistically significant moderate effect size for depressive symptoms compared with control (ES 0.41, 95% CI: 0.24, 0.48).

A relative absence of publication bias was suggested by the approximately symmetrical funnel plot and non significant Begg’s and Egger’s tests.

Group psychotherapy, particularly group CBT, may reduce depressive symptoms in HIV-infected patients, but the results may not be applicable to women.

The review question was clear in terms of the study design, participants, intervention and outcomes. Several relevant sources were searched but attempts to identify unpublished studies were limited. The potential for publication bias was assessed and no strong evidence of it was found. It was not stated whether any language restrictions were applied to the search, thus the potential for language bias could not be assessed. Methods were used to minimise reviewer error and bias in the study selection, validity assessment and data extraction processes. Only double-blind RCTs were included and validity was assessed using an aggregated quality scoring system, but the results of this assessment were not reported; it is therefore not possible to adequately assess the reliability of the evidence. Statistical heterogeneity was assessed, studies were appropriately pooled using meta-analysis, and the influence of several factors was examined. There were limitations to this review but, overall, the authors’ conclusions are likely to be reliable.

Practice: The authors did not state any implications for practice.

Research: The authors stated the need for research to examine the effects of interventions in women with HIV, and for future meta-analyses to assess the effects on access and adherence to highly active antiretroviral therapy.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.