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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Quality of Life Outcomes in the Psychological Treatment of Persistent Depression
McPherson, S., & Senra, H. (2022). Psychological treatments for persistent depression: A systematic review and meta-analysis of quality of life and functioning outcomes. Psychotherapy, 59(3), 447–459.
The World Health Organization ranks depression as the largest cause of global disability accounting for 7.5% of all years lived with disability. Persistent forms of depression contribute to years lived with disability due to its chronic nature and its association with low levels of social and physical functioning, high rates of suicide, and high health care use. One way to look at disability as an outcome is to assess quality of life, which refers to performance in daily and social functioning and satisfaction with these activities. In this meta-analysis, McPherson and Senra examine 14 randomized controlled trials of psychological therapies for chronic or persistent depression in adults. The control condition included no treatment, waiting list, treatment as usual, or only antidepressant medication. The psychotherapies were mindfulness-based cognitive therapy (MBCT), CBT, interpersonal psychotherapy (IPT), long term psychoanalytic psychotherapy (LTPP), and DBT. Chronic depression was defined as a course of depression of at least 2 years and/or non-response to at least two treatments. The quality of life measure had to assess satisfaction with physical health, psychological state, level of independence, and social relationships. In general, the psychological treatments were associated with improvements in patients’ quality of life at the end of treatment (N=11; g=0.24; 95%CI: 0.13, 0.34). At follow up, the effect size was g=.21 (95%CI: 0.10, 0.32). That is, the effects were significant and positive, but small. The psychological interventions resulted in improvements in patient functioning at the end of treatment, g=.35 (95%CI: 0.21, 0.48), which is consistent with previous meta-analyses showing small to moderate effects of psychological treatments for persistent depression. Although there were too few studies to properly assess differences between therapy types, MBCT, IPT, and LTPP in combination with antidepressant medications had the largest effects among the therapies studied.
In international surveys, patients seeking treatment for depression, informal caregivers, and health professionals list quality of life and social functioning as just as important or as more important than symptom reduction. Yet, these outcomes related to quality of life are not often assessed in clinical trials. This meta-analysis of a modest number of studies, suggests that some psychological therapies (MBCT, IPT, LTPP), in combination with antidepressant medications have the largest positive effects on quality of life for those persistent depression.
Cognitive Behavior Therapy vs. Control Conditions and Other Treatments
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: A comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry, 22, 105–115.
Depression is a highly prevalent mental disorder, with about 280 million people worldwide who have the disorder. Several evidence-based treatments are available for depression, including pharmacotherapies and psychotherapies. Cognitive behavior therapy (CBT) is the most researched type of psychotherapy for depression. To date there are 409 trials with over 52,00 patients. In this study, Cuijpers and colleagues conduct the largest meta-analysis of CBT versus control conditions (treatment as usual [TAU], no treatment, other active psychotherapies, and pharmacotherapy). Although early trials of CBT were of low quality (small sample sizes, high risk of bias), the quality of studies have improved over time. In this meta-analysis Cuijpers and colleagues found that CBT had a large to moderate effect compared to TAU or to no treatment (g=0.79; 95% CI: 0.70-0.89), suggesting that CBT is better than receiving no or limited treatment. These results were stable up to one year follow-up. One would have to treat 4.7 patients with CBT to see improvement in one patient relative to no or limited treatment. CBT was compared to other active treatments in 87 trials. CBT was no more effective than other psychotherapies such that the average difference was miniscule (g=0.06; 95% CI: 0-0.12). One would have to treat 63 patients with CBT for one patient to receive a better outcome relative to another psychotherapy. However, if differences did emerge between CBT and other psychotherapies, they were not reliable. The effects of CBT did not differ significantly from those of pharmacotherapies (anti-depressant medications) at the short term, but the effects of CBT were significantly larger than pharmacotherapies at 6–12-month follow-up (g=0.34; 95% CI: 0.09-0.58). However, these follow-up findings also were not reliable. Combined treatment of CBT plus anti-depressant medications was more effective than pharmacotherapies alone at the short (g=0.51; 95% CI: 0.19-0.84) and long term (g=0.32; 95% CI: 0.09-0.55), but combined treatment was not more effective than CBT alone at either time point.
The authors concluded that CBT is effective in the treatment of depression compared to no or limited treatment in the short and longer term. Although CBT gets the lion’s share of attention in the psychotherapy literature, there is no evidence that it is more effective than any other form of psychotherapy or antidepressant medication in the short term. There is evidence that combined CBT and medications may be more helpful than medications alone for depression.
Adding Short-Term Psychodynamic Psychotherapy to Antidepressants
Driessen, E., Fokkema, M., Dekker, J.J.M., Peen, J., Van, H.L…. Cuijpers, P. (2022). Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data. Psychological Medicine.
Short-term psychodynamic psychotherapy (STPP) and anti-depressant medications are both considered empirically supported treatments for depression. And there have been several trials demonstrating the efficacy of long-term psychoanalytic psychotherapy for treatment-resistant depression. Despite this research, it remains unclear which patient might benefit from anti-depressant medication alone and which patient might benefit from adding STPP to the antidepressants. The best use of scarce resources makes this an important question. There are challenges to doing a meta-analysis of patient characteristics that predict different outcomes in antidepressants alone versus antidepressants plus STPP. A key challenge is that common meta-analyses use study-level data (an overall summary of the effect size found in a study), and so statistical power often is limited by the small number of studies. The unique aspect of this study by Driessen and colleagues is that they conducted a meta-analysis of patient-level data. That is, they got individual patient data from the authors of the seven studies that specifically tested the effects of antidepressants alone vs antidepressants plus STPP. So instead of being limited by seven summary effect size statistics, the authors had a sample of 482 patient effect sizes to work with. The effect of adding STPP to antidepressants was larger for participants with high rather than low baseline depression scores [B = −0.49, 95% CI: −0.61 to −0.37, p < 0.0001], for participants with ⩽8 rather than more years of education (B = −0.66, 95% CI −1.05 to −0.27, p < 0.0009), and for participants with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) or less than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). At follow-up, higher baseline depression scores and longer depressive episode duration were still associated with better outcomes for those receiving a combination of antidepressants plus STPP.
The results of this patient-level meta-analysis suggests that adding short-term psychodynamic psychotherapy to antidepressant medication might be particularly efficacious for patients with higher initial levels of depression and/or with longer duration of depressive symptoms. It is possible that the addition of a psychological treatment like STPP may tackle some of the underlying psychological vulnerabilities whose treatment is necessary for those who have more persistent and severe depressive symptoms.
Is Psychotherapy Equally Effective Across Age Groups? Rethinking therapy for children and adolescents.
Cuijpers, P., Karyotaki, E., Eckshtain, D., Ng, M.Y., Corteselli, K.A…. Weisz, J.R. (2020). Psychotherapy for depression across different age groups: A systematic review and meta-analysis. JAMA Psychiatry, 77, 694-702. doi:10.1001/jamapsychiatry.2020.0164
There are now hundreds of controlled studies showing the efficacy of psychotherapy for depression. Most of these studies have focused on specific age groups, so that psychotherapies were tested for children, adolescents, adults, and older adults separately. Few studies have looked at whether psychotherapy has different effects across age groups. This information might be important because it may indicate that some therapies might have to be altered or specifically designed for the age group. In this meta-analysis, Cuijpers and colleagues collected all randomized controlled trials of psychotherapy vs no treatment, usual care, or some other control group for depression across age groups. They found 366 studies representing over 36,000 patients. The studies included those of children, adolescents, young adults, middle-aged adults, older adults, and older old adults. The overall effect size across all age groups was g = 0.75 (95% CI, 0.67-0.82) suggesting a moderate effect of psychotherapy for depressive symptoms at post-treatment. The effect size for children was the lowest (g = 0.35, 95% CI: 0.15-0.55, k = 15), and the effect size for adolescents (g = 0.55, 95% CI: 0.34-0.75, k = 28) was also low. Effects for middle-aged adults (g = 0.77, 95% CI: 0.67-0.87, k = 304), older adults (g = 0.66, 95% CI: 0.51-0.82, k = 69), and older old adults (g = 0.97, 95% CI: 0.42-1.52, k = 10) were not significantly different. Young adults consistently had significantly better outcomes (g = 0.98, 95% CI: 0.79-1.16) than the other age groups except when compared to older old adults.
It is possible that psychotherapies for depression as currently tested in the research literature are less effective for children and youth. This may be because the treatments that are most often used with children and adolescents are age adapted versions of therapy originally designed for adults. Psychotherapy for children and adolescents are affected by parental and family characteristics, and that these contexts may not be adequately accounted for by the therapies as currently tested and practiced. In any case, this meta-analysis suggests that current therapies for childhood and adolescent depression may need to be reconsidered given their relatively lower effects.
Sustained Response to Antidepressants and Psychotherapy
Furukawa, T.A., Shinohara, K., Sahker, E., Karyotaki, E., Miguel, C., ….Cuijpers, P. (2021). Initial treatment choices to achieve sustained response in major depression: A systematic review and network meta-analysis. World Psychiatry, 20, 387-396.
Two common treatments for major depression are antidepressant medications and psychotherapy, both of which have been tested in randomized controlled trials. Antidepressants are among the most prescribed medications, and an increasing number of patients are on longer-term use of these medications. However, it is unclear as to whether choosing antidepressant medication or psychotherapy at the beginning or the acute phase of depression will lead to a sustained response in the longer term. In this network meta-analysis, Furukawa and colleagues examine the important question: “which therapies can get me well and keep me well?” The authors selected randomized controlled studies in which antidepressants or psychotherapy, or their combination were prescribed and compared to each other or to a control condition (treatment as usual or placebo pill). In these studies, adult participants with major depression remained in the treatment or control condition up to 12 months post-treatment. Psychotherapies included many known treatments like CBT, behavioral activation, psychodynamic therapy, and interpersonal psychotherapy. This network meta-analysis included 81 trials representing over 13,000 patient participants. Combined psychotherapy plus antidepressant medication resulted in a more sustained response to treatment (better outcomes) in the long run than control comparisons (OR: 2.52, 95% CI: 1.66, 3.85). Psychotherapy alone was more effective in the long run than pharmacotherapy alone (OR: 1.53, 95% CI: 1:00 – 2.35). The advantage of combined treatment over antidepressants alone was about 14% to 16%, whereas the advantage of psychotherapy over antidepressants was about 12%. There were no differences in longer term effectiveness among the different types of psychotherapy.
This study shows that the effects of psychotherapy when initiated in the acute phase of major depression (at the outset of symptoms) are enduring over a longer time frame. Psychotherapies outperformed antidepressant medications, standard treatment, and pill placebo. The results also suggested that adding pharmacotherapy to psychotherapy did not interfere with the enduring effects of psychotherapy. The authors suggest that treatment guidelines for depression should be updated to emphasize psychotherapy as the preferred initial treatment option.
What Proportion of Patients Benefit from Short-Term Psychotherapy?
Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Hisashi, N., &Furukawa, T.A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 10.1111/acps.13335. Advance online publication.
Many meta-analyses report that psychological therapies are effective to treat depression, that there are no differences between types or orientations of therapy in their outcomes, and that psychotherapy is as effective as medications in the short term and perhaps more effective in the longer term. But what do these findings mean for everyday practice? Many meta-analyses report a standardized mean effect size between treatment and control conditions. However, the effect size is an abstraction that may be difficult to interpret unless you understand the statistic. Clinicians may ask a more practical question: what is the proportion of patients that improve (have meaningful reductions in depression scores) and recover (improved and no longer are depressed)? This meta-analysis by Cuijpers and colleagues of 228 studies representing over 23,000 adult patients looked at the proportion of patients who improved and recovered after psychotherapy relative to those in control conditions (no treatment, care as usual, pill placebo). The psychotherapies were short term manualized treatments like CBT, behavioral activation, interpersonal psychotherapy delivered in individual, group, and self-help formats. About 41% of patients improved with psychotherapy for depression compared to 17% that improved with usual care and 31% for pill placebo. However, after statistically controlling for publication bias (i.e., the likelihood that some unflattering studies were never published), the improvement rate for psychotherapy was 38%. Recovery rates for psychotherapy ranged from 26% to 34%, and recovery in the control conditions ranged from 9% to 17%. There were no differences between therapy orientations. Highest rates of recovery or improvement were achieved by individual therapy and the lowest rates were seen in guided self-help. Deterioration rates were just below 5% in psychotherapy and about 7% to 13% in control conditions.
The effects of time-limited manualized psychotherapies tested in randomized controlled trials were modest. About 40% of patients improved and about 30% recovered. On the positive side, psychotherapies resulted in only about 5% of patients getting worse. The authors argued that clinicians must consider more effective strategies beyond these approaches to improve outcomes for depression. Some have focused on improving psychotherapist effectiveness, rather than on specific interventions. Methods like progress monitoring, managing countertransference, and repairing therapeutic alliance ruptures are means of improving psychotherapists’ effectiveness.