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.
This month...
…I blog about psychotherapy for adult depression, efficacy of CBT for perfectionism, and a measure of ruptures in the therapeutic alliance.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- 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
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
January 2024
Was Hans Eysenck Right About Psychotherapy’s Ineffectiveness?
Cuijpers, P., Karyotaki, E., Reijnders, M., & Ebert, D. (2019). Was Eysenck right after all? A reassessment of the effects of psychotherapy for adult depression. Epidemiology and Psychiatric Sciences, 28(1), 21-30. https://doi.org/10.1017/S2045796018000057
In the 1950s Hans Eysenck, a notorious figure in the history of psychology, suggested that psychotherapy was not effective. This set off a crisis of confidence in the psychotherapy world, but it also energized decades of research to assess whether Eysenck was right. Over the years that followed, many studies were published to assess the efficacy of psychotherapy, and methodologies like meta-analyses were developed specifically for this research area. Meta-analyses are a way of aggregating the effects of many studies in a research area so that one can estimate an average effect based on these studies. The first meta-analyses published in the 1970s showed that psychotherapy was indeed effective, but even back then there were doubts about the quality of the research. The “garbage in, garbage out” principle recognized that if the quality of studies were low, then the meta-analyses would produce biased results. Quality refers to studies that have sufficiently large samples, independent randomization of patients, blinded assessments of outcomes, equivalent training and supervision of all therapists, and all participant data included in the analyses. There is lots of evidence to show that low-quality studies overestimate the effects of treatments. Finally, there is the problem of publication bias, which occurs when researchers do not publish studies if the results are not supportive of the effectiveness of a treatment (i.e., if unpublished, these studies are not available to be included in a meta-analysis). In this meta-analysis, Cuijpers and colleagues focused on psychotherapies for depression because this is a large research area, depression is prevalent in the population, and there are sufficient studies that compare different forms of therapy. The unadjusted effect size of psychotherapy for depression was moderately large (g = .63 to .70), which suggests that about 4.18 patients need to be treated before one patient improves. But only 23% of 369 studies were considered to have a low risk of bias. When the authors accounted for risk of bias (e.g., they removed studies with high risk of bias and statistically adjusted for publication bias), the adjusted effect size of psychotherapy dropped to g = .31. This is a small effect, but still above the commonly accepted threshold of g = .24 indicating that a treatment is clinically relevant.
Practice Implications
Eysenck was probably wrong – psychotherapy as tested in clinical trials is effective and clinically relevant, but perhaps not as effective as once thought. Earlier estimates of psychotherapy’s effectiveness appear to have been inflated partly by biased studies conducted by enthusiastic adopters of newer therapies. The problem of bias also exists for other treatments as well, such as anti-depressant medications, so psychotherapy is not alone. Psychotherapists must strike a balance between being confident in what they are providing to patients and honestly assessing the efficacy of what they offer as treatment.
December 2023
Five decades of research on psychological treatments of depression: A historical and meta-analytic overview.
Cuijpers, P., Harrer, M., Miguel, C., Ciharova, M., & Karyotaki, E. (2023, November 16). Five decades of research on psychological treatments of depression: A historical and meta-analytic overview. American Psychologist. Advance online publication. https://dx.doi.org/10.1037/amp0001250
There is not much new to say about the effects of psychotherapy on depression. Numerous meta-analyses of a large body of evidence have been published over the past few years. Meta-analysis is a way of combining the effects of many studies to produce an overall average effect, and the procedure also allows one to examine the reliability of the findings and predictors of the effect sizes. Meta-analyses are not perfect, but compared to interpreting a single study meat-analyses provide us with a more reliable sense of what is happening in a research area. Research has demonstrated that several types of psychotherapy are equally effective in treating depression including CBT, IPT, third-wave therapies, psychodynamic therapy, and nondirective counselling. Psychotherapy has comparable effects to antidepressant medications in the short term, but psychotherapy has better effects in the longer term. The effects of psychotherapy for depression are comparable across different groups (women with perinatal depression, older adults, and those with medical conditions), but psychotherapies have smaller effects in children and adolescents and those with comorbid substance use disorders. In this overview, Cuijpers and colleagues looked at trends in this research over the past five decades. They meta-analyzed 562 studies of psychological treatments for depression. They found that almost half of the trials were of CBT, and 8 other therapies made up the other half of the trials. The number of studies per year is increasing with an average of 8.6 studies published per year. Only 34% of studies met the criteria for low risk of bias – that is, 66% of studies had some problems with random allocation, blinding of assessors, data analysis, sample size, etc. We know that a high risk of bias inflates effect sizes, and so it is likely that the effects of many studied treatments are inflated. Unfortunately, the relative number of studies testing therapies other than CBT seems to be declining over the years. Trials in Europe are increasing relative to studies in North America.
Practice Implications
This meta-analysis is consistent with the many that preceded it. Psychological treatment for depression is modestly effective, there are no differences between treatment types, although, in the long run, psychotherapy is more effective than antidepressant medications. What is concerning is that research on new treatments may be declining which may further limit the information and options that therapists and patients have about evidence-based treatments for depression.
November 2023
Psychological Therapies Improve Patient Quality of Life
Kolovos, S., Kleiboer, A., & Cuijpers, P. (2016). Effects of psychotherapy for depression on quality of life: Meta-analysis. British Journal of Psychiatry, 209, 460-468. https://doi.org/10.1192/bjp.bp.115.175059.
It is well-documented that depression is the most common mental disorder among adults and is associated with substantial impairments in quality of life. Quality of life refers to a range of life domains including social relationships, physical abilities, mental health functioning, role functioning, and engagement in daily activities. Several meta-analyses exist demonstrating that a range of different psychotherapies are effective in reducing depressive symptoms. Until this study by Kolovos, there wasn’t a meta-analysis looking at the effects of psychotherapies for depression on patients’ quality of life. In this study, the authors meta-analyzed 44 studies that included over 5000 adult patients with depressive symptoms. The psychotherapies varied from CBT to acceptance and commitment therapy, to interpersonal psychotherapy that were compared to a control group in a randomized controlled trial. Quality of life was measured pre- and post-treatment. Typically, quality of life was assessed in two domains – mental health quality of life was defined as personal satisfaction with the current psychological state, and physical health quality of life referred to perceived competence to perform and function in everyday activities. Global quality of life refers to an overall assessment of the mental health and physical health domains. The mean effect size of psychotherapy for global quality of life after adjusting for publication bias was g = 0.30 (95% CI 0.21–0.40) indicating a small but significant effect. For the mental health domain, after adjustment for publication bias, the mean effect size was g = 0.37 (95% CI 0.28–0.47) indicating a small to moderate effect of psychotherapy. For the physical health domain, after adjusting for publication bias the mean effect size was g = 0.13 (95% CI 0.01–0.25) indicating a small significant effect. For both the global measure of quality of life and the mental health domain, the effects of psychotherapy were larger when patients had more severe symptoms.
Practice Implications
Overall, the authors concluded that psychotherapy for depression has a positive impact on various domains of patients’ quality of life like their mental functioning, social and work relationships, and engagement in everyday activities. These findings are especially large for those patients with more severe symptoms who received psychotherapy. It is possible that as depressive symptoms lift, patients begin to have the energy, self-esteem, and concentration necessary to engage in everyday life activities.
September 2023
Psychological Treatment of Depression
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C.Y., ….Karyotaki, E. (2023). Psychological treatment of depression: A systematic overview of a ‘Meta-Analytic Research Domain’. Journal of Affective Disorders, 335, 141-151. https://doi.org/10.1016/j.jad.2023.05.011
About 280 million people worldwide suffer from depression, and this has enormous economic consequences for society. The main treatments for depression include pharmacotherapy and psychotherapy, with over 850 randomized controlled trials (RCTs)of psychotherapy assessing outcomes across all age groups. There are over 100 meta-analyses looking at the effects of psychotherapy for depression, but no single review of the entire literature exists. In this “Meta-analytic Research Domain”, Cuijpers and colleagues describe their attempts to develop a “living” systematic review that they updated regularly. In this update, the authors provide an overview of what has been learned from RCTs of psychotherapy in the treatment of depression. To start, they used the American Psychological Association's definition of psychotherapy as “the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviours, cognitions, emotions, and/or personal characteristics…”. The effects of psychotherapy for depression appear to be moderate. The overall response rate (50% reduction in symptoms) was 41% for psychotherapy and 16% for no treatment. Remission from depression (no clinically elevated depressive symptoms) at post-treatment was about 33%, whereas about 10% of patients in control conditions (no treatment or treatment as usual) remitted after therapy. These effects of time-limited psychotherapy are maintained in the longer term. Although CBT is the most studied therapy, there are no differences between different types of psychotherapy in the treatment of depression. Psychotherapy is effective across the lifespan, but the effects for children and adolescents tend to be smaller. Combined treatment of psychotherapy and pharmacotherapy was more effective than psychotherapy alone (RR = 1.27; 95% CI: 1.14-1.29) or pharmacotherapy alone (RR = 1.25; 95% CI: 1.13-1.37). Most patients in these studies had moderate to severe depression. The average response rate (50% reduction in symptoms) was 29% for psychotherapy or pharmacotherapy alone, but combining treatments resulted in 12% to 16% higher response rate. Psychotherapy was more effective than pharmacotherapy at 6 months to 12 months follow-up. One key downside of the research is that Cuijpers and colleagues classified only 31% of studies as having a low risk of bias (i.e., high-quality studies with sufficient sample sizes and other state-of-the-art procedures), and the risk of publication bias (suppression of negative findings) was high. Low-quality studies and publication bias tend to inflate the effects of treatments.
Practice Implications
There is a large and varied research literature on the effects of psychotherapy on depression. The authors noted no differences among the time-limited therapies, so bona fide and tested treatments will be equally effective. Overall, time-limited psychotherapy is modestly to moderately better than no treatment, with about one-third of treated patients no longer being depressed after time-limited psychotherapy. Results in more severely depressed patients are better with combined treatment of pharmacotherapy plus psychotherapy.
April 2023
More Treatment But No Less Depression
Ormel, J., Hollon, S.D., Kessler, R.C., Cuijpers, P., & Monroe, S.M. (2022). More treatment but no less depression: The treatment-prevalence paradox. Clinical Psychology Review, 91, 102111.
It is widely believed that treatments for major depression (psychotherapy and antidepressant medications) have improved patients’ symptoms since the 1980s. Mental health expenditures and access to treatment for major depressive disorder (depression) have also increased during that time, especially for antidepressant medications. However, we have not witnessed a reduction in the population prevalence (proportion of people who experienced a condition during their lifetime) or incidence (proportion of people who currently have the condition) of depression. How can it be that we perceive treatments to be more effective and available but rates of depression in the population have not budged? In this comprehensive conceptual analysis with a review of the evidence, Ormel and colleagues examined possible reasons for what they describe as the treatment-prevalence paradox. First, one could argue that prevalence and incidence rates are inflated due to a recent greater recognition and acceptance of depression in society. If that’s the case, then any reduction in prevalence or incidence caused by new treatments may be offset by more people coming forward and admitting to having depression. However, epidemiological studies are conducted by trained interviewers using standardized diagnostic criteria, which should reduce any inflation caused by spurious reporting. In fact, large epidemiological studies do not show an increase in incidence of depression over time, so that incidence in the U.S. remains approximately 1.5% and worldwide prevalence remains about 4.7%. Second, it is possible that randomized controlled trials might over-estimate the efficacy of psychotherapy or medication for depression. Thus, even if these treatments are more available, they may not impact population prevalence or incidence rates because they are not as effective as we once thought. The authors found that meta-analyses that adjusted for publication bias (the tendency of researchers or industry not to publish negative findings or to put a positive spin on such findings) reported treatment efficacy to be modest. That is, only about 30% of patients recover from depression following psychotherapy or medications. Third, it is also possible that the actual efficacy of psychotherapy or medications to prevent relapse or recurrence in the longer term is too small to reduce population prevalence or incidence of depression. That seems to be the case. Even if 30% of patients respond initially to treatments like CBT or medications, about half of these initial responders relapse at 1- or two-years post treatment. And many of those who do not relapse still struggle with residual symptoms.
Practice Implications
The authors concluded that even though access to psychotherapy or medications have increased and the treatments supposedly have become better over the decades, therapies have not moved the needle on population prevalence or incidence of depression. Clinicians might consider talking to patients honestly about the efficacy of the treatments they are offering without unnecessarily demoralizing patients. That is, treatments considered to be the “gold standard” by researchers and practice guidelines are only modestly effective. When a patient does not benefit from “gold standard” treatments, it should be considered a failure of the treatment and not a function of “patient non-responsiveness”. It is also quite likely that brief
Short-term Psychodynamic Psychotherapy for Depression
Wienicke, F.J., Beutel, M.E., Zwerenz, R. et al. (2023). Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data, Clinical Psychology Review.
Depression affects 264 million adults worldwide making it one of the most prevalent mental health conditions. Depression affects quality of life, health care costs, and mortality making it a leading cause of disability in the world. Previous meta-analyses have looked at psychological treatments for depression and found CBT, short term psychodynamic psychotherapy (STPP), interpersonal psychotherapy (IPT), and others are effective in reducing depressive symptoms among adult patients. STPP, for example, works by focusing on the underlying personality factors of the patient (defense mechanisms, emotion regulation, interpersonal style, self-concept, attachment) that may lead to depressive experiences. There are very few studies that look specifically at what patient characteristics are associated with better outcomes for a specific type of psychotherapy. The challenge with such patient level analyses is that most researchers report aggregated individual patient data at the study level thus possibly obscuring important variability among patients. In this meta-analysis, Wienicke and colleagues identified 13 studies of STPP compared to a control group. The authors were able to get 11 of the study authors to provide individual patient data of 771 participants. This allowed Wienicke and colleagues to do a meta-analysis of individual patient data. At post-treatment, STPP was significantly more efficacious than control conditions on measures of depression (d = -0.62, 95%CI [-0.76, - 0.47], p <.001), anxiety (d = -0.29, 95%CI [-0.45, -0.12], p <.001), general psychopathology (d = -0.38, 95%CI [-0.59, -0.17], p <.001), and quality of life (d = 0.44, 95%CI [0.23, 0.64], p <.001). At follow-up, STPP was again superior to control conditions on depression outcomes (d = -0.21, 95%CI [-0.38, -0.05], p = .011), but not more efficacious on other outcomes. When the authors looked at individual patient characteristics related to outcomes, they found that length of the current depressive episode was found to moderate post-treatment depression levels, such that STPP was more efficacious for participants reporting longer rather than shorter episode durations (d = -0.006, 95%CI [-0.01, -0.001], p = .002).
Practice Implications
Like what was reported in previous meta-analyses, STPP was efficacious to reduce depressive symptoms in the shorter and longer term. Patients with a longer duration or chronicity of depressive symptoms experienced the most benefit from STPP. It is likely that individuals with longer episode durations have depressive symptoms that are more influenced by their underlying personality vulnerabilities resulting in more complex working alliances and transference feelings with therapists. Training in psychodynamic principles of treatment may allow therapists to identify and work with these therapeutic relational aspects if necessary.