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Leichsenring, F., Steinert, C., Rabung, S., & Ionidis, J.P. (2022). The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses. World Psychiatry, 21, 133-135.

Estimates of the efficacy of psychological or pharmacological treatments depend in part on to what they are compared. One might expect, for example, that these first line treatments for mental disorders may appear more effective if compared to no treatment and may appear less effective when compared to treatment as usual or a placebo. Reviews indicate that compared to no treatment, psychotherapies demonstrate a moderate effect (g = .67). However, some argue that comparisons to no treatment represent “weak” controls that over-estimate the efficacy of treatments. Compounding this problem is that poorly designed randomized controlled trials tend to result in larger estimates of effects in favor of the treatments. In this large umbrella review, Leichsenring and colleagues conducted a meta-analysis of meta-analyses of randomized controlled trials in which psychotherapy and medications are compared to no treatment, treatment as usual, placebo, and to each other. Different forms of psychotherapy (CBT, psychodynamic, interpersonal, EFT) were included. This meta-review had 3,782 randomized controlled trials representing 650,514 patients with a range of mental disorders (depression, anxiety, eating disorders, OCD, PTSD…). The authors’ analyses resulted in a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. Usually, this is interpreted as a small effect such that about 7 patients need to be treated before one achieves remission. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: –0.05 to 0.26) indicating no significant difference between the two types of treatments. The SMD for the combined psychotherapy and medication compared to either monotherapy (psychotherapy alone or medications alone) was 0.31 (95% CI: 0.19-0.44), suggesting that some patients achieve better outcomes if they got combined treatment, but again the effect is small. A troubling finding of this meta-review was that between 1% and 17% of studies were high quality, meaning that most studies likely resulted in biased (inflated) results for both treatments.

Practice Implications

Psychotherapy and medications, or their combination as practiced in randomized controlled trials appear to help a relatively modest proportion of patients. Most of these trials involved short term highly manualized interventions that do not address the diversity and complexity of patients seen by psychotherapists in real world practices. For example, studies in clinically representative contexts show that most patients require many more therapy sessions than provided in clinical trials. Psychotherapy researchers and clinicians need to refocus efforts on therapeutic factors (therapeutic alliance, progress monitoring) and therapist interpersonal stances (interpersonal skill, empathy, countertransference management) that likely impact patient mental health outcomes.

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.

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.

Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 5.

Psychological therapies are culturally bound practices with certain values built into them. For example, common therapies prize independence in patients and rapport in the therapeutic relationship. However, some cultures may value community rather than independence, and respect rather than rapport. In this part of the chapter, Barkham and Lambert ask: what is the effect of a conventional psychotherapy that is based on the values of a dominant culture when applied to a different ethnic or racial group? In one small meta-analysis of 9 and 16 studies, culturally adapted interventions were significantly more effective than unadapted interventions g = 0.52 (95% CI [0.15, 0.90]) and resulted in close to 5 times greater odds of remission. Adaptation usually refers to incorporating some cultural practices into the therapy, adapting the language of the therapist, or providing a therapist who is from the same culture as the patient. Similarly, there is research on the effects of a multicultural competency and multicultural orientation of the therapist. These competencies refer to therapists who learn about a patient’s culture, use culturally relevant treatment strategies, and are aware of their own assumptions and biases regarding the patient’s culture. A meta-analysis of 18 studies reviewed the impact of a therapist’s multicultural competence on various aspect of therapy. Therapist multicultural competence accounted for 37% of the working alliance, 52% of patient satisfaction, 38% of a patient’s perception of therapist competence, and 34% of depth of the session. However, therapist multicultural competence accounted for only 8% of patient outcomes. More recently, some authors have discussed the importance of multicultural orientation, which refers to a therapist’s cultural humility as an attitude towards the patient’s culture, a therapist’s willingness to explore the patient’s racial and cultural identities, and the therapist’s comfort with cultural diversity.

Practice Implications

The research on the impact of psychotherapy on diverse patient populations is still rather small, but some practice implications can be gleaned. Adapting therapies to the patient’s culture and identity likely will improve patient mental health outcomes. The adaptation might include incorporating cultural practices, metaphors, and values into the therapy, and providing therapy in the language of the patient, or finding a therapist from the same cultural background as the patient. Similarly, there is evidence that therapists who are multiculturally competent (learn about the patient’s culture and checks their own biases) can provide a deeper therapeutic experience for their patients. Emerging research on therapist multicultural orientation suggests that a therapist’s cultural humility, willingness to engage in cultural conversations, and comfort with diverse cultures may lead to better experiences of therapy for their patients.

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.

Cuijpers, P., Noma, H., Karyotaki, E.,  Vinkers, C.H., Cipriani, A., & Furukawa, T.A. (2020). A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19, 92-107.

Mental disorders represent a significant health burden worldwide, with over 350 million people affected. Depression is the second leading cause of disease burden. There is ample evidence that psychotherapies and pharmacotherapies are effective in the treatment of depression. There is also evidence for the efficacy of different types of psychotherapy (CBT, IPT, PDT), and for different types of antidepressant medications. Some research suggests that combining psychotherapy and medications is better than either intervention alone, but the evidence is inconclusive. Existing meta analyses only compare two existing treatments directly to each other at a time: psychotherapy vs medications, psychotherapy vs combined treatments, medications vs combined treatments. In this meta-analysis, Cuijpers and colleagues use a method called “network meta-analysis” to study the relative impact of medications, psychotherapy, or their combination. Network meta-analysis is controversial because it relies on indirect comparisons to estimate effects. For example, let’s say one study compared medications (A) to psychotherapy (B), and another study compared medication (A) to combination treatment (C), then a network meta-analysis would estimate the effects of psychotherapy vs combination treatment by using the transitive principle (if A = B, and B = C, then A = C). This logic relies on everything being equivalent across studies. However, in treatment trials one cannot assume that the different studies comparing A, B, and C are equivalent in terms of quality and bias (in fact, we know they are not). In any case, Cuijpers and colleagues found that combined treatment was superior to ei­ther psychotherapy alone or pharmacotherapy alone in terms of standardized effect sizes (0.30, 95% CI: 0.14-0.45 and 0.33, 95% CI: 0.20-0.47). No significant difference was found between psychotherapy alone and pharmacotherapy alone (0.04, 95% CI: –0.09 to 0.16). Interestingly, acceptability (defined as lower patient drop-out rate and better patient adherence to the treatment) was significantly better for combined treatment compared with pharmacotherapy (RR=1.23, 95% CI:

1.05-1.45), as well as for psychotherapy compared with pharmacotherapy (RR=1.17, 95% CI: 1.02-1.32). In other words, pharmacotherapy alone was less acceptable to patients than another treatment approach that included psychotherapy.

Practice Implications

This network meta-analysis by a renowned researcher and in a prestigious journal adds to the controversy around the relative efficacy of psychotherapy vs medications vs their combination. What is clear is that patients find medication alone to be less acceptable as a treatment option, and previous research shows that patients are 4 times more likely to prefer psychotherapy over medications. Unfortunately, most people with depression receive medications without psychotherapy.

Merz, J., Schwarzer, G., & Gerger, H. (2019). Comparative efficacy and acceptability of pharmacological, psychotherapeutic, and combination treatments in adults with posttraumatic stress disorder: A network meta-analysis. JAMA Psychiatry, 76, 904-91.

Posttraumatic stress disorder (PTSD) is a highly debilitating disorder characterized by re-experiencing trauma, avoidance of situations related to the trauma, negative mood and cognitions, and hyperarousal. The lifetime prevalence of PTSD in the population is about 8%, and PTSD is associated with a great deal of medical problems, and social and economic burden. Difference between a variety of psychological treatment approaches for PTSD are small and not statistically significant. Some treatment guidelines tend to recommend both psychotherapy and pharmacotherapy to treat PTSD, but other guidelines indicate only psychotherapy as the first-line treatment. Merz and colleagues conducted a meta-analysis to examine comparative outcomes and acceptability of psychotherapy and pharmacotherapy and their combination in adults with PTSD. The authors focused on randomized controlled trials because these designs tend to produce the most reliable evidence. The authors identified 12 published studies with a total of 922 participants. Six of the studies included data on long term outcomes. The meta-analytic procedures that the authors used in this study included network meta-analyses (which some have argued may produce unreliable results) and direct comparison meta-analysis (which is more reliable, but resulted in fewer studies being included here). I report in this blog only results that were consistent between the network and direct comparison analyses. Pharmacological and psychotherapeutic treatments and their combinations were not significantly different in their effectiveness immediately post-treatment. However, at long-term follow-up psychotherapy was significantly more beneficial than pharmacotherapy (SMD, −0.63; 95% CI, −1.18 to −0.09). Combined psychotherapy plus pharmacotherapy was not significantly more effective that pharmacotherapy alone (SMD, −1.02; 95% CI, −2.77 to 0.72), and combined treatment was not more effective that psychotherapy alone (SMD, 0.06; 95% CI, −0.31 to 0.42). There were also no statistically significant differences between psychotherapy, pharmacotherapy, or their combination in the acceptability of treatments to participants as defined by differing rates of dropping out from the studies.

Practice Implications

This meta-analysis of a small number of studies suggests that psychotherapy produces better long-term outcomes than pharmacotherapy for PTSD. There is also a suggestion that combining psychotherapy and pharmacotherapy does not improve outcomes compared to either treatment alone. This research area seems to be new and not well developed, but so far, the results seem to favor psychotherapy for longer term outcomes. These findings are similar to those from a larger meta-analysis for depression. In that study, the authors suggested that the long-term benefit of psychotherapy was due to participants learning coping and interpersonal skills that were not gained from receiving pharmacological intervention alone.