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Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148

Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.

Practice Implications

The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.

Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A., Furukawa, T.O. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283-293.

Depressive disorders are common, and they have an important negative impact on quality of life and on mortality. For that reason, the treatment of depression is critical. The most commonly tested psychotherapy is CBT but others like interpersonal psychotherapy (IPT), psychodynamic therapy (PDT), and behavioral activation (BA) have also been tested. In this network meta analysis, Cuijpers and colleagues simultaneously test the effects of different psychotherapies for depression. Network meta-analysis, fundamentally, works by the transitivity assumption: if treatment A = treatment B, and treatment B = treatment C, then treatment A = treatment C even if Treatments A and C were never tested against each other in the same study. This procedure is not without controversy: what if the studies of treatment A vs B are all higher quality (thus resulting in lower effects) than studies of treatments B vs C? Is it fair to equate the studies by comparing treatments A and C when we know study quality impacts effect sizes? Nevertheless, network meta-analyses are used by some to aggregate many studies and to estimate relative outcomes across treatment types. Cuijpers included 331 studies (representing over 34,000 patients) in their network meta-analysis. CBT was tested in over 63% of trials, but other therapies (PDT, IPT, BA) were tested as well. All psychotherapies were more efficacious than care-as-usual and wait list controls with almost no significant differences between therapies for treating depression, except non-directive therapy was less efficacious than other therapies. (Non-directive therapy was often treated as a placebo control condition in studies, and so it may have been delivered in a way that limited its efficacy). CBT, IPT, PDT and BA all were more efficacious than care as usual at 12 months follow up.

Practice Implications

Overall, this network meta-analysis of psychotherapies for depression echoes the findings of many meta-analyses that preceded it. All psychotherapies that were examined, except for non-directive therapy, were equally efficacious for treating depression. When initiating therapy, it may be more important for therapists to be responsive to patient characteristics than to focus on which brand of therapy to deliver. For example, patients with internalizing coping styles may do better with insight oriented therapies, those with high levels of resistance/reactance may require a therapist that is less directive, and patients from marginalized race and ethnic communities may do better with a therapist who is multiculturally competent.

Grenon, R., Carlucci, S., Brugnera, A., Schwartze, D., … Tasca, G. A. (2018). Psychotherapy for eating disorders: A meta-analysis of direct comparisons, Psychotherapy Research, DOI: 10.1080/10503307.2018.1489162

Eating disorders can cause a great deal of physical and mental impairment because of the severity of the symptoms and because of comorbid conditions like depression, anxiety, substance use, and others. Anorexia nervosa (AN) occurs in about 0.5% of the population, bulimia nervosa (BN) occurs in about 1.5% of the population, and binge-eating disorder (BED) occurs in about 3.5% of the population. Treatment guidelines include both cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as front line interventions for BN and BED. However, results from previous meta analyses of psychological treatments for eating disorders were confounded by not focusing exclusively on randomized controlled trials, mixing studies of adult and adolescent samples, combining an array of outcomes rather than separately reporting primary (eating disorder symptoms) and secondary (interpersonal problems, depression) outcomes, and not distinguishing between bona fide psychotherapies (like CBT, IPT, psychodynamic therapy, and others) from non-bona fide treatments (like self help, behavioral weight loss supportive counseling). Grenon and colleagues conducted a meta analysis of psychotherapies for eating disorders to examine if: psychotherapy is effective compared to a wait list, if bona fide psychotherapy and non-bona fide treatment differ in outcomes, and if one type of psychotherapy (i.e., CBT) was more effective than other bona fide psychotherapies (like IPT, behavior therapy, psychodynamic therapy, dialectical behavior therapy). Their meta analysis included 35 randomized controlled trials of direct comparisons. Psychotherapy was significantly more effective than a wait-list control at post treatment, so that 53.89% of patients were abstinent of symptoms after psychotherapy compared to only 8.92% who were abstinent in the wait-list group. Bona fide psychotherapies (51% abstinent) were significantly more effective than non-bona fide treatments (40% abstinent) at post treatment, and dropout in bona fide psychotherapies (17.5%) was significantly lower than in non-bona fide treatment (29.1%). Further, the difference between CBT and other bona fide psychotherapies was not significant.

Practice Implications

Psychotherapy for eating disorders are effective for patients with BN or BED. There were too few studies of those with AN to come to any conclusions about their treatment. Patients with BN or BED are best treated with a bona fide psychotherapy that involves face to face psychological therapy like CBT, IPT, psychodynamic therapy, dialectical behavior therapy, or behavior therapy. Non-bona fide treatments like self help, behavioral weight loss, and supportive counseling should only be used as an adjunct to bona fide psychotherapy for eating disorders.

Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847

For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.

Practice Implications

The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.

Author email: Simone.Jennissen@med.uni-heidelberg.de

Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta‐analytic review. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2180.

The therapeutic alliance refers to the collaborative agreement between therapist and client on the tasks of therapy (homework, treatment approach, intervention style) and goals of therapy (to reduce depressive symptoms, to improve interpersonal relationships, to cope better with stress), plus the emotional bond between therapist and client. The alliance is part of a larger concept of therapeutic relationship that also includes the real relationship between client and therapist and the transference relationship (maladaptive relational patterns in the client based on a history of relationships with parental figures). The alliance is thought to be a common factor across different therapeutic orientations, including cognitive behavioral therapy (CBT), time-limited psychodynamic psychotherapy (TLPP), and interpersonal psychotherapy (IPT). In fact, the alliance is known to have a moderate and robust relationship to client outcomes regardless of who rates the alliance (therapist, client, observer), which measure is used, and when in therapy the alliance is rated (early, middle, late). Although Beck emphasized the alliance as a key therapeutic principle in CBT, some CBT writers argue that the alliance is not so important. In this study, Cameron and colleagues conducted a meta analysis of 13 randomized controlled trials that assessed the relationship between therapeutic alliance and CBT outcomes for depression in adult clients. The overall mean correlation between therapeutic alliance and outcome was r = 0.26 (95% CI [.19–.32]), which indicates a moderate and significant relationship. This is very close to the value found in a larger meta analysis of over 200 alliance – outcome studies.

Practice Implications

The study demonstrates the importance of the therapeutic alliance to client outcomes in CBT. The association was at similar levels to those found in other types of therapy. Therapists conducting CBT should attend to building and maintaining an alliance, which provides a context to facilitate CBT interventions. If a client is not completing homework for example, it is likely that there is a lack of agreement on tasks of therapy, and this part of the alliance may need to be renegotiated. Therapists may also benefit from routinely assessing the alliance in therapy with their clients on a session by session basis using short and easy to use measures. Reviewing these scales regularly can alert a therapist to potential problems in the alliance and the need to repair any tensions or ruptures.

So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T.A., & McCrone, P. (2013). Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity. BMC Psychiatry, 13, 113. 

Depression is a major cause of disability in the world, and so efforts to improve access to its treatment have been ongoing for several decades. In particular, many researchers and clinicians propose cognitive behavioural therapy (CBT) as an effective treatment with a good evidence-base. There have been many clinical trials showing the efficacy of CBT. In recent years, there have also been attempts to computerize CBT (CCBT) as a self help intervention in order to increase its accessibility for those with depression, and perhaps also to improve its cost effectiveness. In fact, the Increasing Accessibility to Psychotherapy (IAPT) program in the UK provides CCBT as the most common first treatment for depression. However there remain questions about the longer term effectiveness of CCBT to reduce symptoms of depression, its potentially high patient dropout rate (a negative outcome), and its effects on quality of life of those burdened by depression. In this meta analysis, the largest of its kind, So and colleagues assess these issues with regard to CCBT. They reviewed 14 direct comparison randomized controlled trials that provided 16 comparisons of CCBT versus a control condition (wait list or treatment as usual) for adults with depression. At post-treatment, CCBT was more effective than controls in reducing depression −0.48 [95% CI −0.63 to −0.33]. However, at follow up (up to 6 months), the effects of CCBT disappeared −0.05 [95% CI −0.19 to 0.09]. Also improvement in functioning and quality of life were not significantly different between CCBT and control conditions, −0.05 [95% CI −0.31 to 0.22]. The rate of drop out from CCBT (32%) was almost double that of control conditions (17%), RR = 1.68 [95% CI 1.31 to 2.16]. There was also evidence of publication bias (i.e., a tendency for some researchers not to publish non-significant findings), so that the positive post-treatment results in favour of CCBT might be inflated.

Practice Implications

Although CCBT may be touted as a way to increase access to treatment for depression, this meta analysis indicates some concerns about the widespread implementation of CCBT. The effects of CCBT appear to be limited to a short-term reduction of depressive symptoms that may not be sustained in the longer run. There was no appreciable impact of CCBT on quality of life relative to controls, and so CCBT may have a limited impact on the burden of depression. Most troubling was a high drop out rate of 32%. Drop out from CCBT in the IAPT program in the UK is about 50%, and this may be indicative of the actual drop out rate in real world practice.