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 how the therapeutic alliance works, psychotherapy with Indigenous Peoples, and th efficacy of psychotherapy and psychopharmacology
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
August 2022
Is Psychotherapy Equally Effective Across Age Groups? Rethinking therapy for children and adolescents.
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.
Practice Implications
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.
July 2022
Cognitive-Behavioral Therapy for Depression
Newman, M.G., Agras, W.S., Haaga, D.A.F., & Jarrett, R.B. (2021). Cognitive, behavioral, and cognitive-behavioral therapy. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 14.
Cognitive-behavioral therapy (CBT) is the most researched psychotherapy for many disorders including depressive disorders. Depression is a global health problem that affects physical and emotional health and is associated with many adverse effects (substance dependence, poverty, illness). And so, finding good treatment options for patients with depression is an important goal. Many treatment guidelines view CBT as one of the first-line treatments for depression based on the research that demonstrates its efficacy. In this chapter of the Handbook, Newman and colleagues review the research on the efficacy of CBT. Immediately post-treatment, the effect sizes for CBT were medium to large when compared to treatment as usual (g = .59, 95% CI [0.42, 0.76]), placebo control groups (g = 0.51, 95% CI [0.32, 0.69]) and wait list/no treatment control groups (g = 0.83, 95% CI [0.72, 0.94]). The effects of CBT for depression tend not to differ from other bona-fide psychotherapies including interpersonal psychotherapy (IPT) (g = –0.09, 95% CI [–0.39, 0.20]), psychodynamic therapies (g = 0.25, 95% CI [–0.07, 0.58]), and supportive psychotherapy (g = 0.15, 95% CI [–0.06, 0.25]). The effects of CBT are also similar to those achieved with anti-depressant medications (g = 0.03, 95% CI [-0.13, 0.18]). Approximately 41% of patients with major depression who receive CBT have significantly fewer depressive symptoms immediately post-treatment than the average patient treated in a placebo or waiting list/no treatment control group. There have been some criticisms of the effect size estimates for CBT in some of these studies. For example, research indicates that newer and higher quality studies have resulted in smaller effects. And so there remains concerns that the overall effects of CBT for depression may be over-estimated.
Practice Implications
Treatment guidelines indicate that CBT is one of the first-line treatment for depressive disorders along with anti-depressant medications and other psychological therapies. CBT appears to improve both short-term and longer-term outcomes for some adults. There is also some evidence that if CBT is combined with pharmacotherapy, then patients might experience even greater improvement. CBT may result in patients learning something about themselves and their depression, which might reduce relapse and recurrence of the depression, although evidence for the latter is still uncertain.
October 2021
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.
Practice Implications
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.
August 2021
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.
Practice Implications
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.
June 2021
Psychotherapy for Sub-Clinical Depression in Children and Adolescents
Cuijpers, P., Pineda, B.S., Ng, M.Y, Weisz, J.R., Muñoz, R.F., Gentili, C., Quero, S., Karyotaki, E. (2021). A meta-analytic review: Psychological treatment of subthreshold depression in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, Online first publication.
Depression occurs in 2.6% of children and adolescents, with as many as 14% of adolescents meeting criteria for a depressive disorder before the age of 18. Depression in youths is related to a number of impairments, negative health outcomes, and to increased risk of depression as an adult. Subthreshold depression represents clinically important depressive symptoms that does not meet diagnostic criteria for major depression or dysthymia. Like major depression, subthreshold depression is related to impairment and increased mortality. Subthreshold depression in adolescents is related to increased risk for developing other disorders including future depressive disorders in adulthood. In this meta analysis, Cuijpers and colleagues present a review of direct comparison randomized controlled trials of psychological interventions for children and adolescents with subthreshold depression. The meta-analysis included 12 trials representing over 1500 children and adolescents. Eight studies tested CBT, and the others tested IPT or supportive therapy. The pooled effect size of the difference between the psychological interventions and control conditions at post treatment was g = 0.38 (95% CI: 0.14 to 0.63), indicating a small to moderate effect of psychological therapies to reduce subthreshold depression in children and adolescents. The authors found some evidence of publication bias (i.e., the likelihood that some studies were conducted but never published) and after adjusting for this bias, the effect size dropped to g = .24 (95% CI: -0.06 to 0.54) which was not statistically significant. There were only two studies of the treatment of children which showed small non-significant effects, g = 0.01 (95% CI: -1.16 to 1.18), however the effects of treatment for adolescents were considerably better, g = .44 (95% CI: 0.16 to 0.71). Longer term follow-up data (6 to 18 months) did not show sustained effects of treatment. Children and adolescents had a 48% lower chance of developing a depressive disorder if they received treatment, although this was not statistically significant.
Practice Implications
The small number of studies limits what one can say about the effects of psychological treatment for subthreshold depression in children and adolescents. The effects were small to moderate at post treatment, but the effects were statistically significant only for adolescents and not for children. Longer term effects of treatments were non-significant, and there was no significant effect on the incidence of depressive disorders at follow up. Despite the disappointing findings, the authors concluded that interventions for subthreshold depression may have positive immediate effects at post treatment for adolescents.
Psychotherapies for Depression
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.