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Estimating the smallest worthwhile difference of recommended psychotherapies for depression: observational study

Published online by Cambridge University Press:  10 November 2025

Ethan Sahker Open the ORCID record for Ethan Sahker [Opens in a new window] ,
Yan Luo Open the ORCID record for Yan Luo [Opens in a new window] ,
Kenji Omae Open the ORCID record for Kenji Omae [Opens in a new window] ,
Aran Tajika Open the ORCID record for Aran Tajika [Opens in a new window] ,
Manuela L. Ferreira Open the ORCID record for Manuela L. Ferreira [Opens in a new window] ,
Astrid Chevance Open the ORCID record for Astrid Chevance [Opens in a new window] ,
Stefan Leucht Open the ORCID record for Stefan Leucht [Opens in a new window] ,
Sarah Markham Open the ORCID record for Sarah Markham [Opens in a new window] ,
Roger Ede Open the ORCID record for Roger Ede [Opens in a new window]  and
Andrea Cipriani Open the ORCID record for Andrea Cipriani [Opens in a new window]
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Ethan Sahker*
Affiliation:
Population Health and Policy Research Unit, Center for Medical Education and Internationalization, Graduate School of Medicine, Kyoto University, Kyoto, Japan Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
Yan Luo
Affiliation:
Population Health and Policy Research Unit, Center for Medical Education and Internationalization, Graduate School of Medicine, Kyoto University, Kyoto, Japan Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
Kenji Omae
Affiliation:
Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Japan
Aran Tajika
Affiliation:
Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
Manuela L. Ferreira
Affiliation:
The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
Astrid Chevance
Affiliation:
Center for Research in Epidemiology and StatisticS (CRESS), Paris Cité University and Sorbonne Paris Nord University, Inserm, INRAE, Paris, France Centre Clinical Epidemiology, AP-HP, Hotel Dieu Hospital, Paris, France
Stefan Leucht
Affiliation:
Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
Sarah Markham
Affiliation:
Patient and Public Involvement (PPI) Group, Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, University of Oxford, Oxford, UK Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, London, UK
Roger Ede
Affiliation:
Patient and Public Involvement (PPI) Group, Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, University of Oxford, Oxford, UK
Andrea Cipriani
Affiliation:
Department of Psychiatry, University of Oxford, Oxford, UK Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
Georgia Salanti
Affiliation:
Institute of Social and Preventive Medicine and Clinical Trials, University of Bern, Bern, Switzerland
Toshi A. Furukawa
Affiliation:
Office of Institutional Advancement and Communications, Kyoto University, Kyoto, Japan
*
Correspondence: Ethan Sahker. Email: sahker.ethan.2e@kyoto-u.ac.jp
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Abstract

Background

The smallest worthwhile difference (SWD) represents the smallest beneficial effect of an intervention that patients deem worthwhile given the harms, expenses and inconveniences of the intervention. The SWD facilitates interpretation of the patient-perceived importance of intervention effects. We previously estimated the SWD for antidepressants for depression, but the SWD for psychotherapy remains unknown.

Aims

To estimate the SWD of recommended psychotherapies for depression compared with no treatment.

Method

We estimated the SWD through a patient required difference in response rates between psychotherapy and no treatment after 2 months. We recruited using Prolific, an online cross-sectional survey platform, in the UK and USA in January 2025. We also queried a random subset of respondents to replicate our previous SWD estimation for antidepressants.

Results

In the primary study, we recruited 526 participants (mean age: 36.7 years (s.d. = 12.5); 54% women and 61% White individuals). Of these, 6% reported that they would not initiate psychotherapy with a 100% treatment response. For those willing to initiate psychotherapy, 87 reported moderate-to-severe depressive symptoms but were not in treatment, 184 were in treatment and 131 reported absent-to-mild symptoms with or without previous treatment. The median SWD for people with moderate-to-severe depressive symptoms, not in treatment and willing to consider psychotherapies was a 20% (interquartile range: 10–35%) difference in response rates comparing psychotherapy with no treatment. This was similar to the SWD for antidepressant drugs (SWD = 20%, interquartile range: 10–30%; n = 104). Participant characteristics were not meaningfully associated with the SWD.

Conclusions

Current empirically supported psychotherapy response rates of 15% were sufficient for one in three people to initiate psychotherapy given the burdens, but two in three expected greater treatment benefits or fewer burdens. The SWD for psychotherapy was not materially different from the estimated SWD for antidepressants. Individual patient value judgements and preferences merit greater attention. These findings should be replicated with diverse samples from different geographical locations.

Keywords

Smallest worthwhile effectpsychological treatmentsantidepressantsevidence-based mental healthpatients

Information

Type
Original Article
Information
The British Journal of Psychiatry , First View , pp. 1 - 8
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Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of Royal College of Psychiatrists

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