Comment: The quality of the evidence is downgraded by inconsistency (heterogeneity in patients and interventions).
A Cochrane review [Abstract] 1 included 21 studies with a total of 2658 subjects. Duration of symptoms, reported by 9 studies, was at least several years, suggesting most participants had chronic symptoms at baseline. The mean age was 43 years. Diagnostic and inclusion criteria varied widely between studies. All studies assessed the effectiveness of some form of psychological therapy. Fourteen studies evaluated forms of cognitive behavioural therapy (CBT); the remainder evaluated behaviour therapies, third-wave CBT (mindfulness), psychodynamic therapies, and integrative therapy. Fifteen studies compared psychological therapy with usual care or a waiting list and 5 studies with enhanced or structured care. Only one study compared CBT with behaviour therapy. Duration of follow-up varied between 2 weeks and 24 months. Eleven studies (52%) reported a loss to follow-up of more than 20%. For all studies comparing psychological therapy with usual care, the psychological therapy resulted in less severe symptoms at end of treatment (SMD -0.34; 95% CI -0.53 to -0.16; 10 studies, n=1081). Compared with usual care, psychological therapies resulted in a 7% higher proportion of drop-outs during treatment (RR 0.93; 95% CI 0.88 to 0.99; 14 studies, n=1644). Five studies (n=624) assessed symptom severity comparing some psychological therapy with enhanced care, and found no clear difference (pooled SMD -0.19; 95% CI -0.43 to 0.04). Five studies (n=679) showed that psychological therapies were somewhat less acceptable in terms of drop-outs than enhanced care (RR 0.93; 95% CI 0.87 to 1.00).
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