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Totura, C.M.W., Fields, S.A., & Kraver, M.S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41-47.

There is evidence to suggest that pharmacological treatments are effective for a wide range of disorders. However, a high level of adherence to taking psychotropic medications is necessary in order for them to have a chance of working. Medical interventions in general do not work well when patients are non-adherent to the regimen, and non-adherence is a significant problem in medicine. Treatment adherence is particularly problematic in those with a mental health condition. Low adherence may have to do with problems with the medications themselves, like unpleasant side effects. And low adherence also may be due to issues related to mental health impairment, like low motivation and problems with reasoning. A particular issue in mental health treatment is the manner in which patients receive the medication. Unlike some medical interventions, psychotropic medications are often taken by patients on their own and away from the clinic or hospital. In psychotherapy, we know that a good therapeutic alliance improves outcomes partly because a good alliance provides a context within which psychological interventions can work (i.e., clients may be more adherent to the treatment recommendations) and partly because the alliance itself may be therapeutic. In this meta analysis, Totura and colleagues examine if there is an association between the therapeutic alliance and mental health outcomes for patients who receive pharmacological interventions for their mental illness symptoms. Eight studies of 59 samples representing over 1,000 patients were included. Four studies were of pharmacological treatment for affective disorders, two for schizophrenia, and two for mixed diagnoses. The results indicated a statistically significant and moderate effect: z = .30 (CI=.20, .39, SE=.048, z=6.192, p=.05), such that greater therapeutic alliance predicted better mental health outcomes among patients receiving pharmacotherapy.

Practice Implications

Higher quality of the physician-patient relationship was related to better mental health treatment outcomes for patients taking pharmacotherapy. The therapeutic alliance appears to be just as import in pharmacological treatment as it is in psychotherapy. It is possible that a good alliance with the provider may increase patient adherence, which may lead to better outcomes. It is also possible, however, that the alliance itself is therapeutic. That is, negotiating an alliance and repairing alliance tensions may lead to positive changes in patients’ ability to cope with emotions and to make the most of their social supports. The results also suggest the importance of training physicians in communication skills to improve therapeutic relationships.

Gutermann, J., Schwartzkopff, L., & Steil, R. (2017). Meta-analysis of the long-term treatment effects of psychological interventions in youth with PTSD symptoms. Clinical Child and Family Psychology Review, 20, 422-434.

Natural disasters, physical abuse, sexual abuse, war, accidents, loss and severe illness are traumatic events that can occur during childhood and adolescence. These potentially traumatic events are highly prevalent in youth, and approximately 15% of children and adolescents who have been exposed to traumatic events meet the diagnostic criteria for post-traumatic stress disorder (PTSD). Criteria for a diagnosis of PTSD include: intrusive memories of the traumatic event, avoidance, hyperarousal, and negative change in mood or cognitions. PTSD symptoms are also highly stable over time, and so without intervention they do not tend to improve. In this meta-analysis, Gutermann and colleagues assess the effects of psychological treatments for PTSD in youth, with a special emphasis on their long term therapeutic effects. Forty-seven studies of 3767 participants were included in the analyses. Traumas were varied and included childhood abuse, physical abuse, accidents, wars, and natural disasters. About 68% of interventions were CBT-oriented, and 67% were provided in a group therapy format. The uncontrolled pre-treatment to follow-up effect sizes for PTSD symptoms was large for studies with a follow-up period greater than 6 months (N = 30; g = .99, CI .83, 1.16). However, when psychological interventions were compared to treatment as usual or an active control group in a randomized controlled trial, the effects at post-treatment were small (N = 6; g = .38, CI .03–.74), and effects at follow up periods combined were also small (N = 19; g = .38, CI .20, .55).

Practice Implications

Psychological interventions resulted large effects to reduce PTSD symptoms from pre-treatment to follow-up from treatment. However, compared to treatment as usual or other active control groups, psychological treatments resulted in small effects in the longer term. There were too few studies to assess different treatment approaches, age groups, and modalities (group vs individual). Nevertheless, the results provide support for the efficacy of psychological treatments for PTSD in youth with modest effects at follow-up.

Author email: Gutermann@psych.uni-frankfurt.de

Grenon, R., Schwartze, D., Hammond, N., Ivanova, I., Mcquaid, N., Proulx, G., & Tasca, G. A. (2017). Group psychotherapy for eating disorders: A meta-analysis. International Journal of Eating Disorders. DOI: 10.1002/eat.22744

Group therapy has an evidence base indicating its efficacy for many disorders. Groups represent a social microcosm in which interpersonal factors that underlie psychological distress and symptoms can be effectively addressed. Group therapeutic factors include peer interpersonal feedback, social learning, emotional expression, and group cohesion. Theories of eating disorder symptoms include interpersonal problems and affect dysregulation as maintenance factors. Many treatment guidelines indicate that individual and group CBT are the treatments of choice for eating disorders. However, there are no meta analyses that specifically look at the efficacy of group therapy for eating disorders. In this study, Grenon and colleagues assess if: (a) group psychotherapy for eating disorders is efficacious compared to wait-list controls, (b) group therapy is effective compared to other active treatments (self help, individual therapy, medications), and (c) group CBT is more effective than other types of group therapy (group interpersonal therapy [GIPT], group psychodynamic-interpersonal psychotherapy [GPIP], or group dialectical behavior therapy [GDBT]). The authors reviewed 27 randomized controlled trials with over 1800 patients that provided direct comparisons of group therapy for eating disorders. The mean drop out rate from group therapy was 16.47% (SD = 13.46), which is similar to what is reported for psychotherapy trials in general. Group therapy was significantly more effective than wait list controls in achieving abstinence from binge eating and purging (RR = 5.51, 95% CI: 3.73, 8.12), decreasing the frequency of binge eating and/or purging (g = 0.70, 95% CI: 0.51, 0.90), and reducing related psychopathology (g = 0.49, 95% CI: 0.32, 0.66). Group psychotherapy had an overall rate of abstinence from binge eating of 51.38%, while wait-list control conditions had an overall abstinence rate of 6.51%. Similar findings were achieved a follow-ups. The effects of group psychotherapy and other active treatments (e.g., behavioral weight loss, self-help, individual psychotherapy) did not differ on any outcome at post-treatment or at follow-ups. Group CBT and other forms of group psychotherapy did not differ significantly on outcomes at any time point.

Practice Implications

The results add to a growing body of research that indicates that group psychotherapy is as effective as other treatments, including individual therapy, to treat mental disorders. Despite the fact that practice guidelines indicate that CBT is the treatment of choice for eating disorders, this meta analysis did not provide evidence that group CBT was more effective than other types of group treatments. Clinicians considering group interventions for eating disorders or other mental health problems will do well to make use of group therapeutic factors like interpersonal learning, peer feedback, emotional expression, and group cohesion to improve patient outcomes.

Barlow, D.H., Farchione, T., Bullis, J.R., Gallagher, M.W., Murray-Latin, H.,… Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.2164.

One barrier to disseminating and implementing evidence-based treatments is that therapists have to learn to competently apply many different manualized protocols – at least one for each disorder that they treat (depression, anxiety disorders, eating disorders, and others). Barlow and colleagues argue that it is possible to unify many of these protocols under one umbrella, and so they created a unified protocol for this purpose. The unified protocol is an emotion-focused, cognitive-behavioral intervention that targets temperamental characteristics, particularly neuroticism and emotion dysregulation that underly anxiety, depressive, and related disorders. The unified protocol consists of motivational enhancement followed by 5 treatment modules: (1) mindful emotion awareness, (2) cognitive flexibility, (3) identifying and preventing patterns of emotion avoidance, (4) increasing awareness and tolerance of emotion related physical sensations, and (5) emotion-focused exposure. In this trial, 223 participants with an anxiety disorder (generalized anxiety, obsessive compulsive, panic disorder, or social anxiety disorder) were randomly assigned to the unified protocol, or to the evidence-based treatment specific to the disorder, or to a no-treatment wait-list condition. The sample size was large enough to test a hypothesis of equivalent findings between the two treatment conditions. The differences in changes to symptoms between the unified protocol and the specific interventions for each disorder were small and non-significant at post-treatment and at the follow-up assessments. The treatment conditions were significantly more effective than the wait-list control condition. There were no differences between the treatments in drop-out rates or treatment adherence.

Practice Implications

It may be possible for therapists to competently learn to apply a single unified evidence-based treatment for a variety of anxiety disorders that has equivalent outcomes to currently recognized but separate treatment approaches. The unified protocol suggests that the temperamental factors underlying anxiety disorders (emotion dysregulation, emotion avoidance, cognitive inflexibility) can be targeted to treat a wide-range of emotional disorders.

Schwartze, D., Barkowski, S., Strauss, B., Burlingame, G., Barth, J., & Rosendahl, J. (2017). Efficacy of group therapy for panic disorder: Meta-analysis of randomized controlled trials. Group Dynamics, 21, 77-93.

Panic disorder (PD) is characterized by recurrent episodes of intense fear or discomfort accompanied by physical and cognitive symptoms that may include sweating, trembling, or fear of dying. The panic attacks can lead to avoidant behavior that results in isolation, impaired functioning and lower quality of life. Often, those with PD also experience agoraphobia or an intense fear of having a panic attack in public, open spaces, or in a crowd. PD has a lifetime prevalence of 5% among adults in the US. Patients with PD use health care services at a higher rate than the general population, and those with PD may not receive adequate treatment. An evidence-based treatment for PD is cognitive behavioral therapy (CBT). Practice guidelines for PD recommend pharmacotherapy and psychotherapy with CBT. However, these practice guidelines do not take into account group therapy for PD. In this meta analysis, Schwartze and colleagues included group treatment studies of PD that were randomized controlled trials (RCT) and in which direct comparisons of group therapy to other treatments were conducted. RCTs of direct comparisons provide the best quality evidence of the efficacy of a treatment approach. The authors included 15 studies (14 of which were of group CBT for panic) that had 864 patients. There was a large significant effect on panic and agoraphobic symptoms favoring group over no-treatment controls (k = 9; g = 1.08; 95% CI [0.82, 1.34]; p = .001). Similar results were found for depressive symptoms and general anxiety symptoms. There was no significant difference between group and alternative PD treatments (pharmacotherapy, individual therapy) on the primary outcomes (k = 6; g = 0.18; 95% CI [-0.14, 0.49]; p = .264). Again similar results were found for depression and anxiety symptoms. In total 78% of patients with PD were symptom-free after group psychotherapy, compared with 33% in no-treatment control groups, and 71% in alternative treatment.

Practice Implications

The number of studies were small, but the results of this meta analysis indicate that group therapy is an effective treatment for PD and perhaps as effective as typical alternatives like pharmacotherapy and individual therapy. Group CBT protocols usually involve multiple components such as (a) education regarding the etiology and maintenance of PD, (b) cognitive restructuring (identifying and modifying panic-related cognitions), (c) exposure to external situations (in vivo exposure) or internal bodily sensations (interoceptive exposure), (d) relaxation training and/or breathing retraining. Group therapy may also provide a lower cost, more accessible, and possibly as effective treatment alternative than individual therapy for PD.

Driessen, E., Hollon, S.D., Bockting, C.L.H., Cuijpers, P., Turner, E.H. (2015). Does publication bias inflate the apparent efficacy of psychological treatment for major depressive disorder? A systematic review and meta-analysis of US National Institutes of Health-funded trials. PLoS ONE 10(9): e0137864. doi:10.1371/journal.pone.0137864.

In 2008 Turner published a well-known study in which he found that almost 50% of antidepressant trials registered with the Food and Drug Administration in the US were never published or were positively “spun” (i.e., essentially negative findings were interpreted to be positive). Almost all of the unpublished trials showed unfavorable results for the antidepressants’ effects. By contrast, the published studies were almost always were positive. This is evidence of publication bias caused by selective publication of some data and suppression of other data. As you can imagine, this has important implications for treatment of depression as the published record appeared to over-inflate effects of antidepressants by 25% (the mean effect size decreased from g = .41 [CI_95% 0.36~0.45] to 0.31 [0.27~0.35] when unpublished studies were included). Has the same type of publication bias occurred in the published record of psychotherapy’s efficacy? In this study by Driessen and colleagues, the authors reviewed all psychotherapy studies for depression funded by the National Institutes of Mental Health in the US between 1972 and 2008. They wanted to determine which ones were published, which were never published, and what the impact of nonpublication was on the mean effect size. Of the 55 grants that were funded, 13 (26.3%) were never published, and the authors were able to obtain data from 11 of those unpublished studies. The overall mean effect size (psychological treatment versus a control condition) of unpublished studies was g = 0.20 (CI_95% -0.11~0.51) indicating a small non-significant effect. The overall mean effect size for published studies was g = 0.52 (CI_95% 0.37~0.68) indicating a medium significant effect. Adding the unpublished studies to published studies resulted in a 25% decrease in effect size estimate to g = 0.39 (0.08~0.70), indicating a small but significant effect of psychotherapy.

Practice Implications

This study indicated that psychotherapy is effective but that the effects are likely smaller than indicated in the published record. As in the case of antidepressant medication research, a minority of researchers may not publish findings that are not in line with their preconceived expectations or wished-for results. Regardless, there is certainly room for psychotherapy to improve. After decades of focusing largely on the efficacy of specific psychotherapies like CBT, psychodynamic therapies, and interpersonal therapy, perhaps it is time to shift to studying how and why therapies work, and which patients benefit from specific interventions. There are promising avenues such as research on: repairing therapeutic alliance tensions, enhancing therapist expertise, progress monitoring and feedback, client factors, and managing countertransference.