Blog

The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.

January 2017

Individual versus Group Psychotherapy

Burlingame, G.M., Seebeck, J.D., Janis, R.A., Whitcomb, K.E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53, 446-461.

With increasing service demands being put on mental health systems, clinicians and administrators are looking to more efficient ways of providing care to more patients. One option is group therapy in which more patients can be treated with fewer resources. However, are groups as effective as individual therapy for mental disorders? This meta-analysis by Burlingame and colleagues addresses this question by examining 67 studies in which group and individual therapy were directly compared within the same study. The majority of studies included adults with anxiety, mood, or substance use disorders, with some studies focusing on medical conditions, eating or personality disorders. Two-thirds of studies were of cognitive-behavioral therapy, but other treatment types like interpersonal, psychodynamic, and supportive therapy were also tested. Groups were defined as having at least 3 patients per group. The average number of sessions for group and individual therapy were equivalent (group M = 14.67, SD = 8.75; individual 15.94, SD = 14.37)), and as expected group therapy sessions were longer in minutes (M = 100.39, SD = 30.87) than individual therapy sessions (M = 56.55, SD = 14.37) given the multi-person demands of groups. Groups were primarily closed to new members after starting, they tended to have homogenous membership based on diagnosis, and groups tended to be co-led by 2 therapists. Individual and group therapy were not significantly different for all disorders and outcomes at post-treatment (g = -0.03; 95%CI = -0.10, 0.04), short-term follow-up (g = 0.01; 95% CI = -0.13, 0.11), and long-term follow-up (g = 0.00; 95% CI= -0.12, 0.13). Drop out rates for group therapy (17.28%) and individual therapy (14.96%) were not significantly different (OR = 1.10; 95% CI = 0.90, 1.33), and patients were likely to accept group therapy (88.76%) as often as they accepted individual therapy (84.83%) when one or the other was offered. Pre- to post-treatment effect sizes were moderately large for both interventions (group: g = 0.60, 95% CI = 0.48, 0.72; individual: g = 0.53, 95% CI = 0.42, 0.65). Patients presenting with depression, substance us, anxiety, or eating disorders had the highest level of improvement.

Practice Implications

When identical treatments, patients, and doses are compared, individual and group therapy resulted in equivalent outcomes across of a variety of disorders. This is good news for clinicians and agencies looking to maximize resources to treat more patients. However, running a group is more complex than providing individual therapy. Finding a sufficient number of patients to start a group, assessing and preparing each patient prior to starting a group, writing a note per patient per session, and managing attrition is logistically more challenging. Further, most therapists are not formally trained to provide group interventions and so they may find the task of managing a substantially larger amount of within-session group process information to be complex. Finally, as Burlingame and colleagues indicate, there are institutional considerations so that group programs require a milieu that supports group referrals and flexibility in scheduling. Nevertheless the findings of this meta analysis indicate the potential for group therapy to provide efficacious treatments for mental disorders.

October 2016

The Quality of Psychotherapy Research Affects The Size of Treatment Effects for CBT

Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M., Huibers, M.J.J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15, 245-258.

You might think that an esoteric topic like study quality should not really be of interest or concern to clinicians – but it is an important topic with practice implications. In this meta analysis Pim Cuijpers and his research group updated the meta analytic evidence for the efficacy of cognitive behavioral therapy (CBT) for a variety of disorders (major depressive disorder [MDD], generalized anxiety disorder [GAD], panic disorder [PAD], and social anxiety disorder [SAD]). The important thing about meta analyses is that the method combines the effect sizes from all relevant studies into a single metric – an average effect size. These average effect sizes are much more reliable than findings from any one single study. In fact, whenever possible, clinical decision-making should be based on a meta analysis and systematic review and not on a single study. Meta analyses also allow one to give more weight to those studies that have larger sample sizes, and that employ better methodologies. Even more, meta analytic techniques allow one to adjust the averaged effect size by taking into account publication bias (i.e., an indication of the effects from studies that might have been completed but were never published, likely because they had unfavorable findings). Usually, average effect sizes are lower when they are adjusted for study quality and publication bias. Cuijpers and colleagues’ meta analyses found that the unadjusted average effects of CBT were large for each of the disorders (ranging from g = .75 to .88 [confidence intervals not reported]). However adjusting for publication bias reduced the effects to medium-sized for MDD (g = .65) and GAD (g = .59). Only 17.4% of the individual studies of CBT were considered to be of “high quality” (i.e., studies that use the best methodology to reduce bias, like random allocation, blinding, using all the available data, etc.). After adjusting for study quality, the effects of CBT for SAD (g = .61) and PAD (g = .76) were also reduced to medium-sized. Not surprisingly, the effects of CBT were largest when the treatment was compared to a wait-list no-treatment control group. The effects were small to moderate when CBT was compared to treatment as usual or to a placebo.

Practice Implications

Even when adjusting for study quality and publication bias, the average effects of CBT were medium-sized for a variety of common disorders compared to control conditions. Unfortunately, the quality of the studies was not high for most trials, reducing the effect sizes and lowering our confidence in the efficacy of the treatment. Nevertheless, the findings of this meta analysis suggest that CBT will likely have moderate effects for the average patient with MDD, SAD, PAD, and GAD.

September 2016

Interpersonal Psychotherapy for Mental Health Problems

Cuijpers, P., Donker, T., Weissman, M.M., Ravitz, P., & Cristea, I.A. (2016). Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. American Journal of Psychiatry, 173, 680-687.

Interpersonal psychotherapy is a structured therapy that was originally developed for the treatment of depression. The therapy focuses on stressful life events like grief, interpersonal disputes, life transitions, social isolation or deficits that may cause symptoms. Interpersonal psychotherapy also helps people to connect with social supports and improve their relationships. The treatment emphasizes developing a therapeutic alliance, psychoeducation, and choosing an interpersonal focus. Recently, several trials have been conducted to assess the efficacy of interpersonal psychotherapy for other mental health problems like addictions, eating and anxiety disorders. In this comprehensive meta analysis, Cuijpers and colleagues looked at all randomized controlled trials of interpersonal psychotherapy for any mental disorder. The review included 90 studies representing over 11,000 patients. Most of the studies targeted depression, but some studies used interpersonal psychotherapy to treat other disorders. The effect size of the difference between interpersonal psychotherapy and control conditions was moderately large (g = 0.60), indicating that interpersonal psychotherapy was efficacious. Interpersonal psychotherapy was as effective as other psychotherapies (g = 0.06), and as effective as antidepressant medications (g = -0.13). Combined interpersonal psychotherapy and medications was more effective than interpersonal psychotherapy alone, but the effect size of the difference was small (g = 0.24). The combination of monthly maintenance interpersonal therapy plus daily pharmacotherapy was significantly more effective in preventing relapse of depression compared to pharmacotherapy alone or interpersonal psychotherapy alone (odds ratios between 0.34 and 0.36 with confidence intervals not crossing 0). The effects of interpersonal psychotherapy for eating disorders was mixed largely because of the small number of studies and lower quality of studies. For anxiety disorders, interpersonal psychotherapy was as effective as other treatments (g = -0.16) and more effective than control conditions (g = 0.82).

Practice Implications

Interpersonal psychotherapy showed moderate to large effects in the treatment of depression and anxiety disorders, and it was as effective as other interventions. Interpersonal psychotherapy may be effective for eating disorders as well, though the evidence is less clear. Patients and providers need to have more treatment options since no one treatment is effective for all patients. The relationship emphasis of interpersonal psychotherapy provides an important alternative to medications or cognitive behavioral therapy for some patients.

July 2016

Is it Feasible to Have a Nationally Funded Psychotherapy Service?

Community and Mental Health Team, Health and Social Care Information Centre (2015). Psychological therapies; Annual report on the use of IAPT services: England 2014/15.

There have been calls from mental health professional organizations and by the media to provide publicly funded psychotherapy in Canada. Rates of common mental disorders in Canada are high, such that about 20% of the population will personally experience a mental illness in their lifetime. In 1998, the estimated direct and indirect economic cost of mental illness in Canada was $7.9 billion (all figures are in Canadian dollars). Current estimates of costs to fund a public psychotherapy service in Canada may be about $1 billion to $2.8 billion – which far outweighs the cost. Most outpatient psychotherapy in Canada is provided by professionals in private practice who charge somewhere between $100 and $200 per session, costing Canadians nearly $1 billion per year. Some people are fortunate to have workplace insurance that covers some but not all of the costs, but most people in Canada do not have insurance and so they pay out of pocket or they go untreated. Research shows us that approximately 13 to 18 sessions are needed for 50% of clients to get better with psychotherapy. Which means that even with an insurance plan, many Canadians who need psychotherapy will find it to be a financial burden. Since 2008, the National Health Service in England implemented the Improving Access to Psychotherapies (IAPT) services to provide publicly funded psychotherapy to the population. The psychological treatments provided through IAPT are evidence-based (e.g., CBT, interpersonal psychotherapy, brief dynamic psychotherapy for depression). For mild to moderate problems, individuals get low intensity interventions first (i.e., self help, internet based interventions), followed by more intensive psychotherapy if needed. Treatment outcomes are measured from pre- to post-treatment with valid standardized measures of depression and anxiety. At post-treatment, patients are categorized as reliably deteriorated, not changed, improved, and recovered. The goal of the IAPT is to achieve 50% recovery rates among patients. In their online 2014-15 annual report, the IAPT service reported that it treated over 400,000 patients in that year. 44.8% of patients were rated as reliably recovered – that is over 180,000 mentally ill patients improved and no longer had a mental illness. Reliable improvement was seen in 60.8% of patients – this included recovered patients plus those who still had a disorder but were feeling significantly better than when they started. Recovery was highest for people 65 years and older (57.8%). Rates of recovery were similar for depression (44.6%) and anxiety (47.8%) disorders, and between men and women. Waiting times for treatment was less than 28 days for 66.0% of patients.

Practice Implications

The experience in England with the IAPT is instructive for Canada. The IAPT service provides evidence-based psychological therapies within a publicly funded national health service. The IAPT approached its target of 50% of patients recovering from mental illness, and over 60% of patients were reliably improved. Waiting times were low for most patients. Given the experience in England’s National Health Service, the implementation of a national strategy for psychotherapy appears to be feasible and effective. Will political leaders in Canada be able to see the financial and human value of publicly funded psychotherapy?
Direct Psychological Interventions Reduce Suicide and Suicide Attempts

Meerwijk, E.L., Parekh, A., Oquendo, M.A., Allen, I.E., Franck, L.S., & Lee, K.A. (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. Lancet Psychiatry.

The World Health Organization reports that more than 800,000 people die of suicide per year around the world. However suicide prevention efforts over the past decade have fallen short of targets. In fact, the prevalence rates of suicide in the US have risen steadily since 2000 to about 1.3% of the population in 2014. Many who kill themselves have a mental disorder like depression, anxiety disorders, substance abuse, psychoses, or personality disorders. Best practices suggest that directly addressing suicidal thoughts and behaviors during treatment, rather than only addressing symptoms like depression and hopelessness, are most effective in reducing suicide. However, there are no meta analyses of randomized controlled trials that specifically assess the relative utility of direct versus indirect psychological interventions. In their meta analysis, Meerwijk and colleagues looked at psychosocial interventions aimed to prevent suicide or to treat mental illness associated with suicide. They included 31 studies representing over 13,000 participants. Interventions included cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), case management, social skills training, and supportive telephone calls. Depending on the target problem, the interventions either directly addressed suicidal behavior or they indirectly addressed suicidal behavior. Mean duration of treatment was over 11 months. Studies that looked at direct or indirect interventions were each compared to control groups that received some form of usual care in the community, or psychiatric management, or general practitioner care. Individuals who received usual care were 1.5 times more likely to die of or attempt suicide compared to those receiving direct or indirect psychological interventions. There was a 35% lower odds of suicide and attempts with direct interventions compared to usual care; and an 18% lower odds of suicide and attempts with indirect interventions compared to usual care. The difference between the effectiveness of direct versus indirect interventions was large (d = .77), suggesting that direct interventions were more effective than indirect interventions at reducing suicide and suicide attempts.

Practice Implications

This is the largest meta analysis of its kind. Most direct interventions to prevent suicide and suicidal behaviors were based on CBT and DBT. Indirectly addressing suicide by focusing on depressive symptoms, anxiety, and hopelessness was somewhat effective compared to usual care. However, direct interventions that included talking about the patient’s suicidal thoughts and behaviors and how best to cope were most effective.

May 2015

Effects of Antidepressants in Treating Anxiety Disorders Are Overestimated

Roest, A.M., de Jonge, P., Williames, G.D., de Vries, Y.A., Shoevers, R.A., & Turner, E.H. (2015). Reporting bias in clinical trials investigating second-generation antidepressants in the treatment of anxiety disorders: A report of 2 meta-analyses. JAMA Psychiatry, doi:10.1001/jamapsychiatry.2015.15.

Previous research has shown that the effects of antidepressant medications for treating depression may be over estimated by as much as 35%. This occurs because of publication bias, which refers to the tendency among researchers and editors to prefer to publish positive findings, and also occurs due to the occasional practice of the pharmaceutical industry to suppress negative findings. In these meta analyses, Roest and colleagues assess publication bias in the research of antidepressant medications to treat anxiety disorders (i.e., generalized anxiety disorder [GAD], panic disorder [PD), social anxiety disorder [SAD], post traumatic stress disorder [PTSD], and obsessive compulsive disorder [OCD]). Anxiety disorders are very common in the population, with an estimated year-prevalence of 12%. Second generation antidepressants (i.e., selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors) are the primary pharmacologic treatment for anxiety disorders. Roest and colleagues were also interested in outcome reporting bias, which refers to mis-reporting non-positive findings as if they were positive findings, and spin which refers to interpreting non-positive results as beneficial findings. Positive findings refer to the pharmacological agent significantly outperforming a placebo, and non-positive findings refer to pharmacological agents not significantly outperforming a placebo. Pharmaceutical companies in the US must register any trial with the Food and Drug Administration (FDA) prior to starting the trial if the company wishes to apply for US marketing approval. And so, all medication trials and their findings, whether positive or non-positive must be listed in the FDA register. Despite being listed with the FDA, not all trials and findings get published in peer reviewed journals. This causes a problem for reviews and meta analyses that tend only to focus on published trials, and prescribing physicians tend only to read published trials and reviews. In their meta analyses Roest and colleagues compared findings from all FDA registered medication trials to those that were published in peer reviewed journal. Fifty seven trials were registered with the FDA but only 48 were published. Regarding publication bias, the proportion of studies with positive findings indicating efficacy of antidepressant medications in FDA trials was 72%, whereas the proportion of studies with positive findings in trials published in a journal was 96%. Overall, trials were 5 times more likely to be published if they were positive than if they were non-positive. Regarding outcome reporting bias, 3 of 16 trials that were non-positive in the FDA review were reported as positive in journal publications. Regarding spin, an additional 3 of the 16 non-positive trials interpreted non-positive results as if they were positive. Effect sizes in the FDA data was g = .33 indicating a small average effect size of the medications for anxiety disorders, but the effect size in published journals was g = .38 indicating a small to moderate effect. This represents a 15% over estimation of the effects of the antidepressant medications for anxiety disorders in the published literature.

Practice Implications

The effects of antidepressant medications for anxiety disorders appear to be over estimated by 15% in the published literature. This inflation is not as large as the 35% over estimation in the published literature of the effects of antidepressant medications for depression. By contrast, as I reported in a previous PPRNet Blog, publication bias in psychotherapy trials is small and has little impact on the overall estimate of psychotherapy’s efficacy. Effect sizes for psychological interventions for anxiety disorders are moderate to large, g = .73. Combining medications and psychotherapy only modestly improves efficacy of treatments, and medications may interfere with the efficacy of psychological interventions.

This month...

Type of Research

Topics

January 2017

Practice Implications

October 2016

Practice Implications

September 2016

Practice Implications

July 2016

Practice Implications

Practice Implications

May 2015

Practice Implications

Psychotherapy Practice Research Network (PPRNet)