Blog

Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.

Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.

Practice Implications

CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.

Cuijpers P, Sijbrandij M, Koole SL, Andersson G, Beekman AT, Reynolds III CF (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons. World Psychiatry, 12, 137-148.

Both psychotherapy and antidepressant medications are efficacious treatments for depression and anxiety disorders. However, there remains some debate about whether they are equally effective for all disorders, and whether psychotherapy and antidepressants are equally efficacious for each disorder. As I indicated in the March 2014 blog, antidepressant medications alone have become the first line of treatment for many who have depressive and anxiety disorders. However, a recent meta analysis concluded that monotherapy with medication alone was not optimal treatment for most patients, and that adding psychotherapy results in clinically meaningful improvement for most patients. Cuijpers and colleagues (2013) reported on an overall meta analysis of the studies in which psychotherapy and medication were directly compared to each other in adults with depressive disorders, panic disorder, generalized anxiety disorder (GAD), social anxiety disorder (SAD), or post-traumatic stress disorder (PTSD).  They combined the effects of 67 studies including 5,993 patients. Forty studies included depressive disorders and 27 included anxiety disorders. Most therapies (49 of 78) were characterized as cognitive behavioral therapy (CBT), and the others included interpersonal psychotherapy, psychodynamic therapy, and non-directive counselling. Most patients were seen in individual treatment for 12 to 18 sessions. The most commonly prescribed medications were selective serotonin reuptake inhibitors (SSRI). The overall mean effect size for the difference between psychotherapy and medications was almost zero, indicating no significant difference. Regarding specific disorders and treatments, pharmacotherapy was more effective for dysthymia, but the effect size was small. By contrast, psychotherapy was more effective for OCD, and the effect size was moderately large. SSRI had similar effects to psychotherapy, but non-directive counselling was less effective than pharmacotherapy, though the effect was small.

Practice Implications

This meta analysis by Cuijpers and colleagues found that the differences between psychotherapy and antidepressant medications were non-existent for major depression, panic disorder, and SAD. Although antidepressants were more effective for dysthymia, the difference was small and disappeared when study quality was controlled, and so this finding is not reliable. Psychotherapy was clearly more effective for OCD even after adjusting for study quality and other factors. This is the first meta analysis to show the relative superiority of psychotherapy for OCD, and suggests psychotherapy as a first line treatment. The meta analysis only looked at post treatment results and not at longer term effects. There is evidence from other research showing that antidepressants do not have strong effects after patients stop taking them, whereas psychotherapy’s effects tend to be sustained in the longer term.

Cuijpers, P., Sijbrandij, E.M., Koole, S.L., Andersson, G., Beekman, A.T. & Reynolds, C.F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: A meta-analysis. World Psychiatry, 13(1), 56-67.

Anxiety and depressive disorders occur at a high rate and are very burdensome to those who suffer. These disorders are also related to high levels of health care costs, loss of productivity, and lower quality of life. Both pharmacological and psychotherapeutic interventions are effective, yet in recent years there has been a trend for patients to receive psychotropic interventions alone rather than psychotherapy. Cuijpers and colleagues (2014) conducted a meta analysis comparing pharmacotherapy alone versus pharmacotherapy combined with psychotherapy. Studies in the meta analysis included a variety of disorders such as depressive disorders and anxiety disorders. (Meta analysis is an important tool to review and combine the effects of interventions across a large number of studies. Rather than simply counting studies with positive, neutral, or negative findings, meta analysis allows one to calculate an effect size, average the effect sizes across different studies, and look at predictors or moderators of the effects. Aggregated effect sizes in a meta analysis are much more reliable [i.e., dependable] than any single study result). Cuijpers and colleagues’ meta analysis included 52 studies with 3,623 patients. Most studies tested cognitive behavioral therapy, though a large minority also included interpersonal psychotherapy and psychodynamic therapy. Most studies used selective serotonin reuptake inhibitors (SSRI), though some included tricyclic antidepressants and others. There was a moderately large overall difference between pharmacotherapy versus combined pharmacotherapy plus psychotherapy for major depression, panic disorder, and obsessive compulsive disorder (OCD). That is, adding psychotherapy resulted in a clinically meaningful improvement above and beyond pharmacotherapy alone. There were no significant differences found for type of antidepressant medication or for type of psychotherapy. Eleven studies included a placebo control condition to which medication alone vs medication plus psychotherapy was compared. The effect of combining medication and psychotherapy was twice as large as the effect of medication alone when compared to a placebo control condition. Nineteen studies followed patients after treatment (from 3 to 24 months post treatment), and the superiority of combined treatment versus medication alone remained strong and significant well into follow up.

Practice Implications

There has been a trend over the past decade to provide medication as a first line of treatment for depression and anxiety disorders. However, the results of this meta analysis indicate that monotherapy with medication alone is not optimal treatment for most patients, and that psychotherapy results in additive clinically meaningful improvement for most patients. The additive effects of psychotherapy are especially pronounced for major depression, panic disorder, and OCD.

McHugh, K.R., Whitton, S.W., Peckham, A.D., Welge, J.A., & Otto, M.W. (2013). Patient preference for psychological vs pharmacological treatment of psychiatric disorders: A meta-analytic review. Journal of Clinical Psychiatry, 74, 595-602.

For the most part psychotherapy and pharmacological interventions have equivalent positive effects on depression in the short term, and psychotherapy has better outcomes in the long term (see my May, 2013 blog).  There is also evidence that the effects of medications for depression are overestimated (also in the May 2013 blog). Despite all of this evidence, psychotherapy use has remained the same or declined slightly over the past 10 years (currently at about 3.4% of the population), whereas medication use for depression has doubled to over 10% of the population. At the same time, guidelines for evidenced based practice emphasize incorporating patient preferences when there is an absence of evidence-based decision rules for treatment selection. Providing patients with their preferred treatment is associated with better treatment uptake and outcomes (see June, 2013 blog). McHugh and colleagues conducted a meta analysis to review the literature on patient preferences for psychological versus pharmacological interventions for mental health disorders among adults. They included studies with treatment and non-treatment seeking samples of patients with a variety of disorders. (A quick note about meta-analysis. Meta analysis is a way of statistically combining the effect sizes from a number of studies into a common metric so that an average effect size can be calculated. Meta analysis is now the standard by which studies are reviewed. Meta analysis results are much more reliable than any single study and so represent the best way to inform clinical practice from research findings). McHugh and colleagues identified 34 studies representing over 90,000 participants. Most studies were of depressive disorders and anxiety disorders. When given a preference, 75% of participants preferred psychotherapy over medication to treat their mental health problem. In treatment seeking samples, the percentage was lower at 69%, but still significantly in favour of psychotherapy. Younger people and women were more likely to prefer psychotherapy, though the findings still showed a preference for psychotherapy among older people and men. The availability of combining psychotherapy and medication did not affect the results, so that even when given the option of both psychotherapy and medication people still preferred psychotherapy alone.

Practice Implications:

In all subsamples, participants were 3 times more likely to prefer psychotherapy to medication for their mental disorder. Patient preference for treatment is a core component of evidence based mental health practice that improves outcome and reduces drop outs. Without evidence for superiority for one treatment over another, patients should be given their preference, and on average patients overwhelmingly prefer psychotherapy. To optimize outcomes in clinical settings, providers should consider patient preferences, including their preference for psychotherapy over medication.

Author email: kmchugh@mclean.harvard.edu

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 735-774. Hoboken, N.J.: Wiley.

This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on schizophrenia. Practice guidelines recommend antipsychotic medications as the first line treatment for Schizophrenia. However, up to 30% of individuals show an initial poor response and an additional 30% of patients continue to experience symptoms. Medication side effects can be debilitating, resulting in poor adherence and therefore reduced effectiveness. Further, Schizophrenia spectrum disorders are heterogenous in presentation and course, and so a “one size fits all” approach will not be effective for some or many. Psychotherapies can enhance the effectiveness of medications at different phases of treatment to hasten recovery or reduce medication-resistant symptoms. CBT for schizophrenia was developed to treat persistent medication-resistant positive psychotic symptoms (i.e., positive symptoms refer to delusions, hallucinations, disorganized speech and behaviour; whereas negative symptoms refer to restrictions in: emotions, thoughts, speech, and initiating goal directed behaviors). CBT focuses on reappraising the power and source of hallucinations, evaluating delusions, and addressing motivational deficits. CBT appears to be effective for chronic symptoms of schizophrenia with small to moderate effects, and these effects appear to be enduring. There is currently less and mixed evidence for CBT to speed recovery from first episode psychosis and to improve relapse rates. There is also evidence suggesting the effects of family psychoeducation to reduce relapse and to improve caregiver outcomes. However, family psychoeducation requires the participation of a caregiver, which may be a challenge that limits its utility. There is promising research on multidisciplinary rehabilitation programs that include case management, behaviour management, social skills training, social cognitive training, and cognitive remediation. There is also controversial research on providing psychological interventions alone or in a staged approach (i.e, in which earlier and less severe stages are treated with more benign interventions, and later stages are treated more aggressively with medication). However there are as yet no well-controlled clinical data to support this approach.

Practice Implications

Adjunctive psychosocial treatments appear to improve symptomatic and functional outcomes in individuals with schizophrenia spectrum disorders. CBT is best suited for treating chronic positive psychotic symptoms, but its effect on relapse prevention is equivocal. Individuals who are at risk for relapse might benefit from family psychoeducation, if the caregiver can be engaged. Multidisciplinary rehabilitation programs are a promising avenue of treatment.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 735-774. Hoboken, N.J.: Wiley.

This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on depression. Psychotherapy and antidepressant medications appear to have similar efficacy in short-term treatment trials, though psychotherapy has better outcomes than medication in the longer term. Psychotherapeutic treatments including Brief Dynamic Therapy (BDT), Interpersonal Psychotherapy (IPT), and Cognitive Behavioral Therapy (CBT) confer enduring benefit by preventing relapse and recurrence when compared to discontinuing medication. Antidepressant medication is modestly effective during initial short-term treatments with remission rates less than 50% and long term recurrence range from 40% to 85%. Combining medication with psychotherapy provides a small to moderate short term advantage over monotherapy of medication or psychotherapy. Combining medication and psychotherapy is more useful for when considering chronicity rather than severity of depression. The results are consistent for BDT, IPT, and for CBT.  In the longer term, efficacy of combined treatments is not better than either monotherapy. Taken together, the evidence for combined therapy for depression is modestly positive with little evidence that treatments interfere with each other (by contrast, see the March 2013 blog for findings of interference in combined therapy for anxiety disorders). Nevertheless, prolonged continuation of medication monotherapy is an added expense that is often ineffective. In fact, prolonged antidepressant medication maintenance can worsen the course of depressive illness for some, and efficacy tends to fade after 3 to 6 months of maintenance. Finally, there is emerging evidence of progressive tolerance (tachyphylaxis) or even worsening of symptoms during medication maintenance. Studies suggest that psychotherapy added to maintenance medication was associated with decreased relapse rates when compared to medication alone in the longer term.

Practice implications

Combined treatments (antidepressant medication plus psychotherapy) for major depression provide modest incremental improvements in response over monotherapy. Results of combination treatments are better, though still modest, for those with chronic depression. The evidence does not support the use of combined treatments for mild to moderate depression, unless the individual does not responds to initial monotherapy. Practitioners could consider monotherapy (i.e., psychotherapy or medication) first, followed by switching therapy or augmenting therapy for non-responders. If a patient is started on short term monotherapy of medication, practitioners may consider switching to psychotherapy for better long term relapse prevention.