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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.

March 2017

Long-Term Medical Conditions Reduce Outcomes in Psychotherapy

Dalgadilo, J., Dawson, A., Gilbody, S., & Bohnke, J.R. (2017). Impact of long-term medical conditions on the outcomes of psychological therapy for depression and anxiety. British Journal of Psychiatry, 210, 47-53.

Twenty percent of people have long-term medical conditions, and this percentage rises to 58% for people over 60. These long-term conditions account for approximately 70% of health care costs in the UK. The most prevalent long-term conditions in the population include: hypertension, chronic pain, gastrointestinal disorders, asthma, diabetes, heart disease, and chronic obstructive pulmonary disease. Do these conditions reduce the outcomes of psychological therapies? Dalgadilo and colleagues conducted a large study in the UK of patients who accessed publicly funded psychological services. The authors looked at what impact long-medical problems had on psychological intervention outcomes. Patients accessing the public system in the UK received stepped care - so that they were first given self help followed by a second step of intensive psychotherapy, if they needed it. The sample for the study included over 28,000 patients with a mean age of just over 38 years. About 23.2% had a long-term condition. Sixty-eight percent only received the low intensity self help, and 32% required the intensive psychotherapy. Those with long-term conditions, compared to those without long-term conditions, tended to report higher levels of distress and lower quality of life at the outset. Long-term conditions that were associated with poorer psychological intervention outcomes included: chronic pain, chronic obstructive pulmonary disorder, severe mental health problems, and diabetes. The effects were small (d = .20) to medium (d = .50) sized (confidence intervals not reported). Those with long-term conditions were more likely to receive high intensity psychotherapy after the self help. However, poorer outcomes for those with long-term conditions, compared to those without long-term conditions, were still apparent after they received the intensive psychotherapy.

Practice Implications

Compared to those without long-term medical conditions, those with long-term conditions have a higher level of impairment to start with and tend to finish therapy with greater depression and anxiety. The study points to the need to integrate psychological therapies in medical practices - especially for those with long-term medical conditions. Certain conditions like chronic pain, and having multiple conditions increase psychological distress and likely reduce patient mental health outcomes.

February 2017

Mindfulness-Based Cognitive Therapy to Prevent Relapse of Depression

Kuyken, W., Warren, F.C., Taylor, R.S., Whalley, B., Crane, C….Dalgliesh, T. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse An individual patient data meta-analysis from randomized trials. JAMA Psychiatry, 73, 565-574.

Depression results in a high level of disability and its social and economic costs appear to be rising. Although many effective treatments for depression do exist, relapse of depressive symptoms is a significant problem for many who successfully complete treatment. One of the interventions used to prevent relapse is mindfulness-based cognitive therapy (MBCT). MBCT teaches psychological skills that target cognitive factors that may cause relapse among those who have a history of depression by combining mindfulness training with cognitive interventions. Previous reviews have indicated the efficacy of MBCT for relapse prevention. In this meta-analysis, Kuyken and colleagues update the previous reviews and look at specific sub groups of patients who may respond differently to MBCT. From a comprehensive search of the literature, they identified 9 published randomized controlled trials comparing MBCT to another condition such as usual care, antidepressant medications, or another active treatment. These 9 studies included 1258 patients. MBCT resulted in a reduced risk of relapse in depressive symptoms compared to those who did not received MBCT within a 60 week follow up period (hazard ratio (HR), 0.79; 95%CI, 0.64-0.97). Four studies specifically compared MBCT to antidepressant medication and showed that those who received MBCT had a reduced risk of relapse compared to antidepressants (HR, 0.77; 95%CI, 0.60 – 0.98; I², 0%). The authors also found that the preventive effect of MBCT on depression relapse declined over time. No demographic variables were associated with the effects of MBCT, but higher levels of depression at baseline were associated with a larger effect of MBCT.

Practice Implications

The findings of this meta analysis show that MBCT helps to prevent depression relapse in those who have recovered from depressive symptoms. Its effects appear to be superior to usual care and to antidepressant medications. Unlike anti depressants, those who were treated with MBCT learned skills that helped them to cope with stressors that may precipitate another depressive episode. The effects of MBCT appear to be particularly useful for those with greater depressive symptoms at the outset, but those with lower depressive symptoms may not benefit as much from MBCT.

January 2017

Comparing Three Psychotherapies for Adolescents with Major Depression

Goodyear, I.M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., ….Fonagy, P. (2016). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): A multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, Online first publication: http://dx.doi.org/10.1016/S2215-0366(16)30378-9.

Major depression affects a large proportion of adolescents worldwide. The Global Burden of Disease Study Found that depressive disorders accounted for over 40% of disease burden caused by all mental and substance use disorders, with the highest burden occurring for those between the ages of 10 and 29. Although there is good evidence for cognitive-behavioral therapy (CBT) to treat depression in adolescents, data is scarce for long term outcomes – which is an important issue because maintaining treatment gains reduces the risk for relapse. There is also little research on alternative treatments to CBT and their long term effects. In this large study, Goodyear and colleagues (2016) randomly assigned 470 adolescents with major depression to receive CBT, short-term psychoanalytical therapy (STPT), or a brief psychosocial intervention (BPI). CBT was based on a commonly used model but adapted to include parents and emphasized behavioural techniques. The STPT model emphasized the child – therapist relationship in which the therapist emphasized understanding feelings and difficulties in ones life. STPT also included some family meeting. BPI on the other hand focused on psychoeducation about depression, was task and goal oriented, and emphasized interpersonal activities. The study also compared cost-effectiveness of the three treatments – that is, whether the treatments’ costs relative to their effectiveness were different. There were some advantages in terms of reduced depression to both CBT and STPT compared to BPI at 36 weeks and 52 weeks post treatment, but these advantages disappeared by 86 weeks follow-up. Across all three treatments, about 77% of adolescents with depression were in remission (i.e., no longer depressed) by 86 weeks post-treatment. There were no differences between the three treatments in terms of cost-effectiveness.

Practice Implications

This is one of those rare studies that is large enough to adequately compare the efficacy of alternative treatments for adolescents with major depression. CBT, STPT, and BPI were all associated with reduced depression in adolescents, and with maintenance of these improvements 1 year after the start of treatment. Both BPI and STPT provide alternative choices to CBT for patients and therapists.

December 2016

Effects of Combining Psychotherapy and Pharmacotherapy on Quality of Life in Depression

Kamenov, K., Twomey, C., Cabello, M., Prina, A.M., & Ayuso-Mateos, J.L. (2016). The efficacy of psychotherapy, pharmacotherapy, and their combination on functioning and quality of life in depression: A meta-analysis. Psychological Medicine, doi: 10.1017/S0033291716002774.

Both psychotherapy and pharmacotherapy are efficacious for reducing symptoms of depression. Some studies suggest that functioning (i.e., the ability to engage in work, school, and social activities) and quality of life (i.e., satisfaction with these activities and perception of one’s health) are just as important to depressed patients as is reducing their symptoms. In fact, many patients place greater priority on improving functioning compared to reducing symptoms. In this meta analysis, Kamenov and colleagues assess the relative efficacy of psychotherapy vs pharmacotherapy in improving functioning and quality of life. They also evaluate if combining psychotherapy and pharmacotherapy is efficacious relative to either treatment alone. The meta analysis included k = 153 studies of over 29,000 participants. Psychotherapies often included CBT and interpersonal psychotherapy. Compared to control groups (k = 37 to 52) both psychotherapy (g = 0.35, 95% CI = 0.24, 0.46) and medications (g = 0.27, 95% CI = 0.21, 0.32) significantly improved functioning. Also, compared to controls both psychotherapy (g = 0.35, 95% CI = 0.26, 0.44) and medications (g = 0.31, 95% CI = 0.24, 0.38) significantly improved quality of life in depressed participants. In studies that directly compared psychotherapy and medications, there were no significant differences when it came to improving functioning, but there was a small significant advantage to psychotherapy over medication for improving quality of life (g = 0.21, 95% CI = 0.01, 0.43). Combined psychotherapy and medications (k = 19) was more effective to improve functioning compared to pharmacotherapy alone (g = 0.34, 95% CI = 0.18, 0.50) and compared to psychotherapy alone (g = 0.32, 95% CI = 0.14, 0.49). Combined treatment was also more efficacious for improved quality of life compared to medications alone (g = 0.36, 95% CI = 0.11, 0.62) and to psychotherapy alone (g = 0.39, 95% CI = 0.19, 0.58).

Practice Implications

Combined treatment of medications and psychotherapy is more effective than either treatment alone for improving functioning and quality of life. However, most patients prefer psychotherapy to medications, and some studies indicate that many patients choose not to get treated at all rather than receive medications. Further, quality of life can be substantially compromised by medication side effects. Clinicians should take these factors into account when considering monotherapy with antidepressant medications or combined treatment of pharmacotherapy and psychotherapy for depression.

October 2016

The Long Reach of Nurturing Family Environments

Waldinger, R.J. & Schulz, M.S. (2016). The long reach of nurturing family environments: Links with midlife emotion-regulatory styles and late-life security in intimate relationships. Psychological Science. DOI: 10.1177/0956797616661556.

Although, not a psychotherapy study, this research has important implications for psychological treatment of adults, including older adults. This research, drawn from the original Grant study, is extraordinary because the sample is from a 78-year long study of 81 men. The original cohort of over 200 men were first assessed as adolescents and young adults between 1939 and 1942. At that time, the original authors conducted intensive interviews of the adolescents` family experiences and current life situations. These men were re-interviewed in mid-life in the 1960s (aged between 45 and 50 years), which included interviews and assessments of challenges in relationships, work functioning, and physical health. Waldinger and Schulz recently re-interviewed these men and their current partner in late-life (aged between 75 and 85 years), with interviews focusing on their current partner relationship. Raters reviewed audio recordings and notes from all the interviews and coded for: (a) quality of family environment in childhood (distant, hostile vs cohesive, warm) - taken from the first interview; (b) style of regulating emotions (suppressive, maladaptive vs engaged, adaptive) – taken from the midlife interview; and (c) security of attachment with their current partner (secure, comforting vs insecure, anxious) – taken from the late-life interview. The authors found that more nurturing early family environments were significantly linked with late-life attachment security with a partner (r = .23, 95% CI = .01, .45), and early family environment was significantly related to midlife adaptive emotion regulation strategies (r = .29, 95% CI = .06, .50). Also, adaptive emotion regulation strategies in midlife were significantly correlated with greater late-life attachment security (r = .23, 95% CI = .05, .51). These are medium-sized correlations, but they are remarkable because they represent associations between variables that were assessed decades apart. Through a statistical mediation analysis, the authors also reported that adaptiveness of emotion-regulation strategies partially explained why positive childhood family environments may lead to late-life attachment security (accounting for 6% of the variance).

Practice Implications

This compelling study adds to the argument that early family environment shapes the way adults regulate their emotions, which in turn affects how they experience relationships in old age. More securely attached adults were better able to meet two challenges associated with aging: accepting vulnerability in depending on a partner, and accepting the responsibility of being depended upon by that partner. The early family environment indeed has a long reach. Psychotherapy directed at reducing the effects of childhood adversity takes on a heightened meaning in the context of these findings. Treatment for adults who struggle with the consequences of non-nurturing early environments should include improving emotion regulation strategies.
Clients’ Experiential Depth in Therapy Predicts Better Outcomes

Pascual-Leone, A. & Yeryomenko, N. (2016). The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process, Psychotherapy Research, DOI: 10.1080/10503307.2016.1152409

A key issue in existential-humanistic psychotherapy is the degree to which therapy encourages clients to explore new feelings and meanings in relation to the self. This is often called ‘experiential depth’ or simply ‘experiencing’. Carl Roger highlighted the need for clients to increase their awareness, accept their feelings, and use their feelings as information to further explore and understand themselves. The notion of ‘depth of experiencing’ refers to the degree to which clients engage and explore their feelings moment by moment in therapy to increase personal meaning-making. One way of assessing experiential depth is with the Client Experiencing Scale. Low scores on the scale indicate unengaged levels of experiencing, in which clients recount events in an emotionally neutral or disengaged manner. High scores indicate more introspection as clients begin to process their experiences and identify feelings that lead to creating new meanings that contribute to resolving their problems. In this meta analysis of the Client Experiencing Scale, Pascual-Leone and Yeryomenko systematically reviewed the research literature and found 10 studies of 406 clients that evaluated the scale`s association with client outcomes. The therapies in the meta analysis included experiential-humanistic approaches, CBT, and interpersonal psychotherapy. Overall, they found a moderate association (r = .25; 95% CI: .16, .33) between higher client experiencing and better treatment outcomes. The association was similar for different therapeutic orientations and stages of therapy. On average, client depth of experiencing tended to increase from the early to later stages of treatment.

Practice Implications

Compared to those who did not engage with their experiences in a meaningful way, clients who were internally focused, engaged in exploration, referred to their emotions, and who reflected on their experiences had better outcomes. Experiential depth allowed clients to create new meanings to resolve personal problems. Therapist interventions that deliberately point the client to a deeper level of experiencing, are likely to result in clients following suit and deepen their own process.

This month...

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March 2017

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February 2017

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January 2017

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December 2016

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October 2016

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