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Guidi, J. & Fava, G.A. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder: A systematic review and meta-analysis. JAMA Psychiatry, 78, 261-269.

A sequential model of treatment suggests that one apply two treatments consecutively in order to reduce relapse of symptoms. This might include pharmacotherapy followed by psychotherapy, or vice versa. One reason to consider a second consecutive treatment for depression is that many individuals continue to have symptoms after a first treatment, and having residual symptoms is related to higher relapse rates. Another reason is that many with depressive disorders have comorbid symptoms of anxiety or other disorders, and so one course of treatment may not be enough for such complex situations. In this study, Guidi and Fava conducted a meta-analysis to examine if sequential combination of medications and psychotherapy reduced the risk of relapse for major depression. They reviewed 17 randomized controlled trials representing 2283 adult patients that examined the sequential use of psychotherapy following medications. The primary outcome was remission of depressive symptoms. The methodological quality of the studies was high. After adjusting for publication bias, the sequential approach was significant (RR = 0.885; 95% CI, 0.793-0.988), indicating that sequencing treatment resulted in a lower risk of relapse or recurrence. Continuing versus discontinuing medications during psychotherapy did not result in any advantage for patients. However, providing psychotherapy while continuing with antidepressant medications reduced rates of relapse and recurrence, RR = 0.821 (95% CI, 0.710-0.949).

Practice Implications

The chronic and recurrent nature of major depression is an important clinical challenge. The results of Guidi and Fava’s meta-analysis suggests that adding psychotherapy following pharmacotherapy, either alone or in combination with pharmacotherapy, will reduce the risk of relapse from major depression. Discontinuing medications is reasonable after adding psychotherapy in order to help patients with major depression to stay symptom free. The results support the notion that psychotherapy results in patients acquiring skills to regulate their emotions, and that this might result in reduced relapse of depressive symptoms. Such skill acquisition does not take place with pharmacotherapy alone.

Chevance, A., Ravaud, P., Tomlinson, A., Le Berre, C., Teufer, B., … Tran, V.T. (2020). Identifying outcomes for depression that matter to patients, informal caregivers, and health-care professionals: Qualitative content analysis of a large international online survey. The Lancet Psychiatry, 7, 692-702.

One of the criticisms of mental health treatment research is that the outcomes measured in these studies are those that matter to researchers but may not matter as much to patients. Common outcome measures of depression like the Beck Depression Inventory (BDI), the Patient Health Questionnaire (PHQ-9) or the Hamilton Depression Rating Scale (HDRS) were developed by researchers because of their relative ease of use, and their sensitivity to change following treatment. But these measures provide a narrow view of what it is like to experience depression because they focus only on a limited set of symptoms. But is symptom reduction the only thing that matters to patients and their loved ones? In this large-scale study by Chevance and colleagues, the authors surveyed over 1900 patients with a mood disorder, 464 informal caregivers (family members), and 627 health care providers from a wide range of mental health disciplines. The survey extended across dozens of countries and sampled a range of age groups. The authors asked patients open ended questions about what outcomes are important to them in the treatment of their depression, and then the responses were analyzed using a qualitative method. Chevance and colleagues identified two broad categories important to patients: symptoms and functioning. Regarding symptoms, patients identified several domains in which they wanted to experience improvements. These included: their perception of their self (e.g., self-esteem, self-confidence), physical symptoms (e.g., sleep, energy level), cognitive symptoms (e.g., social interest, cognitive distortions, motivation), emotional symptoms (e.g., mental pain, anxiety, sadness), and symptoms related to burden of suicidal thoughts. Regarding functioning, patients identified four domains in which they wished to see improvements. These included: elementary functioning (e.g., self-care, coping with daily tasks, autonomy), social functioning (e.g., social isolation, interpersonal relationships, family life), professional functioning (e.g., loss of job/studies, professional responsibilities), and complex functioning (e.g., coping with daily life, financial issues, personal growth).

Practice Implications

Clearly, patients, their loved ones, and those who provide treatment have a much broader view than researchers of what constitutes important outcomes to their mental health treatment for depression. The two most common symptom outcomes identified by patients were psychic pain and the burden imposed by suicidal ideation, yet these rarely assessed as primary outcomes in psychotherapy studies. And outcomes like social functioning, family relationships, and personal growth are not primary outcomes, and often they are not assessed at all in research studies. Clinicians would do well to take a broader view of what is important to patients, and to keep in mind their patients wishes as they develop collaborative goals for treatment with patients. It may be useful not only to use standardized scales to aid in developing treatment plans, but also to ask patients what they hope to gain from therapy should the treatment be successful.

Dreissen, E., Dekker, J.J.M., Peen, J., Van, H.L., Maiana, G…. Cuijpers, P. (2020). The efficacy of adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression: A systematic review and meta-analysis of individual participant data. Clinical Psychology Review, 80.

Depression is the single largest contributor to disability worldwide. There are a number of established treatments for depression including antidepressant medications and psychotherapies. One of the psychological treatments that is evidence-based is short-term psychodynamic psychotherapy (STPP). There is evidence in the general psychotherapy research literature that combining psychotherapy with antidepressant medications is more efficacious than providing medications alone. However, no meta-analysis has looked specifically at adding STPP to antidepressant medication. In this meta-analysis Driessen and colleagues analysed data from 7 studies that compare STPP plus medications versus antidepressant medications alone, or that compare STPP plus medications versus supportive therapy plus medications. Although the number of studies was small, the unique aspect of this meta-analysis is that Driessen and colleagues were able to get all of the individual level data from each study, so they were able to analyse data from 482 participants. Typical meta analyses only look at study level data (effects reported from the study as a whole) and not individual level data (effects for each individual who participant in each study). So, the results from Driessen and colleagues’ study provides a more precise and specific analysis of the findings. Combined treatment of STPP and antidepressant medications was significantly more efficacious than antidepressants with and without supportive therapy at post-treatment, but the effects were small (d = 0.26, SE = 0.01, p = .01). At follow up, combined treatment of STPP and antidepressant medications was again more efficacious than antidepressant medications and supportive therapy, but the effects were moderately large (d = 0.50, SE = 0.10). Other findings also suggested that STPP’s specific interventions provided significant added benefit over and above the non-specific effects of supportive therapy. The findings were consistent whether or not analyses were done on studies with complete versus incomplete data, controlling for baseline depression scores, and use or not of a treatment manual. Overall, the quality of the studies was good, and the findings were stable across studies.

Practice Implications

People with depression and their clinicians might expect better outcomes in terms of depressive symptoms if they combine STPP and antidepressant medications, rather than receiving medications alone. The benefits might be related to the specific interventions of STPP, which suggests that therapists may need specific training and supervision in order to make the most of STPP’s effectiveness.

McPherson, S., Wicks, C. & Tercelli, I. (2020). Patient experiences of psychological therapy for depression: A qualitative metasynthesis. BMC Psychiatry, 20, 313. https://doi.org/10.1186/s12888-020-02682-1

Many times, researchers choose what to study in psychotherapy trials without really consulting patients who are receiving the care. For example, researchers are often primarily interested in how well psychotherapies reduce symptoms in patients with a particular disorder, or researchers might be interested in certain constructs that might affect patient outcomes (e.g., therapeutic alliance, therapist empathy). But are these the things that patients are really interested in when they seek psychological therapy? Although many treatment guidelines emphasize patient choice and experience, none of them take research of patient experiences into account to develop the guidelines. When presented with findings from randomized controlled trials of psychotherapy, patients reported that the research was of limited value in helping them make an informed choice about therapy. In this metasynthesis of qualitative studies, McPherson and colleagues aimed to bring together qualitative evidence concerning adult patients’ experiences of psychotherapy for depression. Qualitative research typically involves interviewing patients and systematically categorizing their responses into meaningful themes. The authors found 38 qualitative studies involving patient interviews of their experiences in receiving psychotherapy for depression. Several key themes emerged from the analysis. First, many people who receive remote therapy primarily from a computer program felt dissatisfied because of the lack of or limited contact with a real person therapist. Most patients did not feel connected to the computerized therapy and so their motivation waned quickly. Second, patients found psychological models and techniques to be less relevant than their need for help with their immediate family or social problems that likely triggered their depressive symptoms. This points to the primary importance of quality of life and of the social and cultural context for patients, despite that many psychological therapies tend to focus on symptoms almost exclusively. Third, this metasynthesis pointed to reports of negative effects of therapy, in which some therapeutic techniques like body scans induced flashbacks in some patients. Other patients had mixed or sometimes negative feelings about requirements for homework, which sometimes felt overwhelming, culturally out of step, or irrelevant.

Practice Implications

This metasynthesis of patient experiences in psychotherapy point to the importance of asking patients about their goals, expectations, and preferences in therapy. The findings highlight the importance of some common factors across therapies (e.g., therapist warmth and humanness, collaborative agreement on tasks and goals, and patient factors like culture and individual differences). Patients prefer human connection with therapists, and they tend to place less value on techniques of therapy. Patients also tend to value outcomes related to quality of life, social connection, and they want therapy consistent with their cultural values. Patients should be fully involved in a collaborative discussion about which therapy you offer them, how you provide the therapy, and what they want to achieve in therapy.

Janis, R.A., Burlingame, G.M., Svien, H., Jensen, J. & Lundgreen, R. (2020): Group therapy for mood disorders: A meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2020.1817603

Mood disorders are common mental health problems, with a 12-month prevalence of 7% in the population for major depressive disorder (MDD). Researchers have tested group therapy as a treatment for MDD and bipolar disorder. Recently, the American Psychological Association added group therapy as a specialty, attesting to the empirical evidence of group therapy’s efficacy and also the need for specialized education and training. Despite this, some treatment guidelines do not list group therapy as a first line therapy for major depression. Over the past 10 years, an international group of researchers have conducted a number of meta-analyses on the efficacy of group therapy for many disorders. In this particular meta-analysis, Janis and colleagues assessed the efficacy of group therapy to treat mood disorders by looking at randomized controlled trials of group therapy compared to waitlist controls, treatment as usual, and anti-depressant medications. They identified 42 randomized controlled trials of group therapy for mood disorders that included almost 3,000 patients. Treatment orientations included CBT, DBT, psychodynamic, and interpersonal therapies. For primary outcome measures of depressive symptoms at post treatment, the effect of group therapy versus waitlist controls was large and significant (g = .86, 95% CI [.66, 1.06], p < .001, k = 9), and those receiving group treatment were 6.81 times more likely to recover compared to those waiting for treatment (95% CI [3.70, 12.55]). Group therapy also resulted in better outcomes than treatment as usual on primary outcome measures of depression at post treatment with a medium sized effect (g = 0.46, 95% CI [0.22, 0.87], p < .001, k = 11), and those receiving group therapy were 2.75 times more likely to recover than those receiving treatment as usual (95% CI [1.59, 4.72]). Finally, there was no significant difference between group therapy and medications on rate of change in depressive symptoms or on rates of recovery.

Practice Implications

Overall, group therapy was more effective than no treatment and treatment as usual for major depression symptoms. Group therapy was as effective as anti-depressant medications. Group therapy is likely more cost effective because it is a multi-person treatment. Many patients do not respond to medications or they struggle with medication adherence because of unpleasant side effects. And most patients prefer psychotherapy to medications if given the choice. And so, group therapy provides a cost-effective alternative and should be considered as a first line treatment for depression. As indicated by the American Psychological Association’s recognition of group therapy as a specialty, providing group therapy requires specialized education and training in order to offer effective care. Continuing education opportunities exist with the Society of Group Psychology and Group Psychotherapy and with the American Group Psychotherapy Association.

Once-Weekly or Twice-Weekly Sessions of Psychotherapy?

Bruijniks, S., Lemmens, L., Hollon, S.D., Peeters, F.P., ….Huibers, M.J. (2020). The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients. The British Journal of Psychiatry, doi: 10.1192/bjp.2019.265. [Epub ahead of print].

Some research has suggested that the number of sessions per week, not the total number of sessions received, is correlated with patient outcomes. It is possible that higher session frequency per week might lead clients to better recall the content of sessions, which in turn may lead to better treatment outcomes. Or perhaps, higher frequency of sessions might lead to a better therapeutic alliance and higher client motivation thus leading to better outcomes. Although previous research has suggested that more sessions per week is better, no study has ever directly assessed this issue until now. Bruijniks and colleagues conducted a large randomized controlled trial of 200 adults with depression seen across nine specialized clinics in the Netherlands. Researchers randomly assigned clients to receive either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for a maximum of 20 sessions. Half of the clients in either type of therapy received the 20 sessions on a twice a week basis, and half of clients in each type of therapy received the 20 sessions on a once a week basis. The therapies were manualized, therapists were trained and supervised, and clients were carefully selected to meet criteria for depression. More patients dropped out of weekly (31%) compared to twice weekly (17%) therapy. There were no differences between CBT and IPT in depression outcomes. However, there was a significant effect of session frequency on patient outcomes in favor of twice weekly sessions (d = 0.55). Using a strict criteria of “recovery” from depression at 6 months post treatment, 19.6% of patients receiving once weekly therapy “recovered” compared to 29.5% of patients receiving twice weekly therapy.

Practice Implications

This large multi-site study has intriguing implications for practice. More frequent sessions per week may result in significantly better patient outcomes regardless of the type of therapy offered. Not surprisingly, IPT and CBT were equally effective. However, their effectiveness was limited in that only between 20% to 30% of patients recovered from depression. This finding is similar to the results previous trials, and speaks to the limitations of time-limited manual-based therapies for depression. Nevertheless, it appears that more frequent therapy per week may be a better option for some clients.