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Johnsen, T. J., & Friborg, O. (2015, May 11). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015

Depression is a highly debilitating disorder and ranked third in terms of disease burden in the world. Cognitive behavioral therapy (CBT) is an effective treatment for depression that was introduced over 40 years ago. In part, CBT sees depression as caused by maladaptive thoughts that maintain emotional distress and dysfunctional behavior. Reducing depression is achieved by eliminating the impact of or chancing maladaptive thoughts. CBT is the most researched psychological treatment for depression, and the research goes back several decades. A number of technical variations and new additions have been made over the years to CBT to improve patient outcomes. The volume of research and its history provides a unique opportunity to assess time trends in the effects of CBT. In this meta analysis, Johnsen and Friborg asked: “have the effects of CBT changed over time”? They also looked at whether client factors (e.g., demographics, symptom severity), therapist factors (e.g., age, experience, training), common factors (e.g., therapeutic alliance, client expectancies), and technique factors (e.g., fidelity to a treatment manual) can explain these trends. Johnsen and Friborg reported on 70 studies of 2,426 patients conducted from 1977 to 2014. Males accounted for 30.9% of patients, 43% had comorbid psychiatric conditions, and the average patient was at least moderately depressed. The average effect of CBT in reducing depression was large (g = 1.46 after accounting for publication bias). Women had better outcomes, studies with poorer methodological quality showed larger effects, and patients of more experienced therapists had better outcomes. There were too few studies measuring therapeutic alliance to assess the effect of common factors on outcomes. Most interesting was a significant relationship between effect sizes and year of publication. That is, the effects of CBT declined significantly over the years, though the average effect remained large. Surprisingly, there was a steeper decline for studies that used a treatment manual compared to those that did not. No other variables were reliably associated with this decline.

Practice Implications

Women and patients of more experienced therapists appear to benefit most from CBT. Although the effects of CBT declined over time, the treatment remained highly effective. Johnsen and Friborg’s study could not easily explain this decline. The authors suggested that the placebo effect (expectation on the part of patients, researchers, and therapists) is typically stronger for new treatments. However, as time passes the strong initial expectations tend to wane thus reducing the overall effect of the intervention. They also suggested that CBT treatment outcomes may be improved not by technical variations and new additions, but by better ways of integrating common, therapist, and client factors.

Author email: tjj@psykologtromso.no

Cuijpers, P., Hollon, S. D., van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ open, 3(4).

In another in a series of meta analyses by this primarily Dutch group, Cuijpers and colleagues tackle the question of whether the longer term effects of cognitive behavioral therapy (CBT; a short time-limited treatment for depression) outweighs the long term effects of continuation on anti depression medications. CBT is considered an efficacious treatment for depression (see my June 2014 Blog). CBT also has comparable effects as antidepressant medications, but CBT tends to have lower rates of treatment drop outs. What is not clear is whether short term CBT leads to lasting change that is comparable to long term use of medications for depression. One could argue for example, that short term CBT or other comparable psychological interventions teaches patients skills or changes psychological functioning such that future recurrences of depression are less likely. That is, psychological interventions may cause changes that eventually will prevent relapse. Pharmacotherapy on the other hand, may not result in psychological change or acquisition of new skills to forestall a relapse. In fact, patients with chronic depression tend to be kept on medications indefinitely, and patients who recently remit (i.e., no longer have symptoms of depression) are typically kept on pharmacotherapy for another 6 to 12 months to reduce the risk of recurrence. Information about the relative longer term effects of short term treatment with a psychological intervention like CBT versus longer term maintenance on pharmacotherapy can help practitioners and patients decide on the best course of action depending on patient preferences. Cuijpers and colleagues asked: is short term CBT without continuation of treatment as effective as short term treatment of pharmacotherapy with and without long term continuation? They conducted a meta analysis in which the effects of short term CBT were compared to pharmacotherapy in adults diagnosed with depression across follow up periods of 6 to 18 months. Nine studies representing 506 patients were included in the meta analysis. There was a non-significant trend showing that short term CBT outperformed continuation pharmacotherapy at one-year post treatment. On the other hand, CBT resulted in better long term outcomes compared to pharmacotherapy that was discontinued at post treatment. The odds of dropping out of treatment were significantly higher for those receiving pharmacotherapy compared to CBT. There were no differences in any of the findings for type of antidepressant medications.

Practice Implications

The findings reaffirm CBT as a first-line treatment of depressive disorders. It also suggests that equally effective other psychological treatments may also have similar enduring effects compared to pharmacotherapy. Patients and providers need to consider all of the evidence when weighing the pros and cons of psychotherapy or medications for the treatment of depression. Although pharmacotherapy might be more widely available to patients through primary care physicians, the research is suggesting that enduring effects and treatment compliance are higher among those who have access to psychological interventions.

Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W. et al. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, Advance online publication: doi:10.1176/appi.ajp.2014.13111514.

Social anxiety disorder is a highly prevalent mental disorder, with lifetime prevalence of about 12% in the population. As Leichsenring and colleagues note, the disorder has an early onset and can have a chronic course leading to many psychosocial impairments. Also, social anxiety disorder often is comorbid with depression. There is good evidence for the efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder and some evidence for psychodynamic therapy (PDT), but most studies have only assessed short term outcomes. In this large mulit-center randomized controlled trial comparing CBT and PDT for social phobia, Leichsenring and colleagues report on outcomes up to 2 years post treatment. The study had 416 adult patients randomly assigned to one of the treatments, and 79 randomly assigned to a waiting list. Outcomes were reported at post, 6 months, 12 months, and 24 months post treatment, and included remission of social phobia, depression levels, and interpersonal problem scores. The CBT intervention for social phobia was based on the model by Clark and Wells. The PDT was based on Luborsky’s model but specifically adapted for social phobia. Participants received 25 sessions of individual therapy, and therapists received advanced training in the models. CBT resulted in significantly greater remission of social phobia than PDT at post treatment, but the difference was small. Remission rates at 6, 12, and 24 months post treatment were not different between treatments. At 2 years post treatment 39% of those receiving CBT and 38% of those receiving PDT no longer had clinical symptoms of social phobia.  Results were similar for interpersonal problems in which CBT showed an earlier response, but the two treatments were equivalent at each follow up. Depression scores improved for both interventions at post and follow ups.

Practice Implications

The findings of this large study suggest that both CBT and PDT are effective treatments for social phobia. Although CBT had a small advantage at post treatment, PDT appeared to have an “incubation effect” in which patients continued to work on interpersonal problems and symptoms of social phobia over the longer term. Despite these positive outcomes, Leichsenring and colleagues suggest that there remains room for improvement in treating social phobia. Those who do not respond to these interventions may require different forms of treatment that is more specific, intense, or of longer duration. Leichsenring and colleagues also suggest integrating elements of the effective treatments within a single protocol. Although intuitively appealing, this integrated approach has not been tested.

Cuijpers, P., Huibers, M., Ebert, D.D., Koole, S.L., & Andersson, G. (2013). How much psychotherapy is needed to treat depression? A metaregression analysis. Journal of Affective Disorders, 147, 1-13.

The question of the number of psychotherapy sessions and of frequency sessions (i.e., number of sessions per week) that are optimal for good outcomes could have implications for how psychotherapy is practiced and how it is reimbursed. In my August 2013 PPRNet Blog, I reported on research that indicated half of patients recover after 21 sessions of psychotherapy. However, that also means that half do not recover in that number of sessions. Many of those who do not recover require another 29 sessions to recover. Research and practice in psychotherapy is largely based on a “one-session-per-week” model. Some researchers, however, have found that an increase in the frequency sessions per week could improve or speed up outcomes. Cuijpers and colleagues (2013) did a meta-regression to assess these questions for short-term psychotherapies for depression. (Meta-regression is a type of meta-analysis in which predictors from many studies are aggregated and their averaged effects on the aggregated outcome are assessed. This produces much more reliable findings than are possible from a single study.) The authors assessed predictors such as the number and frequency of sessions, and they looked at symptom outcomes for depression. The authors found 70 controlled studies that included 5403 patients. More than two-thirds of the studies included CBT as the psychotherapy. Average length of treatment was 11 sessions, and the maximum number of sessions was 24. The number of sessions across studies ranged from .44 to 2 per week, and the average per week was 1. The overall effect size for the treatment was medium sized (g = .59), though the effect became smaller (g = .40) when publication bias was corrected. (Publication bias refers to the likelihood that some less favorable studies or results were not published thus creating an overestimation of the effect of the treatment. See my May 2013 PPRNet Blog). Cuijper and colleagues’ meta-regression showed a small but significant association between greater number of sessions and outcomes for depression; but more importantly, a greater number of sessions per week had a considerably larger positive influence on the effects of psychotherapy for depression.

Practice Implications

The findings from Cuijpers and colleagues (2013) meta-regression are particularly relevant to time limited treatment of depression with CBT. The total number of sessions was less important than the frequency of sessions per week. The results suggest that increasing the intensity or frequency of CBT sessions per week might result in a more efficient therapy and faster relief for patients with depression.

Author email: p.cuijpers@vu.nl

Bell, E. C., Marcus, D. K., & Goodlad, J. K. (2013). Are the parts as good as the whole? A meta-analysis of component treatment studies. Journal of Consulting and Clinical Psychology, 81, 722-736.

Component studies (i.e., dismantling treatments or adding to existing treatments) may provide a method for identifying whether specific active ingredients in psychotherapy contribute to client outcomes. In a dismantling design, at least one element of the treatment is removed and the full treatment is compared to this dismantled version. In additive designs, an additional component is added to an existing treatment to examine whether the addition improves client outcomes. If the dismantled or added component is an active ingredient, then the condition with fewer components should yield less improvement. Among other things, results from dismantling or additive design studies can help clinicians make decisions about which components of treatments to add or remove with some clients who are not responding. For example, Jacobson and colleagues (1996) conducted a dismantling study of cognitive-behavioral therapy (CBT) for depression. They compared: (1) the full package of CBT, (2) behavioral activation (BA) plus CBT modification of automatic thoughts, and (3) BA alone. This study failed to find differences among the three treatment conditions. These findings were interpreted to indicate that BA was as effective as CBT, and there followed an increased interest in behavioral treatments for depression. However, relying on a single study to influence practice is risky because single studies are often statistically underpowered and their results are not as reliable as the collective body of research. One way to evaluate the collective research is by meta analysis, which allows one to assess an overall effect size in the available literature (see my November, 2013 blog on why clinicians should rely on meta analyses). In their meta analysis, Bell and colleagues (2013) collected 66 component studies from 1980 to 2010. For the dismantling studies, there were no significant differences between the full treatments and the dismantled treatments. For the additive studies, the treatment with the added component yielded a small but significant effect at treatment completion and at follow-up. These effects were only found for the specific problems that were targeted by the treatment. Effects were smaller and non-non-significant for other outcomes such as quality of life.

Practice Implications

Psychotherapists are sometimes faced with a decision about whether to supplement current treatments with an added component, or whether to remove a component that may not be helping. Adding components to existing treatments leads to modestly improved outcomes at least with regard to targeted symptoms. Removing components appears not to have an impact on outcomes. The findings of Bell and colleagues’ (2013) meta analysis suggest that specific components or active ingredients of current treatments’ have a significant but small effect on outcomes. Some writers, such as Wampold, have argued that the small effects of specific components highlight the greater importance of common factors in psychotherapy (i.e., therapeutic alliance, client expectations, therapist empathy, etc.). This may be especially the case when it comes to improving a patient’s quality of life.

Author email: david.marcus@wsu.edu