Are Couple-Oriented Interventions Effective Across Chronic Illnesses? A Commentary on Martire et al.

In their recent meta-analysis, Martire et al. [1] reviewed 25 studies of patients with cancer, arthritis, cardiovascular disease, chronic pain, HIV, and type 2 diabetes and reported that couple-oriented interventions had significant effects on depressive symptoms (d = 0.18), marital functioning (d = 0.18), and pain (d = 0.19). They broadly concluded that couple interventions were more efficacious than patient-only psychosocial intervention or usual care. Meta-analyses on interventions are conducted so that clinicians and policy makers can assess the likely effects in clinical practice of a particular treatment for a particular patient group. Beyond reporting a summary effect size, meta-analysts are expected to transparently report steps taken to identify and extract data from relevant studies, synthesize data, and assess risk of bias, such as from methodological shortcomings in original studies [2]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [3], which has been adopted by the Annals of Behavioral Medicine, describes steps to be followed to ensure that key information is transparently reported in meta-analyses. Martire et al. did not report on several key items from PRISMA. For example, PRISMA requires that summary data be provided for each study, including the individual effects combined to generate an overall effect estimate. Martire et al., however, only reported a single synthesized effect size for each outcome. Similarly, PRISMA requires a transparent description of how risk of bias in original studies was assessed and reflected in data synthesis and conclusions. Martire et al. stated broadly that methodological improvements are needed in couple-oriented intervention research, but did not document how they arrived at this conclusion or provide information on risk of bias in individual studies. As a result, independent confirmation of the reported results or an assessment of the degree to which results might be influenced by potential bias in original studies would require readers to review individually each of the 25 studies included in the meta-analysis. PRISMA also recommends that the questions addressed by a meta-analysis be explicit in terms of participant characteristics, interventions, comparisons, outcomes, and study design. Martire et al. included studies on a broad range of intervention strategies, in individual and group formats, delivered in three to 20 sessions, for patients with many different challenges, leaving clinicians with little guidance regarding what treatment strategy and format might work for whom. In addition, Martire et al. combined outcomes from the studies they reviewed if they were reported in the original studies, but without regard to whether outcomes were specifically targeted by interventions. An intervention specifically designed to improve pain management in arthritis, for example, might have a different effect on pain than an intervention intended to enhance weight loss, even if pain reduction was reported for the latter. Meta-analyses are cited more than any other type of study design and are prioritized in practice guidelines [4, 5]. Researchers, peer-reviewers, and journal editors should work to improve adherence to PRISMA standards so that clinicians and policy makers can more confidently interpret results and incorporate evidence-based strategies into practice.

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